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-N  r 


!  r- 


SrmnCAL  OBSKRVATIOXS. 


CASES   AND   OPERATIONS 


lit 


J.  MASON   WAKREN,   M.II» 

MWIFO^  rtt  THE  MAMjWIIISETTH  ('fJSKBAl-    IIHSPITAL  ;    rEl.tJPW    I'V  THK 
WKRItAS    AC   lURSlV    i>V     \HT!*    AX|I    M■|ElfC'E^.    im   - 


NKW     vim;  K  : 
WILLIAM     WOOD     A     roMTANY. 

I  sc;. 


Eatend  sccordin^  to  Aat.of  CoDgrcBB.  in  the  jrar  iW7,  Ivy 
J.    MiSON  VARBEN, 

in  the  Clqrt'h  Office  *>f  the  Dirtrict  Court  of  the  District  of  MiuJiKhnnett*. 


TO 


ROBERT    HOOPER,  Esq,, 

PREalDENT, 

EDWAItD   WIUGLESWORTH.  Esq..  ViCB-PuftTDSTCT, 

J.  THOMAS   8TEVESS0N.  Esq.,  TtBASDum. 

THOMAS  B.  HALL,  Esq,,  Secbetart, 

&  tfie  fHafiftad|u0ett0   BttttxH  J^oftpital; 

And  to  the  TnMea, 
Hurftr  fi.  RaaRn§,  Sahuel  G>  Howb, 

JaXD  U.  BeEBE,  JaIUQ  L-   LlTTLEt 

WruJAu  S,  BuujLRD,  Jonn  Loweu^ 

Chaulei  H.  DALTOHt  EzBA  Fabithwortb, 

Samuel  F.uot,  Charlea  S.  Sronsow, 

Geoboe  HiooiiriioiT,  Hehbt  A.  Whttnet,  Esq.'g, 

UitdB-  wkoK  vae  manayemrBt  rAc  Inililution  hai  attaintd  iti  prtieni  imporianoe 
fs  llwnattitff  ami  Sciota, 

S^  0'olanu 

It  inKfibfdf  ru  a  Tettimanial  of  rea/Mct  and  fjifffm, 

BY    THE   AUTHOB. 


This  volume  contains  aome  results  of  aurgical  experieni^e, 
and  develops  And  illustmcee  what  was  ndranced  by  the  author 
m  an  addreas  delivered  before  the  Massachusetts  Medicil 
Society,  and  eotitled  "Recent  Progress  in  Surgery." 

The  cases  which  are  c'lted  have  been  mostly  derived  from 
prac^ce  in  the  Jlasaachusetts  General  Hospital;  and  some  of 
tbem  have  been  previously  published.  Many  others  might 
have  been  given  ;  but  it  has  been  thought  proper  to  relate  only 
those  of  which  the  histories  have  been  well  ascertained. 

As  a  convenient  method  of  classificaticn,  the  regions  of  the 
body  have  been  used ;  and  this  order  has  been  kept  through 
the  book,  except  in  the  last  chapterSf  which  relate  to  Gunshot 
Wounds,  Tumors,  and  Miscellaneous  Cases.  It  is  not  pro- 
posed in  this  volume  to  comprehend  every  surreal  subject,  or 
to  enter  into  much  descriptive  detail;  but  simply  to  indicate 
the  chief  points  in  the  cases  and  operations  which  are  recorded, 
and  to  add  such  remarks  and  conclusions  as  have  seemed  to  be 
pertinent. 

PjiBK  Street,  Apiil,  1867. 


CONTENTS. 


CIIAPTEE    1. 

THE    UEAD. 

Fractures  of  die  Cranium     ...............  1 

Tr«pbj]ung  for  Epilepsy ^     -     .      .     .     ^     .     ^  7 

InjuricH  of  the  Scalp  .................  15 

CooGuuion  of  the  Brain  . 16 


CHAPTER    n. 

THE    FACE. 

TUrinopIaBtic  Operations  . 18 

OperatioDs  for  the  Reatoration  of  the  Lower  Ejciid  .     ......  42 

Epithelial  Cancer  and  Rodent  Ulcer  ............  47 

The  Eye 68 

TbeEar 69 

HoiM 60 

D«viadon  of  Septum  of  Now 62 

Tumon  of  the  Jaw-bone       .,............>  64 

Eputis 70 

Cjstic  Tumors  of  the  Jaw 72 

CaDceroqs  Tumors  of  the  Jaw 80 

FibrouB  Tamora  of  the  Jaw S4 

Apparent   Tumors   of  Lower  Jaw,  secondary  to  Removal  of  Cancer 

of  Lip   ....,......-.......'  B6 

NecrosiH  of  Jaw    .........,.....--■&& 

The  Tongue 02 

SaliTiry  Calculus W 


Xn  CONTENTS. 

CHAPTER     HI. 

THE   NECK. 

Foreign  BocUea  tn  the  Air-paBsagta      ............  Wi 

Croup.    Tracheotomy -.,.-....  106 

Foreign  bodies  in  the  (EKophagn.i  .............  \'1'2 

Strirture  of  the  tEaophngua -,......,  114 

TutitorH  m  tho  Qi^BOphagus      ...............  llti 

Removal  of  Tonriilji ..................  119 

FiMurcof  Soft  aiiil  Han!  Palalo 126 

Harelip 14^ 

CHArrER     IV. 

Parwnteifb  Ttiorauia  .................  116 

CIUFTER    V, 

THE        ABDOMKS'. 

II<>miA,  —  Strangulated  Hi'm  in  . 152 

Radieal  Cure  of  Hernia 164 

Artifii'ial  Anus 16S 

HkcTuuior 179 

CHAPTER    VL 

A  SUM. 

Hemorrhoids ]@3 

Fissure  of  the  Aiiuh IS6 

Fistula  in  Auo 1^1 

FiBluloua  Opening  conUioing  Hair     ............  192 

Prolapsus  Ani 194 

Polypus  of  the  Rei-'tum 193 

Lnperforate  Anus  ind  RctCuin  ..............  196 

CIL^TER    Vn. 

OByrro-cniNARr  omnNf*. 

Stone  in  the  Bladder 204 

Stricture  of  tlie  Urethra,  with  Ret«ntioa  of  Urine      .......  226 


CONTENTfl.  XUI 

Periiietl  SettioQ 230 

Diaeaaea  of  the  Prostate 240 

WouDdoftheBMder 241 

Vesieo-roL-tal  Fistula 242 

Cincer  of  Rectum 243 

InduTUled  Tumor  of  Penifl 245 

Tumors  of  the  HSpermatic  Cord    .....,,,..     ^     -     -     ,  348 

Phimoai 250 

llydrowle 251 

lIeiiu(ocel« 252 

Vflricocelo 254 

Retuaed  Testicle 257 

FKtfALC   GENITO-UBISARY    ORl>ASS. 

Rapture  of  tJie  Ferintcmn 2A8 

^'"wt'th'VaginaJ  Fiatub  .................  2G3 

ProUpseofWaJl8ofthvVag!Q& 2U3 

Vascular  and  Sensitive  Tumor  of  Female  Urethra     ,     , 270 

Cancer  of  Vulva 272 

TomorofVa^a 273 

Polypus  Uteri 274 

Foreign  Body  In  Vagina .....  276 

Ocdaaion  of  tbe  Vagina 278 

Occlnsion  of  Ob  Uteri 29X 

Hypertrophy  of  Cervix  Uteri      ...,...,..,...  294 

Ovariotomy 300 

Cdculus 303 

Absence  of  Vagina  and  Uterus .,.....,  306 

Hennaphrodiam  .     .     .     - - 310 


CHAPTER    Vin. 

THB        EXTKKMTTIBa. 

Fractures 318 

Dislocations     .,, 348 

Ajnputations 384 

Excisjon  of  Joiiitd    .,,,...*.. 409 


CHAPTER    DC. 

ARTKmiE^     AVD      VRIN8. 

Aneurismal  Tumors,  and  Ligatures  of  Arti;ri<^      ........     424 

VaacuUr  or  Erectile  Tumor  . 441 


XIV  CONTENTS. 


CHAPTER    X. 

INJURIES    XND   D18EASE9   OV   NEBVES.  4Cfl 

CHAPIER    XL 

TL'UUlfH. 

Tunjora 479 

TiiQiorn  in  tbc;  I'arotiil  Rfgjoii    ,.»,. 488 

]>f'iicoi'ytUicJ»ia    ....     - Af>l 

Oporaiionii  fur  Cani'er  (Tjkblc)  .     .....,.,.,.     ,     .  SM 

CHAFrER    XII. 

«  U  NHIIOT      WOUXDtf.  542 

CirAPTER    XIIL 

MIHCELLANEOUS        CASES. 

Pon<^lrating  Wouncis  of  Cheat  flild  Abriomi'n 569 

Hip  aiid  Spinal  Diaeasoa    ,,..........,..,  573 

Appi-ti'lix  Vomdfurniln . 575 

I[ydropbobifl  ....     ^     ,........,.,..     .  584 

Extra  tion  of  Noedltn 590 

InjurioB  of  the  ih  Covcy-i^is 593 

FrarturpoftJieBaso  of  Skull 597 

Wn-  Nc<'k 601 

CoDgeaital  Fuaion  of  Fingora      ..............  609 

CHAPTER    XIV. 

Ether  and  Chlomform 613 

Local  ADvathcsia      ,     . 631 


ILLUSTRATIONS. 


FBONTI8PIECR.— Fungoid  Tumor  of  Forehead,    See ^83 

Wooi>cuT.  —  Deatniction  of  Nose,  Case  XIII 20 

RJiinopU^tlc  Operation  for.  Cast  XTII £5 

Taliacotian  Rblnoplasty 33 

37 

Tuiiior  of  (£sophagi]A   t     .     .     ,     .     .     ^     .     .     .     .     ^  IlT 

Section  of  Neck  representing  the  Tumor  *n  stVw   .     .     .  UB 

Ton§illotorae 123 

Median  Fisiure  of  Hani  Palate 140 

Plate  T.  —  InBtniments  used  in  Operations  for  Cleft  Palaie  ,     ,     ,     ,  142 

WooitCUT  (after  Hugnier),  —  Hypertrophy  of  Cervix  Uteri    ....  298 

,,          Dislocation  of  Thigh  Downwards 37B 

Platis  TI.  —  SubclaTJan  Aneurinu     ............  425 

„      nL  — Erec^le  Tumor  of  Face  and  KiH'k 446 

„       IV.  —  The  same  afler  Operation 449 

Wooi>CTrr. —'Tumor of  Head    .........,,,,,  4ftfi 

„               Parotid  Tumor 493 

„               Tumor  of  Arm 520 

Pi.ATR  V«  — Tumor  of  0§  Frontis,  containing  Air    ..,,,,.  576 


SURGICAL    OBSERVATIONS. 


CIJArTKlt      L 

TUK    HEAD. 
FRACTUBES  OF  TUB    CIEAKR"M, 


LT  ie  Tcrv  frequently  ofj^ervcJ,  that  cxtcnpivo  injuries  of  llio 
head,  ivitli  comminuted  fnicturc  of  tlie  fikull,  Jo  reiiiurkjtbly 
well,  even  vpHcti  there  ha«  been  laecratitin  of"  ihe  mcnibrnncs  and 
considemble  loas  of  cerebml  Bubfihince.  Tlje  cnscs  w!iii:Ii  ure, 
jjcrhn]*^*  moat  to  he  drcndcd  arc  thoee  in  wiiifli  the  de])res^iou 
ie  liniiteU,  and  the  frti^^iK-nts  eo  firmly  lacked  as  to  rtqiiii^c  the 
0|>cratiif[i  of  trephining  for  tbcir  repkccnient.  In  those  cuses. 
the  rc*iih^  appear  to  be  generally  unfinoridjlc.  The  qucfititm 
of  trephining  in  c^iaes  of  injury  of  the  ekull  with  depreeaion, 
both  i  in  mediately  ot^er  the  atvidcnt  where  no  cer<:bral  JiFiturl>- 
ancc  IB  present,  nnd  at  a  later  jjcriod  wlicn  epile|>tie  i*ym|itomB 
}iave  come  un  in  conacqucnec  uf  tJjc  irritation  produced  by  the 
(Icpre«pc<i  pieec  of  bone,  it^,  however,  atill  an  o[k-ii  one.  Many 
civiea  in  whii;li  there  is  considerable  depression  of  the  ?kulJ.  and 
in  nhicli  not  the  BJighlest  eei^bml  JidtiirUuicc  has  appeared  nt 
the  time  ijf  the  awidontj  are  Bubjcct,  after  the  lirst  deprcBsion 
cmiQcd  by  the  injury  bae  diaappenred,  to  chronic  heikdac-ho«; 
and  I  have  ocen  a  numhcr  v*ho,  a  year  or  mure  a^lcrwarJi^, 
hav«  been  eei-ted  with  epileptic  eonvultiions^  and  have  then 
urgently  eougbt  the  relief  proTuiacd  by  an  operation.  Extrenie 
d<nibt  niusl  ahynya  exist,  in  these  caaee,  na  to  the  probable  buc- 
rp'"-  uf  any  operation   for  elevating  the   bone  after  ao   long  a 


2 


TH£  inrAD. 


perio*!,  eflpecially  us  we  muat  almost  aJwftys  be  in  total  igao- 
TitncG  of  the  extent  to  wKir:h  the  dura  luaicr  unJ  arachiifnij 
membranes  are  implicuted  in  the  original  injury. 

pLLlicnts  are  ufton  so  excessively  urgi^nt^  however,  in  their 
deeirea  for  relief,  and  their  lives*  are  rendered  so  wretched  by 
their  Bufferitiga,  thsit  it  seema  fair,  in  certain  coses,  to  attempt 
the  operation,  wher  we  are  sure  that  its  Jann;er  and  UDeertninties 
are  liilly  understood  by  themselves  and  tlieir  frienJs.  Sorae- 
tlnies,  however,  &  «tfite  of  partial  dcran^ment  aeema  to  follow 
flrom  the  eflecta  of  Liic  injury  ;  in  wliich  vii&q  they  may  icsiat  on 
an  operation  where  there  is  little  or  no  ehtinee  of  beoe£t. 

Tlie  diagnosis  of  fracture  of  the  eraiiium  Is  occasionally  ex- 
ceedingly difficult,  enjiecially  in  the  cftse  of  children  who  have 
Buffered  from  blows  on  the  head.  After  these  aeeidents,  we 
very  oJ>en  observe  a  remarkable  phenomenon  ahout  the  sealp, 
Huggcsting  a  depression  of  the  skult :  thU  appearance  in  «o 
deiaijitive  that  practised  surgrfmj*  will  often  be  at  varinn<w  in 
the  opinion  whether  the  skuJl  i^  depressed  or  not;  a  matter 
aometiniea  of  conslder^le  consequence,  if  eymptoms  of  com- 
pression happen  to  l>e  preseut.  Some  rimes,  however,  with 
ynnng  children,  even  if  the  akull  h  depressed,  it  seems  iifier  a 
time  Co  rise  up,  and  resume  its  natiind  position.  On  the  other 
hand,  in  one  iriHt.ance  which  I  remember,  where  it  was  suppoaeil 
that  the  appeaininces  of  depres^iJon  were  entirely  caused  by  tiie 
injury  (jf  the  acidp  and  perioateum,  ami  where  no  symptoms 
ejilled  for  un  opemtlou,  it  was  found,  that  at  the  end  of  three  or 
four  weeks,  afler  uJl  swelling  had  subsided,  a  depression  really 
exidied. 

C^EK  I.  —  ^xietUive  Crjfrtpojiti^  Frtcture  of  the  ShnU. 
liifcovf^rtf.  —  May  18,  1832,  I  was  nKjUested  to  see  a  tine, 
handhome  boy,  aged  12,  who,  the  night  before,  had  fallen  a 
distnnce  of  tweuty-flvc  feet,  striking  on  the  right  parietal  bone, 
and  producing  an  extensive  eompound  comminut&l  fracture-  He 
liad  been  inseuftibJe  at  lirst,  imd  in  a  t^ollapMed  state;  but  had 
griLdually  recovered  vitality,  and,  wheu  I  saw  him,  was  sensible. 
Portions  of  brain  escaped  from  the  wound.  By  the  aid  of  in- 
dsionti,  loo^e  bits  of  hone  wei-e  removed,  imd  a  large  {]uad- 


(guIflT  deprcMod  poriion  —  oxtordinjf  up  to^vrmls  tin?  yertoac 
was  elcvftied-     Acother  portion,  di'ivea  umler  the  adjacent 
inea,  was  removed.     The  rough  oclges  of  bone  were  sniuotLed 
off  with  Hey's  sjiw.     Cold-water  dresnings  were  npjjlied  to  the 
wcund,     lie  was  kept  under  strict  diet,  very  carcftdly  watched, 
,     imd  recovered  eotopletely. 

B     Ten  years  afterwords  he  entered  the  army,  wlien  ho  suifered 
the  first  inconvenience  from  his  former  injury*  eonriinniona  of 
I     c«nnon  prwlnoin^  sncli  a  stunning  effect  upon  ilic  Irain  as  to 
Beaitae  vertigo^  and  uUimutcly  obliged  him  to  quit  the  sGrviee. 

H     Cabe  it.  — Extensive  Fracture  of  the  Brute  of  the  I'y'htU, 
Horif/  iitipture  of  tfte    Opposite   Side   of  the  Hi-am-     Death 

^  after  ten   dat/i.      liemrtrlcahle  Ahuetice  of  StjinplOTHs  indi- 

»cath'e  of  /lo  severe  ati  lajiiry. —  May  18,  185^,  n  woman  was 
)>n)u;j;ht  into  the  HcBphal,  and  died  after  a  few  days,  with  very 
deiyqitive  aymptonis.  A  week  beforB,  while  reaching  out  of  a< 
tliinl-etory  window,  ahe  lot^t  her  balanee^  and  fell,  first  upon  % 
toehe{],  and  ilienee  itito  the  street.  She  was  tiken  vip  bsensihle, 
but  soon  recovered  herself  suffieienily  to  itpeuk,  though  inco- 
herpntly.  Slie  was  snppowd  at  firiJi  to  l>e  laboring  under  the 
edcf-'ts  of  opium,  which  slic  was  in  the  habit  of  raking  freely, 
a  large  bit  of  which  was  found  in  her  pocket.  Wlicn 
^brought  into  the  Hospital,  a  wound  was  discox'ered  over  the 
right  parietal  bone  ;  hut  the  finger,  being  paeseil  in,  coidd  detect 
no  fVaclLire.  Tlia  head  was  carefully  examined  in  every  direc- 
ition;  but  no  fracture  could  be  found.  The  patient  exhibited 
■igns  of  concKPsion,  hat  none  of  compression,  of  the  braiji. 
Th<?re  was  no  vomiting,  no  dilatation  of  the  pupUs,  no  blec*!ing 
Irom  the  ear.  She  was  uneasy  and  restless,  like  a  poraon  under 
the  influence  of  spirit,  to  which,  and  o|iium,  her  symptoms  were 
tnaJnly  acmbuted.  She  gradually  iniproveJ,  and,  after  a  day 
^tor  two,  got  out  of  bed  to  search  tho  drawer  of  the  tabTe  for 
the  o|aum  which  had  been  tnken  out  of  her  pocket-  On  the 
tcTilli  day  after  the  injury,  whco  slie  seemed  much  better,  and 
anawercd  the  ijiiestions  of  the  nurse  coherently,  a  friend  mndo 
her  a  vinit,  and  brought  Jier  a  bit  of  opium.  The  same  night 
ahe  Hudilculy  iheil. 


TOE   HEAD, 


At  first,  it  wa*  very  natuiTillv  snpposetl  tliat  the  opujra  whicli 
elie  hail  taken  v^ns  tlie  cnufie  of  the  sudden  change  in  her  avmp- 
tomA ;  but  the  post-mortem  cxAminntion ,  made  by  Dr.  EUia,  re- 
vealed the  fallowing  very  acvcre  injuriea  of  the  jskull  and  brain: 

An  extensive  fra^tui'o  wns  found  nt  the  base  of  the  skulli 
on  the  right  aide,  passing  l>eh[nd  tlie  auditory  foramen,  atid  into 
the  for.inien  magnum ;  this  wtia  net  by  nnother  fracture  at 
right  angles  to  it.  On  raising  the  dura  mater  from  the  opposite 
aide  of  the  brain,  a  layer  of  blood  was  seen  spread  over  tbe 
whole  of  it;  and  the  middle  lobe  of  the  cerebrum  waa  mvet 
extensively  Iacerate<l. 

In  this  cn^,  nearly  ah  the  eyraptoms  scorned  to  be  ei^ilicn- 
ble  by  supposing  concussion  combined  witli  a.  state  of  delirium 
tremens,  eau^etl  by  the  constant  ui?e  of  nnrtotic-s;  and,  without 
an  examination  at^cr  <leatfi,  the  fatal  termination  would  have 
been  attributed  to  thia  cauec,  brought  on  by  the  shock  from 
the  falli  and  assisted  by  the  doee  of  opium  givca  to  her  that 


Cask  III,  —  Exicmive  Fmcinrc  of  thtBasc  of  the  Sknll^ 
and  of  ikti  Hones  of  the  I'^tffx.  Death  after  ten  hours.  J're- 
vioiie  Injun/  of  fli<^  Mtad,  with  proloitffed  l/ncoitsciirnttncaft*—^ 
A  gentleman  G8  years  of  age»  while  driving  a  young  horse»  and 
being  unable  lo  cimtrol  him,  was  eeen  to  jump  out  of  the  eJeigU 
in  which  he  was  riding,  still  holding  on  to  the  reins.  A  person 
aeized  the  hori^e  by  the  hcitd,  and  requested  the  gentleman  to  let 
go  the  reins,  whieh,  however,  he  either  could  not  or  would  not  do. 
The  horse  going  on,  he  wna  brouglit  up  violently  against  a  tree, 
striking'  the  side  of  his  head.  iVrtsistance  arriving,  he  gave  his 
name  and  residence,  was  taken  home,  a  distance  of  three  milce, 
all  the  time  making  violent  muscular  movca^ents.  Ho  lived 
twelve  hours,  dcprcd&ion  coming  on  very  suddenly.  The  cii'u- 
aion  of  blood  under  the  skin  of  the  face  waa  bo  great  as  wholly 
to  obliterate  his  features,  Blood  ran  freely,  also,  from  the  left 
ear. 

On  examination,  twelve  hours  siHcr  death,  it  waa  found  that 
the  whole  frii^nt  part  of  the  face  had  been  broken  away  from 
the  bones  of  the   head,  the  friu;turc  eiteuding  through  both 


I 


I 


orbits.  The  fracture  waa  fouud  Aho  to  f^tcnJ  tlirounrli  the 
botlj'  of  tlic  sphenoid,  nnd  amother  ihrougfj  the  lictroua  portiitn  of 
the  tcmporrJ  bono*  ao  thikt  a  probe  passed  freely  from  the  exter- 
md  amiitory  meutus  into  the  tavity  of  the  cranium.  The 
midiJIc  lobe  of  ihe  left  ^^crcbrsil  hemisphere  was  filled  with  co- 
agulated Llood.  The  amount  of  injury  was  greater  llian  I  have 
ever  witncsacil  in  a  cnec  of  fnieliirc  of  the  altLdl ;  yet  he  waa 
able  to  give  \xm  name  mid  addreaa,  and  lived  twelve  hourd  after 
the  receipt  of  the  injury. 

TliJ^a  i^entlemEia,  thirteen  montlie  before,  wa.a  knoeked  down 
by  a  sled,  striking  the  letl  eidc  of  hid  head,  imd  breaking  the 
k'ft  dnvicle  near  ita  outer  third,  witli  great  diriploecmcnt  ol' 
tJic  Irugmcnta,  Jlc  tcmuincil  in  a  partially  unconseioua  atAtC  for 
three  wccka,  and  ^vcndd  nut  euhniit  to  any  treatment  for  the  fruc- 
tored  bone-  Ilia  li.-\\.  le^r  he  moved  with  (hHieidCy,  either  from 
eome  blow  which  lie  hud  received  upon  it,  or,  aa  waa  supposed  at 
the  limC)  from  a  partial  paralyaid  dcpcmlont  on  the  blow  on  tlie 
iieod.  During  the  greater  part  of  this  time,  he  conipkined  of 
excessive  pain  in  the  head,  requiring  the  eon^tant  nae  of  coid 
opplicationBi  lie  finally  eomplcteJy  recovered,  without  appa- 
rent symptomd  of  having  sustained  any  severe  injury.  Aa 
AOOQ  as  he  would  allow  it,  ius  arm  was  kept  confined  hy 
biuid&gce,  hr  a  period  of  three  wccka.  At  the  present  exaininii^ 
tion,  we  were  naturally  desirous  of  invefltigating  the  cause  of  the 
extraordinarily  priilongccj  cerebral  aymptoma;  no  signn,  how- 
ever, could  be  discovcredi  oitlicr  of  old  Ihicturo  or  ol'  tliiekening 
of  the  doiii  mater  at  the  epot  where  the  blow  Imd  lieen  rceeivcd, 
fior  were  there  any  other  inarka  of  Uiscaao  in  the  iamiediatc 
investing  membi-ancs  of  the  brain.  The  only  appcanme^i  of 
disease  was  a  strong  adhesion  of  a  sm»ll  portion  of  the  right 
eidc  of  the  bnun  to  the  dura  niatcr,  bo  fxrui  that  a  part  of  die 
brain  Avns  torn  away  in  ee|jiinititig  it.  The  elaviele,  which  for 
three  wccka  had  had  no  treatment,  and  in  thct  had  been  vich 
ly  thrown  about  in  nil  dii-cctIon3,  had  tirmly  united,  and  wufi 
rAortenL-d  about  tlireo-fourtha  of  an  ineh,  hut  wilhout  any  pro- 
jecting angle,  —  a  good  commcotary  on  the  Bulwetjuent  neeeeaity 
for  using  complicated  bandages  in  the  treatment  of  these  in- 
juries. 


6 


THE  HEADi 


It  miL^  Ve  alaled,  tbat,  ju^t  LcFore  tlifi  rccei[)t  of  Eua  fatal  in- 
jury, lie  lofornied  mc  that  he  could  ecurcelj'  tell  on  nliich  «lde 
the  clavicle  had  been  fnictured,  rctuni  of  power  in  the  injured 
limb  havijig  been  so  com  pic  tt^. 


Case  IV,  —  Chtmhoi  Fracture  oftht  Occipkal  Bone  loilh-- 
mil  immediate  Srfinploms.  Denth  n/ier  iwcntn-Jtve  day 'i  from 
Ahvct^e  of  the  Ifratn.  —  Dr.  VVhcclcr,  of  Chelsea,  gave  me  an 
occipital  boDG,  with  a  fracture  throui-h  both  tables,  caused  hy  a 
MiuiiS  ball-  On  the  mner  aurfacewere  several  fraignieiita  TvliicL 
bul  been  driven  inwjtrda,  wilb  rough  eptculo;,  encroaching  nt 
Iccut  half  an  inch  on  the  cavitr  of  thcr  cranium;  on  the  outside 
was  an  indentation  corresponding  in  size  and  t^hape  to  die  flat- 
tenctl  ball.     He  also  sent  tlic  following  account  of  the  caae  :  — 

"A  captain,  3^  jcara  of  age,  iK'longing  to  the  Thirty-fifth 
llcginient  of  MaasaL^biisctta  Vohinlecre,  in  a  moTcment  ^ith 
the  Ninth  Army  Corpa,  on  the  Weldon  Ifailroad,  near  Peters- 
burg, Va.,  in  action  on  the  nineteenth  ilay  of  August  (1^64), 
received  a  wound  of  the  scalp  npon  the  back  of  tlic  hcid,  by  a 
ririe-hal]  ptriking  the  occipital  bone  near  the  apex,  and  juat  with- 
in the  lanibdijidal  euture  of  the  rigiit  aide-  The  immediate  efiect 
of  the  coaeuaaion  caused  luni  to  tail,  witli  a  momentary  faint- 
nesa  and  loss  of  his  eyesight ;  but  hia  coneciouencse  was  retained. 
In  a  few  momenta  he  was  able  to  get  up,  and  walked  to  the  rear, 
where  the  bidl  waa  picked  out  trgm  its  bed  under  the  ecalp< 
No  Bjniptoms  of  comprcaaloo  were  present,  no  fracture  wna 
then  euflpectcd,  and  the  injury  waa  recorded  na  a  Hcah  woundt 
He  waa  transferred  to  City  Point,  Va.,  and  from  thence  to  a 
general  Hospital  near  New-York  City,  wliere  be  remained,  very 
comfortablci  eomc  eight  or  ten  diiya.  He  waa  then  furlougbcd) 
and  arrived  home  fncnr  Boston)  <in  the  first  day  of  Soptciiiber 
folloiving.  lie  cumplaincd  but  little  of  hia  bead,  but  said  tiiat  it 
felt  heavy  at  times,  and  that  hli3  cycaight  was  not  quite  aa  good 
na  ueuoJ.  These  symptoms  did  not  confine  him  at  home:  be 
walked  out,  called  to  see  hia  friends,  and  alflO  attended  in 
person  to  some  business  matters,  The  wound  in  the  scalp  was 
suppurating  moJcrutely,  and  was  looking  well.  The  day  he  ar- 
rised  boue,  a  fissuro  and  depression  of  bone  were  didcovcittl  to 


I 


I 


TRGPTUKIKO  FOU  BPJ 


cxiat ;  but,  lis  no  Bjrn»ptoiiia  of  comprcseioE  or  cerehrul  diatLii-b- 
nacc  were  present,  it  waa  tboiight  that  surgio-al  Juterlereiicc  wua 
harjiy  called  fur.  But  abuut  the  7th  of  September,  or  aoEue 
cigbtccD  dnye  ofier  tlie  dutc  of  the  injury,  he  corapJaiacd  of  a 
chill,  wbirh  wjw  followed  by  fever  and  pain  in  the  back  of  ilio 
head :  nnd,  in  a  few  hours,  slij^ht  iklirium  canic  on.  The  de- 
lihumi  heat,  and  other  eyniptomfl  became  more  severe  from  day 
to  day,  iiQiJIy  ending:  in  i^rofoiind  toma,  with  slight  convul- 
eione.  He  died  on  the  15th  of  September,  jual  twenty-five 
days  after  the  injury." 

An  autopsy  uxhibitod  a  fracture  of  tlie  occipital  bone.  In 
addition  to  the  appcaraacca  meniioned  above,  ■*  the  dura  mnter 
gave  ei^s  of  active  in  fJ  a  tarnation  in  a  ciiTidar  apot  of  about 
Iwo  inehed  in  diameter.  It  wa&  not  lacerated,  wfl»  quite  dnik 
in  color,  nad  rftidily  aeparateil  from  the  bone.  Juftt  bcneiuh 
this  portiou  of  tlic  membriiQc  vfus  tbuad  a  wcll-flcfiucil  abacess, 
Containing  about  two  ounces  of  pus,  formed  ia  tlie  subatancc  of 
the  brain. 

"'The  history  of  this  case,  with  but  a  glance  at  the  bony 
fipecimcD,  will  at  once  euggest  the  tre|>hine  and  its  eady  use  aa 
the  beat  mcana  to  ward  oil'  inilammation  and  It^  coni]equenee«<" 

TKEPlIlX'iSa    FOR    EPa,EPSr, 

Case  V.  - —  Operf/titnts  on  th^  //eW  for  Epiltp^j  follo^c- 
it9ff  lujanj  iff  I  he  Skull.  Tr^p/tininff  for  an  old  Deprc^- 
non  cftuein^  Cotivalaioue  aiid  Idioctf^  — Thia  girl,  10  yenre 
of  age,  was  efruck  in  infancy  upon  the  hciul ;  and,  although  the 
corporeal  facultica  bad  dcveiope<l  normnlly.  there  had  been  little, 
ii"  any,  nianifeatation  of  iniclli*fcnce-  The  child  recognized  im- 
perfectly her  parcntrt  ;  was  a  voracious  eater  ;  eiceaaivcly  strong, 
vrild,  and  unnianageable,  at  times  so  violent  tliat  it  was  impoa- 
aible  to  restrain  her.  She  was  unable  to  articulate,  but  would 
frequently  nin  through  [he  houae,  uttering  a  kind  of  bowl,  and 
leaping  to  (he  diatauce  of  niauy  feet  like  a  wild  beoot.  She 
Wiia  al*o  eubjeet  to  the  moat  diatreeaing  convulaione.  Under 
tlicflc  cireum*taucca  she  was  brought  to  mOt  with  the  carncat 
rcqucGt  that  I  would  endeavor  to  do  flomcthlng  fur  her  relief. 


i^& 


B  THE  niUD. 

Un  examination,  there  wns  found,  extending  niToss  the  heaJ, 
jaat  behind  the  coronal  «iiture,  a  longitudinal  dei>re3tiion,  three 
to  four  jnchea  in  length  by  one  in  width.      I   suggested   to  the 
porcnlti — giving    them    ii>    f\i\ly    iinderfitfjnd    it^     djing<»r  —  tlw 
removal  of  tlie  depre9.«H3  porti<Jn,  na  the  only  reniLnly  whieh   oc*       , 
curred  to  mc-     This  being  eubniittt^fl  to  a  (consul tiatinii  of  thi9^| 
surgeons  oF  the  ITofipitnl,  it  wna  deternnncd  to  ndvise  it,  ^lon-  " 
aidering  ibe  despernte  nature  of  Clie  rase.      AVhon   brought  into 
the  arnphulti^uire,   the  piitient  rushed  in  with  her   head  down 
biirdly  re^trnine:!  hy  the  Jitrength  of  two  men.      After  she  h 
Leen  hroiigbt  under  tlie   inrtiiene*^  of  ether,  the  nci^es^^ary  inci 
ions  were   made    throngh    the   inlcgumenta,   the   hone  wms  eia 
through  wiih   two   iTowns   of   the   trephine,   unl   the  opening* 
joined  by  cutting  ont  the  intermcdiflip  pieee  with  n  Hey's  saw. 

For  the  first  &ijl   davfi  ^hc  did  well ;  but  died,  on  the  ninth, 
^om  a  bleeding  from  ihe  longitudinal  tsinu^i  whieh  ruptured  al\ 
Bfinie    Kudden   mid   \!olcot   miivcjueut   ni;bile   by   the   [inlient  in 
bed.      The  fiither  thought  there  was  nn  apprecinhle  ineiMPJise  of 
the  amount  of  intelligenee  after  the  operatitin  ;   nnd  it  wiL>i  ohv 
oUH  to  every  one,  tJuil  r*he  took  I'ognizani^e  of  pJiTSons  and  tliln 
about  her  in  a  way  she  h»Ld  never  done  before. 

I  p^irtly  attribute  tho  failure  of  tlitu  opcmtloti  to  my  folio 
ing  the  siiggestinn  of  a  bystander,   nnd  sewing  np  the  wouniI> 
instead  of  allowing  the  flap  to  i'all  down,  and  Jidliei-e  to  the  par 
beneatk     The  coneerjuence  was,  tbnt  pns  tolleeted  in  llic  cavi 
formed  hy  tlic  t^alp,  eaii^irig  derooipfiH^irJon   of  the  dura  ma 
wbieli  nKstHted  in  eroding  the  tcAtures  beneath. 


Case  Vl,  — T}^phiituig  fnr  Dt^jn^xttmn  of  the  SkuU  cum 
iutf  H^pihpfiif.  — J.  C.J  21  yearj^  i^  age,  apjjlicd  to  me,  Octi 
25i  lbJ)Oi  and  gave  ibe  following  aecnnnt  of  himself.  FouJ 
teen  years  before,  he  Lad  fallen  Againj^i  a  poet,  and  received 
flevere  blow  on  the  left  eide  of  hU  liciid.  His  ecaJii  was  cut 
ojx^Mf  but  tlicre  waa  no  pereeptible  fnieture  of  the  Hkul!.  ^Vith- 
iu  a  year  ailer  the  aeeldent,  he  waa  attaL'ked  with  epileptie  iits, 
to  which  he  waa  suhgetjuently  subject,  at  inlerTalti  of  one  or 
two  monllie>     The  attacks   were   fulUiweil  by  pain  and  drowal- 


iieM.      The  paiii   wua    felt  cliiedy   at  the  point  where   the  iu- 


THEPllJNO'O  FOK  TPTLET^T, 


9 


jiir/  waft  received,  and  also  over  ihe  rigJit  orbit-      IliB  memory 

ilVfbs   iiiipuircfl  j   be  was  erratic,   impetuous,  nntl  unniana^^cfiblc. 

I'be  bone,  at  llie  fcat  of  tLtr  mjurv,  apjicared  tljickedCil  aiid  ^n- 

Dtive.      FiuJiLig  that  lie   was   bctM>utLUg   n   burden   ti}  himaelf, 

iftiH]  in  iluiii^er  ul'  luoiiig  bis  iiilinl,  lie   iip|)lied  to  niu  tu  JK-Tfonu 

iJic  opcrulion   of   Irepl lining,   having   iiii'urmed   Ijimaelf   on  all 

IpomU  wtlb  regard  to  it.      Oct.   2fi,   1850,  bein-^  edieriaed, 

110  ACalp  *v^as  rtii^eil  hj  a  V-abaped  incision  over  the  injured 

pftTt;    aikd   a   trefjlunc,    oue   incb    !□    diameter,    was    applied 

over  ibc  suture  between  tlie  frontal  and  parietal  bones-     On 

trailing  tbe  bone,  the  frontal  wad  fuund  to   be  uiorc  than  three 
timcri  a»   thick  as  tlie  parietal.      A  t^imple  water  dressing  was 
applied  to  the  wound.     Oct*  27.  the  day  lljllowiug  the  o^jera- 
tion,  the  Hospital  record  Plates  that  be  had  severe  vomiting; 
lii*  pulac  was  ninety-six.      On  tlie  28lh,  be  complained  of  bcad- 
aclie,  but  had  eeme  sleep  through  the  night.     Tbe  next  week  or 
^ptwo,  be  bad  more  or  leas  pain  in  the  bead,  hut  graduaflj  im- 
proved.     Nov.  St^th,  he  seemed  quite  well*  and  the   inciaiop 
^_  made  bjr  Uie  operation  was  bcakd-     lie  remained   under  my 
^Bcogntzance   a   month   longer   and   was   iuially  discharged   Dec. 
24tl],  lumng  hod  no  epileptic  attack  during  the  two  months 
Umt  be  remained  in  the  lioapital ;  and  hLs  moral  and  physical 
condition  otherwise  matcriaJiy  unproved. 
^B      1  heard  from  biiu  some  months  aBerwards,  and  be  made  a 
good  report.     He  auhauquenlly,  however,  as  1  understood,  fell 
into  irregular  babit;^,  and  dieil  idtimately  "with  a  cereljrjil  attack. 


Case  Vn.  —  Optt-tdionfor  Depr^tfsion  oj"  the  ^kuU  cfzuffsd 

btf  a  rtd-kot  Pvktr  pa^dlnfj  cUroif(/h  the  liontiii  and  jKnetrat' 

inff  the  3raln.  — A  finc-luoking  yomig  man,  ^3J  yeara  of  age, 

Nova  Seotian  by  birth,  applied  to  me  in  December,  1S57,  on 

mat  of  severe  epileptic  fita,  canecd  by  a  depression  of  the 

from  an   injury  he  had  i^x^elved  three  yoara  before.      liis 

iftcXK^UAt  of  tho   circuuistuncc  was  thid :    He  wae    by  trade  a 

tsmiUi;  and,  while  enj,^aged  at  work,  phiyfuily  threw  soma 

[l-  at  a  fellow-workuiun  near  bim<      ThU  person  returned  it, 

by  throwing  at  him  a  red-hot  poker,  which  he  hod  in  his  hand. 

[The  p[>ker  atrudc  bim  on  the  frontal  boue,  Juat  above  the  orbit: 


10 


THE   HEAD. 


il  passed  tliroiigli  tlie  bone,  ami  catered  about  lliroe  irichoe  into 
t]ni  cerebral  flul.>9tanco.  He  inimediaLtely  aei^ced  the  iiistniiiient 
hinirielf,  and  drew  it  out  bj  mniD  forc^c.  Tliere  waa  but  ]ittJ« 
bleeding  fnirn  the  wounJ,  He  did  not  at  tbe  moment  become 
insensible  ;  but,  an  hour  afrerwiirde,  he  fell  into  ft  comiitoae 
state,  in  wlucli  he  remained  for  u  part  of  tUe  reat  of  llie  day- 
He  was  Ten-  earelully  attended  by  Dr.  Hooker,  of  East  Cftm- 
briJi^  ;  and  in  nbout  threo  lutmlhs  llie  wound  was  Kutficienlly 
well,  and  his  health  so  far  restored  od  to  allow  liiiu  to  reeuine 
hid  businesa. 

About  four  months  nfter  the  injuryT  he  was  seized  with  a 
severe  epileptic  convulsion ;  and  theee  attacks  have  followed 
pretty  regularly  since,  at  intervals  of  three  monthd.  He 
says  he  falls  very  suddenly  without  the  sli^litest  warning, 
and  somelitues  injures  him^lt^  severely.  He  lately  fell  bnck- 
wanls  u|>on  his  anvil,  etrikinij;  the  back  part  of  his  head,  and 
cutting  the  Ht-.alp,  behind  the  ear,  down  to  the  bone.  The 
conTulsionB,  of  late,  have  increased  in  fi'equenoy  ;  aud  be  feared 
lest  bia  mind  should  become  affected  by  tbem-  He  was  aldo 
apprehensive  that  he  might  some  day,  while  at  work,  fall  into 
the  fii'e»  nnd  burn  or  seriously  injure  hlmeelf.  Vmler  tlieec 
circumstanced,  both  lie  and  his  friends  were  very  urgent  to  have 
an  operation  performed. 

On  an  examination  of  his  head,  a  depressed  portion  of  ^kull, 
of  the  size  of  half  a  dollar,  was  found  just  over  the  ri^ht  internal 
angular  process,  partJy  iinplioating  the  fronlal  sinu^.  In  tlie 
centre  of  this  depression  the  skull  was  deficient,  nnd  a  ttiick 
Btrong  eientriK  indicated  the  point  at  whieh  the  dura  mater  Wiia 
adherent  Ut  the  lEitegumcnt.  The  pulsations  of  tlio  hriuu  were 
here  distinctly  visible. 

After  seeing  this  patient  onee  or  twiee,  and  carefully  investi- 
gating hi^  casCf  I  tiaidly  advised  an  opemtiDn,  fullj'  informing 
Lim  of  the  liazard  of  it.  He  entered  the  Hospital ;  and  the 
enrgeona,  in  consultation,  having  concurred  in  tlie  propriety  of 
my  opicion,  the  operation  was  jierfbrmed  on  Dec,  24t[i. 

The  principd  dit!ieulty  consisted  in  £xia<^  tbe  trephine  so  its 
to  make  it  lake  hold  of  the  akuU,  on  account  of  the  impossibility 
of  using  tbe  pin,  from  tlie  bony  deficicticy  in  the  centre  of  the  de- 


TnEPIIIMNa  FOR  EPILEPf 


11 


prcMion.  To  meet  this  difficulty,  a  bit  of  tblck  leather,  wliich 
Jiad  tM^en  prc™usly  prcpai-cd  with  a  hole  m  it  tt»  receive  tlic 
ircphine,  iras  fixed  to  tlic  head  ;  Imt  tliis,  iti  practice,  was  found 
&ot  to  &n«wcr  ite  intended  purpose.  Allcr  coumdcrable  labor^ 
the  trephine  was  maJc  to  take  hold  ;  and  the  rest  of  the  opoiii- 
tion  was  done  with  a  modcnite  degree  oF  fucilitj.  The  portioQ 
of  bone  reoiored  catirc  comprised  about  half  a  cirole;  the 
antcriur  part,  being  tliut  whieh  formed  the  roof  of  the  fri>ntnl 
einiLa,  came  a^ay  in  bits-  From  the  interior  of  the  portion 
removed,  a  sharp  apine  projected,  which  waa  imbetlded  in  the 
brain.  The  memhranca  of  the  brain,  where  they  penetnitcd 
the  boue  and  ndhcred  to  the  ecdp,  were  cftrcfully  separated  from 
their  attachment  to  the  bone  by  means  of  a  probe ;  being  at  oae 
point  30  exccaiivqly  thin  and  deJicate  aa  to  have  hardly  the 
coiisi&lency  of  blotting-paper.  Here  an  inevitable  tear  t^Jitk 
place,  with  the  esctipc  of  a  yery  minute  quantity  of  Limpid  iluid 
from  within.  This  was  Htc  only  unsalisfaotory  occurrence  m  the 
course  of  the  operation-  The  wound  waa  very  lightly  dressed, 
and  no  suturea   usedi 

In  the  aflemooD,  the  patient  was  sitting  up  in  bed,  quite 
bright,  and  aecmcd  ecarcejy  atlccted  by  the  operation.  On  the 
lollowing  day,  he  aa'id  he  wa&  doing  well,  otid  lind  pa^acd  a 
good  ciglitp  On  Uie  third  day,  he  was  not  so  well :  his  face 
wii£  tludhcd,  pulse  ninety,  akin  hot;  and  he  ficemcd  indi9{>oaed 
to  talk.  There  were  evident  aigna  of  inflammation  of  the  mcm- 
bnuiee  of  llic  bnun*  An  active  eatlinrtie  wae  adniinidicrcd»  and 
cold  applications  were  made  to  the  head*  On  Dec.  27th,  tho 
third  day  after  the  operation,  I  found  him  almost  inseneible ; 
pupils  ni>t  dilated ;  pulse  one  hundred  aud  nineteen.  Sistccn 
ounces  of  blood  were  taken  from  him-  The  symptoms  hod 
increased  in  wvetity  by  the  following  day ;  and,  in  the  course  of 
it,  lie  died* 

By  permission  of  his  frienda,  an  examination  of  the  body 
was  made  by  Dr.  Ellis,  on  the  day  uftcr  hie  decease.  The 
whole  surface  of  the  arachnoid,  on  the  eidc  affected,  waa  covered 
with  pU3 ;  and  eome  waa  found  underneath  that  membrauo.  At 
the  point  of  injury,  extending  two  inchca  into  tiic  brain,  there 
vTAd  an  orgnnizcd  clot  still  retaining  somewhat  of  its  color,  and 


12 


Tim  HEAD. 


ahowmj  distinctly  the  course  piiretied  hy  the  rerl-hot  iron  lliree 
yeara  before.  The  inner  siirfjioe  of  the  ekiill  waa  amooth;  Jiml 
ftdiicrent  to  the  edrrog  of  it  (where  it  hud  been  dLvidt;d  hy  ibe 
saw)  were  two  amall,  fljit^  ivoi-y-lookiag  pieces  of  bone,  alioui  the 
cite tL inference  of  n  pea.  These  bits  hod  prolwiblv  been  ori^jin- 
ally  detached  by  the  poker,  but  were  now  firmly  adherent  to 
the  bone, 

Hejuiti'Jcs. — In  view  of  the  ^ront  difficulty  of  fixing  the  treJ 
plitne  ill  tliie  operation,  it  occurred  to  me  afterwards,  whi-tfier 
iiny  other  pinn  could  have  offered  better  cbancea  for  despatch. 
The  only  one  which  siiprrrceleil  itself  wru  to  have  made  n  mini- 
ber  of  holea  around  tbe  circumferences  of  the  opcriiip-  in 
skull,  and  connect  these  differont  pcribrationa  by  a  fimal]  saw. 

The  non-sueeeea  of  the  operation  must  be  attributed  to  the 
porfonition  of  the  membranes,  nt  the  point  of  ihair  intiinnte 
connection  with  tbe  aperture  in  the  bone,  where  they  passed 
tlirongh  to  form  a,  union  ^vith  the  ficatp ;  and  this,  apparently, 
no  care  could  have  avoided. 


Case  Vm^  —  Case  of  Depression  of  the  Inter7\nl  Tahie 
the  Skiifl,  cattsin^  Epihpitjf.  —  M.  N.,  \^  yours  of  nj 
entered  tlie  Hospital  in  April,  1i*(>h'5,  for  the  purpose  of  havu 
an  o}>eratinn  done  for  trepbiniug  tho  ^kull,  on  aoeouDt  of  a 
pre^sion  cansinj^  epilepsy.  He  stated  thai,  eix  years  before,  he 
bad  been  kicked  in  the  hcail  by  n  horsc^  that  his  skull  bnd  been 
fractured  and  dcpresac*!,  and  that  he  had  been  unconscious  for 
BcvcraJ  weeka.  There  ia  eome  doubt  in  roi^rd  to  this  part  of 
his  account,  as  ho  was  seen  by  practised  surijconu,  and  no  opera- 
tion was  thouglit  necessary.  Ho  recovered  from  tbe  accident  in 
about  four  months,  and  returned  to  work.  He  remaEued  well 
until  March,  tf<6-t,  when  he  wii^  seized  with  an  epileptic  fit,  and 
rcmaiaed  uuconseious  for  fifteen  minutes.  He  hod  two  similur 
attacks  in  May,  one  in  December,  and  one  in  February,  1365. 
Since  the  1st  of  January,  1865,  he  had  miffered  from  general 
weakness,  lofla  of  appetJto,  tcndcrneaa  in  tbe  epigastrium  ;  hr* 
ej^eeeh  was  stuttering;  and  he  complained  of  a  constant  ticking 
sound  in  his  head.  An  examination  of  bis  head  disclosed  an 
L|>parent  extensive  depression  of  the  parietal  bone,  above  and 


FOH  EPTLEPBT, 


13 


tjchind  tlw!  left  cnr,  Althuugli  be  was  urgent  for  an  operation » 
and,  on  a  consultntion,  it  waa  Oeddecl  Uiat  an  operation  was  ap- 
pri^prmtc.  1  was  very  rcKictaiit  U>  proceed  to  it,  Jrom  the  great 
unccrtaiTitj  attending  openirions  for  trephining  in  tbcso  caeeei 
ami  tlici-eforc  decided  first  t<»  try  the  efiects  of  trcntmcnt- 

lie  was  kept-  quiet,  dieted,  hnd  a  scton  put  in  the  back  of 
Ma  neck,  and  took  ten  grainfl  of  bromide  of  potai^ftiiEm  twice  a 
day*  At  the  end  of  five  or  six  weckrt»  an  eslcnsi%'e  eruption 
of  oene  nppciircd  <»n  the  face,  nnd  tiie  bromide  was  Jiacontiniicil. 
He  retrained  in  the  Hoapital  three  wecka,  under  treatment, 
and,  during  tbat  time,  had  no  ronvtilsloiia ;  it  was  therefore  de- 
cided that  he  should  go  into  the  country  for  the  eummer.  and 
continue  the  treatment.  Throughout  the  eummcr,  he  had  but  a 
single  convulsion;  but  that  looted  an  hour  and  a  half.  He 
enlercl  the  HoJipital  again  in  January,  18IjC,  inflating  on  an 
0])oriition.  Since  hia  la^t  attack,  hia  eymptora^  h^ul  all  been 
aggravated;  his  liead  ''felt  nn  if  it  would  split  open,'*  and  he 
wafl  almoet  afraJd  to  lie  down,  on  account  of  the  flggi'avation 
of  thid  etcQ^alion  ;  the  ^tonmcli  waa  mucii  dieteuded  with  thitue, 
Kwl  he  had  naiieea  after  eating. 

'Ihc  sculp  having  bten  shaved,  the  vacuity  in  the  bones  be- 

uiore  evideut,  and  a  pulsalion  was  detected  a»  if  coining 

the  brain  ;  this  wne  not  constant,  but  naa  most  obaervi^ 

priacipally  when   he   roi^e  up  suddenly-      On  deep  preaaure,  a 

resistance  was  ivlti   aud  It  wtia  not  possible  to   savt  witli  Cer- 

itainty,  that  nuy  p;irt  uf  the  (^kull  wna  delieient  at  thic^  spot. 

The  potieiit,  having  heeu  properly  prepared  for  the  ojHjnitlon 
by  a  purpiiivc  the  day  befure,  and  taken  nothing  but  liquid  for 
brenkrafitt  was  etlieriKed.  A  circular  inciaioi],  describing  two- 
thirds  of  a  circlet  was  made  through  the  scalp,  with  the  con* 
fcrexity  t^xti^ndiiig  hthiw  tlte  depression  i  the  Hap,  being  diseected 
"  lip,  unciivered  a  space  about  three  inches  in  diameter.  It  was 
at  once  found,  on  raising  the  tla[j,  and  scraping  u|>  the  penos- 
Itenm  at  the  edge  of  the  depression,  lliat  the  bone  was  completely 
deficient  ai  that  point,  which  waa  dlled  up  with  the  [ueuibranes 
oftlie  Itraiu,  thnmgh  which  the  pulsations  of  tliat  organ  were 
'diatinctly  observed.  The  external  table  of  the  skull  tb'd  not  seem 
'depressed,  and  it  was  impossible  to  say  what  had  become  of  the 


11 


THE   HEAD. 


deScient  frjtgrierits.  A  email  quaDtitj  of  the  amcbnoid  fluid 
could  be  aeien  inckling  oui,  exactly  from  nbat  pc^fnt  could  not 
be  detected.  As  no  tre^luring  opemtion  gecmcd  iiidif:Ai€(I^  a.Dd 
as  it  was  impossJUe  to  proceed  williout  opening  ike  eorebnd 
coverin^H,  it  was  decidod  to  Jcsial  from  farthur  proeeedingSi 
The  tiap  wa8  aeoordingly  brought  down,  and  £j^cured  by  sutures. 
In  the  afceraoonf  he  had  recover»I  from  the  etbar,  expressed 
himself  relieved,  and  the  folJowing  day  wiua  in  a  TCry  entisfoc- 
tory  coiuiition.  On  tlie  2*5Ui  of  January,  two  days  after  tho 
operation,  he  be^n  to  be  confused  in  lib  mind :  his  utren^Lh 
seemed  to  fail,  ond  he  could  not  answer  queationa.  On  iho 
27th.  he  had  an  epileptic  fit,  lasting  half  sui  hour.  On  the  i'^lh. 
he  had  a  continued  bucccseIou  of  fitd;  the  left  pupil  w&s  dilatedf 
iLnd  the  urine  pn^^ttd  involunUirily ;  pulfic  one  hundred  and 
twenty ;  the  right  leg  waa  piiralyzed.  On  the  S'Jlh,  iie  died 
nbout  2J,   P.M. 

On  post-mortem  examination  of  the  head,  there  wo*  an  ex- 
tensive inilummatory  deposit  between  tlic  aruchnoid  and  pia 
mater;  tho  veins  of  tho  bntin,  on  tho  left  side,  were  grcntly 
engorged-  The  cftcctB  of  tho  accident  on  the  skull  were  re- 
marliiiljic :  fur  a  space  of  three  inches  or  more  beneath  the 
opening  in  the  sknU,  the  internal  tabic  wjis  depressed  nearly 
thrce-ijuorttra  of  an  ineh  below  the  level  of  tho  external  table, 
this  depression  extending  oft'  on  each  aide  for  some  distance; 
tho  dura  mnlcr  and  arachnoid  projected  throu^li  tliis  iiseure, 
and  were  attaehcd  around  the  margin  of  the  external  opening, 
which,  at  some  port^,  was  simply  Eilled  \nth  the  arachnoid  alone ; 
throngli  tliii,  at  one  [toint.  Wits  a  uuiintc  afKsrture,  cansed  very 
possibly  by  llic  Jisflcction  of  the  tealp,  which  hod  been  made  at 
the  time  of  the  operation.  From  the  condition  of  the  ekull,  no 
opcrationt  of  courae,  which  could  have  aflbrded  bini  relicFj  v^ould 
haye  been  practicable.  The  caec  is  an  inetaaec  of  tlie  entire 
unccrtuiuty  which  wo  must  be  pre])arcd  to  encounter  when  wo 
proceed  to  an  operation  of  this  description. 


INJURIES   OF 


15 


C/ura  Df  TrffiJiinirigJbrEjHifpBf  tuTHtrinifHt  the  Af'txtirfittMrtir  Grnftfil  If^mpiini. 


rn:tt. 

•ti. 

AQK- 

(■ACTBX. 

UEBtTLT- 

TtME, 

Fell.  31,  leaa 

P. 

ZB 

Dejircfiniriu  wlUa  Epilrpey 

Cored 

4  monibi 

Svpl.  Ift,  1M3 

u. 

la 

Eplltpay 

Tilefl 

s  w«t<kfi 

uaj  or,  lus 

M, 

94 

I>0pTi^iunD  wJIhKpHfpsy 

Cun-d 

flj  wi'tki. 

OvL  U,1«U 

H. 

31 

Epilepg^ 

RclM 

3  □ii>n(bB 

Dta.  1«,  leU 

F. 

SB 

Epilopv 

Curti 

Aj  jniiiitbH 

Ch-c.  14»  L0fi7 

U. 

%% 

Dtjirwislon  wlUi  Epfleimy 

Piud 

*  (ixya 

Aug.  U,  IfiM 

u. 

U 

EpllepBj'  af^  Kncture 

Iliad 

lOdifB 

Ju.   13, 1S61 

u. 

W 

£pilep9j  HltDr  Kn^turD 

Dit^ 

£f  wv«kB 

Ans-  01,  1603 

u. 

U 

iHprefibbu  wiili  K|filei»>- 

R^^l'd 

I  niH^ki 

JftH.  —  iet» 

IL 

31 

Dejircsflon  wilh  EiiLlejuy 

DkMl 

0  lUj't 

C^TFll I 

Died   -    .    -    .    .         G 

Wbulo  nuBiti^grcucB -...,.  Iff 


iNJUKIEa    OF    TTIE    RCAI-P, 

IHjc  fijilowiiig  aista  of  cxtfosive  laceration  of  Uie  siinlp,  witli 
rt  total  (Itmidnlian  of  llio  hoiicd  of  die  henil,   arc  rcix^i-tcil 
lowing:  liow  prmiiptlv  recovery  may   tjikc  pliice  atlcr  sudi 
linjunea,  cren  under  circumstances  eeeiiuiigly  moat  unfuvorfllile. 


I 


Cape  IX.  — A  boy  aged  12  was  knocked  over  by  a  wagoa, 
the  wheel  pnflaing  over  bie  head,  rcmovin^^  the  whole  eualp,  fixjiii 
the  top  oHiid  hcjwl,  comiijciicing  at  tlic  occiput,  and  carrying  it 
d^iwn  over  bis  cyca,  Wlien  I  sjtw  bim,  about  nn  hour  nFter- 
warJ*.  the  surf^ice  of  the  inverted  iiwilp  and  the  Jcnuded  ekull 
■were  etili  covered  with  dirt  aud  gravel,  iilthou^'h  n  partial  at- 
tempt bad  hccix  riiide  to  cicaji  it  by  wiishiugp  After  cleansing 
it  etill  fitrtbcr,  the  skin  wil^  roplaccd*  nnd  secured  by  a  great 
Dumber  of  auturca.  The  whole  united  by  the  first  intention, 
and  witb  ficarccly  any  Euppuration  or  dcformltyi 


le 


T>IE  tlFi:Al>. 


Cask  X.  —A  mnn  was  hmiiirht  into  the  Mftssn**hiiwt;Ia  Gen- 
eral Ho,Mpitnl,  iiml  i-^mc  unih^r  mv  cnre^  who  biul  fallen  fnmi  ilip 
tangUG  uf  hia  cart  wHIIb  unleep,  the  trout  fdre-wlioel  of  which 
hud  pik«si>d  iivt^r  l:is  heiid,  teAriti^  iitid  rolling  up  the  «nrire  acaJp, 
nnd  IpftTing  it  ;:overiny  his  fiua:- 

After  bein*r  llioruu^hly  cleaned  hy  having  warm  water 
Hijueezcd  ovor  it,  ant!  the  eponrpu  heing  u?ed  as  h'ttle  iia  possible, 
it  WEis  replaced  and  t^eciired  l)y  a  large  niLralier  ol'  aulurea. 

He  recovered  rapidly,  without  any  Muppuration,  aud  with 
sltnoBt  complete  union   by   the  firi^t  intendon- 

OOSCUSSION   OF   THE  BRA[N. 

Case  Xr.  ^Coanixition  nf  thfi  Uriiht,  with  roftJpfi^/c  J^cnf" 
9i€/is^  and  iiijiri'if  iif  Sea/ p.  ^  A  gendeman  GO  y^nrs  old  wa* 
thrown  frcnn  a  chalae,  in  JiEoe,  1861 ,  striking  his  head ,  tearing 
the  &c\il]t  Hhiui&t  coitjpliftdy  off'^  ani1  prmliiring  a  ojinciission  of  the 
brain,  nnder  whirh  he  remained  in-ii^neiblo  one  or  two  weeks.  He 
wan  aftenvards  irirnnried  by  liid  medieid  aittendant,  thiit  there 
had  been  some  blewling  from  the  ears.  The  aealp  was  re|iliiced, 
and  nnii.ed  perlet-tly  Jn  afnnLt  two  montlw.  He  ha^  nerer  l>een 
nh\e  to  lieiir  tlie  Hliglite.HL  sitiind  Hinou.  lie  speaks  well,  how- 
ever, and  with  a  good  intonation  of  voice.  He  is  a  clergyman, 
and  is  able  lo  preach. 

In  February,  IHCrZ,  he  applied  to  me  for  advice-  On  exam- 
ining the  ears,  tlie  drum  of  the  right  one  wils  foand  to  be 
uninjured  ;  the  left  waw  piHumteil,  aod  red  and  fle.flliy  in  sippcftr- 
atice^  with  a  jiundeiit  di^ehjir^re  from  its  sorfliee.  1  intiirmod 
him,  that  bin  little  bn^nefu  was  to  be  expected  from  treatment. 


Case  XII.  —  The  following  ease  of  eoncussien  ia  on  instance 
of  severe  eymptonia  coming  on  a  week  after  the  injnry;  show- 
ing the  iniportaii^^B  of  care  in  the  rannagement  of  persona  who 
have  received  severe  hlows  on  the  haul,  though  in*  symptoms, 
for  the  momeht,  are  preaont  :  — 

A  nmn  agol  35  waa  bnjught  to  the  Hospital,  April  9,  1804, 
having  had,  tho  diiy  liefore,  slight  convulsions,  drowsineaa, 
and   an   unwilliagnej^rt  to  talk.      A  week  before,  he  had   fallen 


COXOTTBSTOX  OF   TRE   fiRAlN. 


17 


I 


out  of  bia  wagrm,  strikintr  liia  liciul  on  llip  pin'fiment.  For 
eix  flays  no  iin^oEivenieucf  foUuwral  llic  HwHeiil,  nnd  be  iliil 
hb  work  as  u.sual.  lie  \^'jtlkt!d  i'n>iii  his  1ji>eu(c  tu  tlit^  lluf»|)i(al 
with  the  Msifltance  of  Ms  wife.  Hi*  apjiwinince  wa*  sleepj. 
He  compliuiieil  of  jiain  in  tfie  Imck  of  liLs  hcail,  where  an  eleva- 
tJoa  of  the  cranium  was  fi^lt,  wliicfi  might  be  normal, —  nil  un- 
usual (Ieveio|im(.'nt  of  tUc  uoui[>iNhl  protuberance.  Pressure  upon 
this  part  cuu^Lil  liiui  to  tluxjw  \i\s  ar[iiJi  Eibout,  and  coriipliLui  of 
pain.     lli&  pu|jiU  were  roiitrai^U-^I ;  ptilse  Ad\\\ 

April  lOtli,  lip  was  lying  on  his  bai:k,  with  hts  eyes  eloscil, 
nia  pupiiti  were  contracteil,  und  the  urine  was  pu^aed  involunta- 
tHy.  He  wju  ordered  li  dor^,  len  graini^  eachf  of  cidomel  wud 
jalap.  On  ilie  1 1  th,  ihi-  UHfilidnc  hiul  o[H'rsitwl  freely  ;  he  waa 
mure  sensible,  and  nnsweretl  questionti ;  urine  as  before*  On  the 
12th.  he  was  again  dnin^y.  and  eould  not  l>e  roused  to  uiij^wer 
qu<!aLiuii^  ;  juJse  iilij-lwo,  f^iiiall.  Aiiril  l<lth,  still  di'onaj. 
He  vfjis  imlen*il  nn  lnjci:tiun  of  weak  miiMartl  and  witter,  ami  ii 
Mislcr  u|iplieil  tn  the  hiiek  of  hw  neck,  April  14ib,  wind  he  felt 
&  gn-at  deal  hetUir,  April  ^3d,  he  was  aumcwbat  stupid  ;  pain 
iu  hi^  head;  piiUe  ftixty-^ix.  On  the  28th,  he  vta^A  up  loid 
dresaed-  and  Ins  iniinl  wiw  dearer,  aiid  s[M"4"ch  was  inuth  im- 
proved.     A[iril  2Dlh,  he  was  dischargi?d, — well. 


CHAPTER    IL 
THE    FACE, 

KniNOl*LASTIC      OPERATIONS, 

The  operation  of  rittnopksty  is  of  very  ancient  date.  It  hnd, 
however,  for  various  reaaon&TfuUen  into  moat  unmerited  diercpute 
until  between  tliirty  and  forty  yeara  eince,  when  it  waa  revivwl 
in  Europe  by  Grsicfe,  Dieffenba^ch,  and  Labat  on  the  continent, 
and  Liston  in  Great  Britain. 

In  the  ancient  operations  of  thia  kind,  the  lost  organ  wn* 
reBtore<I  at  the  expense  of  the  inte^njentfl  in  ite  immediate 
neighborhood.  Advantage  Iwing  taken  of  the  extensibility  of 
the  skin  of  the  clieeks,  the  integuments  were  diaeected  up  on 
both  sides  of  the  nasal  fos^a,  brought  forward,  and  united  in 
the  centre  by  points  of  tlie  interrupted  auture.  If  the  extensi- 
bility of  Clie  integuments  was  not  sufficiently  great,  tnciaions 
were  mode  in  front  of  the  cars,  so  as  to  diminish  the  tension  of 
the  ekin ;  the  wotmds  thus  made  were  afterwards  allowed  to 
fill  up  by  granulation.  This  opern.tion,  however,  did  not  restore 
the  form  of  the  lost  organ  ;  and  the  only  advantage  gained  was 
a  flap  of  skin  to  eover  the  existing  deformity-  The  operation, 
which  was  afterwards  adapted,  and  whicli  now  bears  the  name 
of  the  author,  was  that  of  Taliacutius.  In  this  operation,  it  was 
required  that  the  arm  should  be  conflncd  in  contact  with  the 
face  for  ten  or  fifteen  days,  or  until  union  had  taken  place. 
The  disadvantages  of  this  metliod  ui'c  at  once  manifest :  the 
length  of  time  during  whieh  it  was  necessary  to  keep  the  limb 
in  this  painful  condition,  sufficient  in  some  eases  to  produce 
partial  |)anilyeis,  and  the  danger  that  ensued  in  the  too  early 
separation  of  tlic  transplanted  skin  from  its  source  of  nutrition^ 
were,  of  tliemselves,  reasons  of  sufHcicnt  weight  to  cause  it  to 
fail  into  disuse. 


i|ienilii>n  whirh  lias  nttnincii  the  mo?t  cdcbrity*  imd 
wliioh  has  bctn  muet  trcfjucntl}'  practiced  in  Fraucc  onii  Kng- 
laml,  U  iLat  whidi  p^ocs  bv  the  nitme  of  the  Indian  method^  iu 
whioh  the  Hap  ia  taken  from  the  forehead* 

It  wFia  niy  poud  fortune  to  witness  a  vcvy  Inrgc  number  of 
pperatioiLB  by  the  Indian  method  by  the  dislinguiehcd  M.  i>ief- 
fi^nbach,  of  Berlin,  at  the  time  of  hie  visit  to  Paris  m  1*434» 

Soon  after  my  return  home,  I  had  an  oyiportunity  of  |>eH'ui"m- 
ing  sevend  oporations  for  the  restoration  of  the  noae;  em- 
ployingf  in  one  case,  the  Tahiictitian  or  Italian  method  ;  and,  in 
nuother  ease,  taking  the  rcffuieile  material  from  the  fore-arm. 
The  Indian  metliod  I  have  very  frequently  employed  ;  in  uioet 
ra^es,  with  cxcdlont  rc^ulta.  The  ^eur  loft  on  the  forehend  is 
much  Jewa  conspienonH  ihan  might  he  cxpeetcd,  and  the  great 
eurtiirin-r  to  the  ^mtient  whieh  results  from  the  confinement  of  the 
nrni  to  the  head  in  the  It^itian  method  ih  nvoide<l.  The  principal 
jneonvenienee  wliieh  I  have  observed  in  theae  operationt^  dc])en<lfl 
iij»un  tlie  faet,  that  the  material  for  the  ecptmn*  and  often  for  the 
lip  of  the  nose,  mn^t  be  taken  from  the  sonlp.  The  conaei^iienec 
is,  tliat  the  hair  tiontiaues  to  grow  upon  these  parts  j  requiring 
frcfjocni  *liavia;;j,  or  t'straetion  with  fuivepe.  DepUutoriea  1 
have  often  tried,  but  Imvc  never  found  that  tbcy  produce  mote 
than  a  transient  eETcet. 

The  Ibllowinp;  and  some  of  the  Huceeetlin^  eaECa  are  tlic  first 
performed  in  Ameriea  with  eiicce**^  anil  probably  p;iive  the  im- 
pctiiA  to  the  inlruduetion  of  tliis  ela^fi  of  operations.  The 
Taliucotiuu  operation,  a«  performed  by  the  diEcovercr,  of  trnufl- 
planlin;^  a  portion  of  the  akin  from  another  part  of  the  bijJy, 
had  DOl  been  ndo|ited  by  modern  European  surgeons  j  so  that 
the  cneea  of  thnt  (jperation  mentioned  below  were  probably  the 
t^nly  oncd  thnC  had  been  succcutifully  done  for  a,  number  of 
jcara:  — 


Cakk  XIII.  —  Rhinoplaatic  Op^rttt'tmu — A  young  man. 
2#1  yeare  of  age,  in  the  aprin^  of  1B34  received  a  blow  on  the 
noac,  whieh  dialoeated  the  cartilage  to  the  left  eide-  Thld  was 
tiillowetJ  hy  l>rief  influnmiatory  action.  As  be  was  out  of  town, 
find  at  a  dUtnnee  from  medieal  adviee^  nolhing  wa^i  done  to  re- 
place die  eurtilageT  which  remained  permanently  displaced. 


20 


THE    FACE. 


In  the  fallowing  spring,  a   reJ   spiit   apjienred  nn   Llie  ngli 
cheek   below   tlie  eye,  which   very  floon  increaHt^l  in   size;   ihe 
i  II  fla  Hit  nation  gradually  apread,  ntta<:k«l   ihc  lip,   and  llien  L"i- 
tcnileil  ta   the   ncBe.   which    became    reJ,   t^wulicn,   mid   fiii;Lli^^ 
ulcerutcdi  ^^ 

It  will  be  iiTiiiccesBnry  to  go  further  into  the  dctniU  of  tlie 
cnee :  ii  U  EUJfivient  to  euy,   thut,   h\   ihc  (bourse  of  ei<rhtcen 

montlis,    all     the 
textiiren     of    '^^| 
nose  were  piircee- 
aively      attacket 
and     fiunlly 
jstro^ed*      Sul 
r|uently,     cjcal 
zatLui]  took  ph 
leaving    the 
tient  in  tlu;  btute 
'  '&>*  in    whiuh    I    8ILW 

liim,  fiix  mom 
lifter  his  recnvi 
I'roin  the  disease, 

At  I  hid  [lenj 
h  living  aocideni 
eoino  aercsa  n  dc* 
^cription    of    tJie 
Tulincotifin  oper- 
iiliiin    in    nn    old 
mngnzinci  he  wua 
dcBiroufl  of  know- 
ing whether  nny  Mng  ol  J\  aiiiiilar  kind  could  he  done  to  remedj' 
hia  frightful  deformity.     The  fL»ll*>wing  was  his  ^tatc  as  ho  a 
pcnrcd  on  the  fii-al  examination  :  — 

The  noBc,  aa  already  etntcd,  was  completely  destroyed,  lea 
ing  in  the  place  it  ori^rinally  occupied  an  opening  about  tin  inch 
in  diameter,  bordered  hy  n  firm  eieutriec ;  the  eeptiim  o\  the 
noatrila  was  gone,  ond  the  two  na«al  cavities  thrown  into  one; 
externally  n  Finall  ciealrix  de^^ccndcd  from  the  lower  and  left 
cd^  of  thid  opening  to  the  angle  of  the  moutli.     Jo  the  eourao 


t 


] 


KHIXO PLASTIC   OPfillATIONS. 


21 


of  tho  disease  llie  futir  front  tenth  bnd  boon  lost,  whtdi,  to- 
gether with  the  abfiorplion  of  tho  alveolar  protJeBSPs,  hndciiused 
the  upper  li[j  to  *ick  much  below  the  level  oi'  the  lower 
one-  An  openbjj  exiitod  betwten  the  lip  und  upper  jew, 
through  wliich  n  probe  mii;ht  be  pnfi^scd  from  the  rnoutii  into  tho 
niitful  eaviiies.  The  ecnee  of  emdl  wae  quite  lust ;  und  ho  was 
Bubject  !i>  a  How  of  learB  over  tlie  fuce,  nrisin*;  undauhtodlj  ft"om 
the  too  t^ndden  conlaet  of  tlic  jiir  with  the  liiehrymal  ducts. 

A  lburou<^h  c^uniitiEitJon  of  Ula  vaac  having  been  made,  and 
findifi^r  thero  was  no  obstacle  to  the  poi^eibility  of  a  fiuocceaful 
opemtjon,  ita  diflioullioa  were  distinctly  stated  to  him,  —  the  im- 
prubftbility  of  its  eiicceedinp;  so  f\s  to  restore  the  organ  in  Bueh  a 
luimner  ihut  the  dcn^rmity  ebould  not  bu  knciwn;  that  the  new 
nose  luiglit  beeoQie  very  mueh  fattened,  nnd,  jierhups,  on  the 
np|icarunce  of  cold  weather,  ^in^cnc  nu^ht  take  pincc  ;  and, 
findly,  that  even  h'v^  life  ini^'hc  be  endan^^ered  by  It.  I  felt  it 
■■-inydtity  to  «tatc  tbc  i^se  plainly,  having  Been  all  these  accidents 
iKt'iir  (ihruad  from  lijc  operation ;  in  two  enbes  death  bein^  the 
eoii*ci|Heiiee,  from  severe  erypipdatoufl  inflammation  i?f  tljc 
ecalp. 

»      Notwithstanding  nil  tliceo  objections,  be  decided  to  Ttinir  any 
rif>k  wlii^'h  ivould  give  btLii  the  ten^t  chance  of  baviti^'  the  tletor- 
inity  uuder  whieh  be  labored  obnutcd.     It  was  thoui^^ht  exjx;- 
dient  to  delay  tho  operation  a  few  wocksf  in  order  to  prepare 
bim  by  a  courac  of  diet  and  regimen.      At  the  end  of  six  wcektf, 
IIS  ho  utiU  persisted  in  the  determination  of  having  it  pertornie:!, 
■  prtptirationa  were  made  to  do  it  at  once,  eiace,  on  account  of 
Hthe  approach  of  cold  weather,  no  lime  was  to  be  sj>art'c!, 
H      The  prcpanitione  having  hiien  nuvde,  the  operation  waa  pcr- 
Bformed   on   the    Ttb    of   September,      A   piece   of  paBtebonrd, 
cnt  in  the  shape  of  ihe  letter  V,  that  ie,  of  a  triiingular  form, 
and  with  n  projection  from  its  base  convepomlJiig;  to  the  columm* 
<if  the  nose,  w/is  pineed  U|>on  the  forehead,  and  a  truce  made 
li[\>i]nd  it  vrilJi  the  nilrale  of  silver,  which  was  used  in  pi"efercncc 
lit  ink.  a»  rceonimcaded  by  Lififmnc,  in  onler  that  it   might  net 
lie  eflaced  bv  the  hlood,      A  ti-aec  wod  al^Kj   made  around  ihe 
'p|ien]n^  of  the  atisnl  fo^iaa,  at  the  points  whore  it  would  be 
.'tii'ccsaary  to  remove  the  integnineiits  lor  planting  the  new  ekiii 


22 


TllE    KACE. 


taken  frrjiTi  tlif*  roroho;»i.U  Tliis  wns  done  on  llie  nij^lit  prevmua, 
in  f'rder  to  prevent  anj  undue  delay  on  the  day  of  tlie  ope- 
mtion- 

All  iinnert'ssiiry  nrlidea  of  clothing  hflving  been  i^crinved »  the 
|ia(ipnt  «'iis  pliirwT  on  ii  table  in  a  recnmljont  position,  biw  lace 
towards  tlio  windtiW^  nnd  tlio  operator  behind,  so  as  In  havp  the 
full  cominnnd  of  the  hend.  The  traces  made  hy  the  nitrate  of 
silver  were  about  tu'o-thirds  nf  an  incli  apart  between  the  eye- 
bruw«  ;  oacii  ^ide  of  tlie  trian^idar  portion  jf  skin  was  three 
itichea  and  a  quarter  in  length,  with  ft  base  of  three  and  a  lirdf 
int^lies ;  and  the  projeetion  for  the  t'clumnn  of  the  nosp,  whieh 
was  to  be  taken  entirely  from  tlie  sealp,  previously  shaved,  was 
Hn  inch  and  a  half  lun^,  and  two-tliirds  of  no  ineh  wide. 

The  bond  t>eing  finnly  sujtporied  by  two  assistnats,  the  in- 
cision waH  c'oniinenced  hetwoen  the  eyebrowrt^  and  the  flap  of 
j^kin  dl^^-'eeted  uji  srt  as  to  isolate  it  entirely  from  the  skin 
of  the  forcheiid,  except  where,  for  the  pnrpoae  of  nutritionj  it 
w!iw  left  adl^crent  ait  rlie  ro<it  of  the  nose.  The  incision  on  the 
leW  ^hXq,  Iwtvveen  tbo  evelirows,  was  extended  a  little  fiirtber 
down  than  on  the  ri^ht^  lo  faeilitate  the  twisting  of  the  flap. 
Tliin  ineliLded  the  skin,  f^nlx'ntimeous  eelhilar  tin^ue^  and  n  por- 
tion of  ihe  oei;ipito-fronlidls  iuu>iele  ;  eare  Itoing  tukeri  not  tu 
raise  the  perinsieum,  from  fear  of  neerosis,  i 

Thi?  flip  tluis  diiijierted,  and  twisted  round  to  the  left,  side,  wa^ 
Ciarefidiv  wrajijted  in  a  compress  uf  linen  ekifh  ;  and,  before  tJie 
operation  wn^  proceeded  w]th^  attention  wiis  given  to  diminisb*. 
ing  the  liirge  wonnd  made  in  the  sealp.  Little  hrmorrbai^a  had 
trtken  pbiee ;  and  the  leinpora!  nrteHes^  which  had  been  cut,  very 
aonn  T-erracted,  :md  eejised  bleeding.  The  anirles  jf  tlie  tvoutid 
were  firat  broii^dit  together  by  the  twisted  suture,  two  pins  being 
emptoyp^l  on  eiihcr  Ji^ide.  Its  etlges  between  the  eyebrows  were 
i;]mi>  approxinniied  in  a  similar  manner  :  by  this  nLeana  the  wound 
in  the  forchejul  was  dlminisbed  tit  once  to  l&ss  than  half  its  origi* 
n;d  hixe ;  it  wa.**  still  further  rediieed  by  the  nue  of  a  few  strijw  of 
ndbeHive  plaster,  and  ji  tittle  serapeil  lint  lilled  np  the  remainder 
*if  the  wound.  Lint  spread  witli  cerate  waj^  npplied  over  the 
whole  mirfiu'e,  a  compress,  and  tlie  whole  i^eeured  by  a  bandnge 
tiiiind  the  head. 


RH1V0PI>ASTIC    OPERATlOSfi- 


23 


Tho  upkI  object,  wae  to  fix  the  bon-owed  nkin  m  its  plnoc.  In 
|<trdcr  to  do  i\ii&t  it  was  iicoc^EAry  to  1'rc:^hcTi  tiie  bur^Icrs  uround 
[tlie  D[>€D:n^  of  the  uatia\  Iobbh,  the  tmcoa  oi  whichf  oa  etated 
above,  liad  been  previously  mncle  with  nitrate  of  silver.  For 
ll»ia  purpoacr.  n  ebort  narrow  knifo^  soniowlmt  ^imUiu'  to  a  cntanict 
krufo,  was  used,  and  a  utrip  of  iiitopninicnt,  a  third  of  nu  inch  in 
broadlh,  removodf  mdudin^  all  tbnt  portion  wbieli  hod  huGH 
Itidiirutdl  durin*;  the  ckMtrizaliaii  of  the  ulwnitioiis.  Th<^  knitc 
^as  jdso  jmsricd  between  the  iiji  and  ii|pptt  jaw,  m  which  exist- 
ed, as  before  fitalod,  an  opening  Inrgc  enough  to  paes  a  probe; 
and  tJie  adhesions  botween  tho  two^  fur  the  epat^e  of  nn  inoh, 
eaiircly  cut  away.  Thia  was  done  for  the  double  purpose  of 
Igiving  the  colunina  of  the  nose  a  more  deep  and  ^rm  adhc>:iiori, 
[«nd,  in  the  intlnniiLintioD  whioJi  would  t^ubscqu cully  ensue,  to 
up  the  unnatural  eommunieatlon  between  the  mouth  and 
cavity. 
The  1!ap  vfHA  now  brought  down  into  its  place,  itii  ODi^les  a 
little  rounded  with  the  scisaora,  the  hotter  to  r^iinuhitc  ilie  ulu* 
of  the  no8o»  und  the  wholu  secured  iji  itti  plnee  by  pjn^i,  nud 
iinta  of  tho  interrupted  suture.  ITrom  that  portion  of  the  akin 
■which  was  to  foriu  the  coluuma  of  tho  noae,  the  cpidermk-  side 
ivins  pared,  ao  that  it  nilglit  form  nn  adheaiou,  not  only  uuder- 
[jieiLth  to  the  jaw»  but  on  its  sides,  to  the  quudran^^ular  wound 
Lade  for  it  iu  the  upper  lip. 
Scraptil  lint  wii^  now  plaf^cd  under  the  ends  of  the  pina,  and 
*  rtrip  of  oiIe<l  Unt  introduced  inti>  each  nostril^  to  prevent 
odhceioD  ;  another  strip  was  placed  upon  the  nodc  to  prcacrve  its 
lemporalurc.  The  drcaaiui^f*  were  aocured  by  a  band  of  adhesive 
plaater,  Hxed  to  the  foreiieiKl  above,  and  pai-tialty  divided  in  the 
middle,  eo  that  it  nil^dit  descend  on  each  eido  of  tho  nose  to 
■  the  lip. 

H  During  tlic  whole  of  thia  long  and  painfid  operation,  the  pa- 
H  tient  kept  up  hU  eoura^'e,  and  nut  a  cry  was  uttered,  nor  the 
BlcaAt  etru^'gle  made  that  could  at  all  impede  the  motiona  of  the 
oj>cralor.  Not  much  blood  was  loat,  and  hia  strength  waa  ao 
Uttie  exhausted  that  he  wue  able  to  run  up  atau"a  to  bia  chamber. 
He  waa  ordered  to  go  to  bed  nnmediutely,  to  keep  perfectly 
quiet,  nud  a  watcher  IcH  witli  hiDa^  who  hod  dircotione,  iu  cose 


n 


THE    FAHE. 


of  hia  fiiUin^  nsWp,  to  prevent  liirn  fr*im  either  rullin;^  over 
his  eide,  or  r.iiaing  his  hand  to  the  tioae.  so  as  to  derange  the 
dressing;  nlao,  to  woke  him  imnictllntely  ^houh)  he  broathe 
through  the  nose.  To  have  arrow-root,  or  gruel  rmd  leiaoujiJe, 
for  nourishment. 

On  visiting  him  in  the  aflenioon,  he  wns  found  comforlJible ; 
the  new  nose  wns  wflrm,  and  hfid  hied  a  little  from  the  edges 
whioh  formed  the  nostrils,  both  ahowing  that  the  circulatioa  wm 
not  at  flll  impedetl. 

Sept,  10th.  Passed  a  good  nif^hl,  elept  wt^ll,  pulae  eeventj- 
nincT  Odmpkinfl  of  no  pain ;  the  no^e  of  about  the  nntiiral  lem- 
periiture,  A  pier>e  of  cork  waa  confined  between  the  leetb,  so  as 
to  keep  the  mouth  o|>en ,  and  prevent  him  from  hrenthinp;  through 
llie  uosG  during  sleep.  The  introduction  of  the  eork  prov^ 
BucecasfuL 

12ih,  The  first  dressing  took  pince  four  dnv^  nfter  the  opera* 
tlon,  nnd  t!io  folkiwinp;  was  found  to  be  the  state  af  the  pat<t«  :  — 

The  dres«ing^  on  the  forehead,  after  being  well  soaked,  were 
firfll  ronioved.  The  angles  of  the  wound  were  found  to  Uhtc 
united  throughout,  so  that  two  of  the  pins  were  at  once  dis^wnsed 
with.  Union  had  also  taken  place  in  iini  liiwer  part,  just  above 
and  between  the  eyebrowa  :  tlie  rcmiiuJor  of  llie  wound,  thai  is. 
ita  centrfil  part,  in  which  union  by  the  first  intention  could  not 
take  place,  was  suppuriiting  well,  nnd  filled  with  healthy  granu- 
lations- 

Upon  reinovuig  tlic  lint  from  the  nose,  it  waa  found  that  en* 
tire  union  hnd  taken  place  on  botli  ^idea.  The  alx  and  the  lower 
cdgei4  could  Tiot  easily  he  seen  without  niaklng  use  of  too  much 
violence.  The  oohimnn  was  curved  inwEirtls,  and  the  eiitures 
concealed.  The  nose  was  of  the  natural  color  and  temperature, 
und  (be  circulation  through  it  seemed  uninterrupted. 

Two  strips  of  lint,  dipped  in  oil,  were  laid  over  the  cicatrix 
on  each  etde  of  the  noae,  and  no  other  dressings  uaed.  The 
patient  was  altowe^l  to  alt  up  a  little,  and  to  take  any  article  of 
lic|Tiid  food  lie  might  fancy. 

On  tbe  13tli  he  was  quite  as  well,  with  the  exception  of  a 
little  (edema  of  the  upper  eyelids,  arising,  undoubtedly,  from  the 
prcflsure  of  the  bandages  and  other  drcasinga  on  the  forebeatL 


RBn^OPLASnO   OPERATIOXB. 


S5 


I 


One  of  flic  pins  was  removed  from  the  forehead  on  the  15th; 
and  nnotbor,  the  only  reniainlng  odCi  on  the  tbllomn^  day. 
The  doeailfi  of  lint  which  hud  hoaa  pkocd  in  the  nostrih  still 
remaintHl  th^^re.  £riii]y  caked  in,  Theiic  were  not  removed  until 
the  ItJth,  when  ihcir  places  were  supplied  by  two  pieces  of  hol- 
low eouod> 

On  the  14ib*  »  quantity  of  hair  began  to  appear  on  that  por- 
tion of  the  dlun  forming  the  coJumna  of  the  noec,  whieh,  &om 
time  tu  timCf  re- 
quired lo  be  re- 
moved. He  vvae 
put  upon  a  nour- 
ishbg  dict>  Willi 
tJic  caution  tou«e 
the  jaws  aa  little 
as  pofiHiblc,  lie 
itated  that  occjt- 
ftionally*  when  be 
Dwtkllowcd,  he  had 
»  flcnaation  bb 
though  iie  would 
■*  swallow  hi?' 
nW." 

16lh.    The  re- 

fcwoycd  l'n>ni  llii 
e  of  the  noee. 
•nd    the  two   eu* 
nw  wliich  Cun- 
the    aIid  ; 

thI  on  ibe  17th,  ten  i]xyH  .iftor  tlie  i>|ientlion,  ihtj  two  ligatured 

diioh  cuiiHneti  tlic  coluiona  in  [(«  plact  were  alfio  removed. 

At  tliifl  [>eriod.  tiie  ^tJlte  of  ihc  parts  waa  aa  follows  ;  Tlie 

ound  in  the  forehead  had  diminished  to  a  thiiJ  it£  oiiginal  size  ; 

nd   the   Bznall  triangular  epaec  which  re»iained*  together  with 

at  portion  of  the   si^ilp   from  which   the  colunma  of  tlie  noeu 

hml  l>ecn  taken,   wae   ftUed   with   litiidlhy  grauulatioiifl.      From 

ihc  wound  to  die  root  of  the  noee  waa  a  linear  cicatrix  nearly 


S6 


THE   PACH, 


two  jnchee  in  Iciif^h,  nnd  continuoua  wilh  the  ci^-ntruc  on  the  Ii 
eido.  Adiiceion  of  tbc  intcguinent^  liad  taken  \Aace  on  botb 
sides  of  the  noao :  at  the  ri<rl»t  nlii,  however,  the  union  ww 
not  quite  eo  perfect  »ts  at  the  left;  that  ia  to  say,  the  whole 
thickncas  ctf  the  ekm  did  not  nppenr  to  have  unitcdr  To  aasiat 
the  unionj  tJie  akin  of  the  fni.'e  whicli  lay  under  it  waa  slightly 
senritied  with  die  point  of  a,  knife. 

Tlie  cuhiinnn.  was  a  little  ci)rve<],  and  ite  cd^a  had  refrncted 
inwards  upon  them^elvee.  Tho  inwidc  of  tho  noee  W!i&  suppura- 
ting wqQ  ;  and,  at  ita  upper  part,  iidiimoD  Heemed  to  have  takfifi 
plftue  between  the  two  bleeding  eurfucee  whicii  had  been  op- 
posed to  each  other.  The  tip  of  tlie  noae  waa  weU  defined,  and 
ita  edgoa  were  curved  inwurdflf  so  ats  to  eimulate  the  natuml 
appeumnee  of  the  uhe ;  and  just  above  the  iiln>,  ajipnrently  from 
atmospheric  pressure,  a  deprei^ioii  was  taking;  pluce,  forming 
their  sujterior  boundary.  Tins  was  assisted  by  the  patient 
inakinif  lUi  oceosional  pressure  witJi  liU  ^n^eva  at  these  points- 
He  fdt  well,  had  a  ^ood  apiietite,  and  eat  up  all  day*  Ho 
breathed  freely  through  the  tube«  plaettl  in  tJio  noAtribi,  which 
retjuLred  lo  be  remuve^l  daily^  in  order  to  clear  out  obstm cations. 

At  the  end  of  a  month,  the  wound  in  the  forehead  had  eon" 
traded  to  ub<tut  u  ijunrier  of  its  ori<;inal  size  ;  adhesiim  i>f  the 
notis  was  perfect  al  all  pointa  ;  the  noBtrda  were  re^darly  round- 
ed, and  BJnmlntai  weli  the  natural  contour;  the  tip  of  the  noec 
wuB  well  preserved,  and  the  eur\e  from  its  root  to  tho  end  of 
the  or^aD  was  regular, 

Tn  six  week^T  he  wa&  able  to  go  out ;  hut,  as  the  weather  be- 
came cold,  he  waa  advised  to  confine  himself  to  the  house, 
fiince  cold  evideiitly  had  a  very  f;jreat  etieet  in  retardir^  ciejitri- 
zation.  By  reference  to  the  second  figure,  a  jtretty  correct  idcn 
will  be  formed  of  the  state  of  things  six  weeks  al^er  tlie  opera- 
tion h 

At  the  ead  of  two  months,  it  was  tl:ou;^bt  time  to  proceed  to 
the  second  operation,  which  was  req^uired  lo  remove  the  twist 
at  the  root  of  the  nose.  Underneath  the  pedicle  which  con- 
nected the  noflc  with  the  furcliead,  a  sn)an  portion  of  sound 
akin  remained;  and.  of  course,  no  adhesion  had  tsdcen  place  be- 
tween this  portion  and  the  jjediele  tying  over  it.     The  method 


fiHlKOPLA&TlCi   OPERATIONS- 


27 


oeually  a^lnptcd  by  opcmtora  hae  been  to  cut  the  liodiele,  nfter 

IlUa  Du^  hQ:^  united  sutlicicnlily  to  Justify  its  sc|»ariLtioa  from  tlid 
«ourc(?  Cff  Dutrition,  nud  t<]  fix  it  duwn  at  tlie  root  of  the  nose, 
in  a  traD«ver«e  inciaioa  madi?  for  it  nt  that  point, 
Tti  thifi  metJiod  lliorc  are  some  eorloua  objections-  First,  tlia 
dan^r  of  inflnmraatioa  in  bcparritiiig  tlic  }>cdiole;  eccond,  of 
aloQnrhing  of  the  or^ron,  on  Jividing  its  vflsculAr  connGCtions; 
and,  laatN'T  tho  very  f>ercoptible  trnnsverse  oiaitrix  whJdi  re- 
niains.  Tlic  coureo  rojsorlcd  tc>  in  the  [trceeiiL  ciisr  ie  liable 
to  none  of  these  objcctione,  except  perhnpB  the  fret  one,  in 
which  the  dtuiger  is  much  diuuniehoi:!. 

This  was  ns  I'ollows :    An  incision  wna  milder  conimenolng 

■nenr  the  internal  an^Io  of  the  eye,  and  extending  to  that  piirt  of 

the  baso  of  the  nose  w^here  ndhceion  had  not  taken  plaeo  ;   a  cor- 

^re^pondiii^  ineision  wns  alao  made  on  the   pedi<^lc.      The  skin 

g  dieeected  up,  tLo  wi'inkle  iu  the  into^iiment  nt  tlte  upper 

of  llie  wound  was  removed  ;  the  edges  were  then  broug;ht 

"^gether  by  euturea.     Union  look  place,  throughout,  by  the 

firet  intention. 

B      Four  months  after  the  oporfttjou,  he  was  entirely  wcli.    There 

Hwti«  no  eeerction  from  the  nostrils;   and,  on  h>oking   into   thase 

"cavitiee,  a  new  ekin  was  found  to  line  thcin  throutjbout-     Tho 

noso   itself  gradually  contractcdf  eo  that,  first  ^ly  the  ehrinking 

of  the  inti?gumcntH,  and  Bubticquently  from  suppiiralion,  it  de- 

Icreuficd  to  about  two-thirdii  the  gize  of  the  Hup  whieh  was 
laken  from  th&  f.M-chcad.  CoiitriLCtion  aJi^o  took  place  in  ita  lon- 
gitudinal oji'is*  The  Doeo  was  much  improvccl,  when  the  four 
front  teeth,  which  bad  been  lost,  were  repJaued  by  the  dentist, 
which  brougikt  out  the  ueiOct  lip,  und  at  tJie  same  time  raided 
Bthe  tip  of  the  or^fan.  The  cioatrix  in  the  fjrelkead  became  very 
etnall,  and  gradually  aeaumol  the  eolor  of  the  surroundmg  integ- 

fumeutfl  ;  the  acalp  Irom  which  the  columna  wo^  taken  was  lost  in 
tlic  liair;  the  noee  was  quite  firm,  of  a  good  form,  and  the 
Dicnti-LX  on  each  eide  aoju'cely  pereeptible.  At  tlte  root,  on 
the  left  tfide,  and  nt  that  portion  wliich  furmcJ  the  |>edi<.'le,  a 
snmll  iiflaurc  romainwl,  which  woa  concealed  by  a  atrip  of  coiirt- 
»[Euter. 
Hi^  health  had  never  been  better,  hU  eeruse  of  amell  gradually 


28 


THR   FACE. 


returned,  and  the  t^&rs  remimecl  their  natural  cliannel ;  and  he* 

DB  well   ns  his  friendB,  utmgratulated   thoraaelvefl,   both   on   the 
mornl  jn;d  i>JjyHir;iI  tifGCts  of  tlie  operation. 

At  the  end  of  tliree  years,  no  senstljle  alteration  had  takco 
place  in  the  reatured  pEirt.  The  aha|]e  tif  the  nose  was  perferfJj 
preserveil ;  and  there  was  none  of  lluil  flattening  which  has  usu- 
ally been  brongljt  forwanl,  by  tlie  opponents  of  this  operation^ 
as  one  of  tlie  greatest  aljectiorift  to  be  preferred  against  k-  In 
thoae  caseE  where  this  Raalty  oceurSf  it  almost  univerMnlly  ariBcA 
froiEi  tlie  flap.  In  the  fir^t  pliice,  heiug  tiKt  stnall ;  and,  the  inter- 
nal burliiccii  not  heing  wetl  oppjsed,  adhesion  fails,  and,  as  soon 
OS  the  swelling  sidj^idea,  the  nose  ia  left  flat  and  defiirraed. 

In  the  present  inslanee,  the  operation  was  alnioet  a  new  life 
to  the  subject  of  it,  restoring  him  to  the  society  of  hii^  liiendst 
and  enabling  him  to  eaUibli^h  htin^elf  in  busine^. 

Re^mtirksM  —  One  of  the  greatest  diffipiilties  of  the  operutioii 
was  the  management  of  tiie  t^iitnres  to  close  the  wound  In  the 
forehead,  and  to  confine  tIl^^  iifw  nose  in  its  situation. 

At  that  [mrt  of  tJie  flap  which  was  to  sinmlate  the  a]a^.  —  as 
it  was  necessjiry  that  the  integument  ehould  be  directed  inwards, 
—  pina^  of  course,  could  not  be  used;  and  here  a  plan  recom- 
mended hj  M.  Ijahat  was  adopted,  which  weis  followed  by 
partial  success.  A  tlrcnd  being  paesed,  first  tlirough  the  integ* 
uinent  of  the  face,  and  then  through  the  flap,  at  about  two  lines 
distant  from  their  edges,  the  ligature  was  so  tJed  as  t*:  produce 
a  fold;  and,  the  better  to  oHect  this,  n  small  cylinder  of  adhe- 
sive pla-^ter,  was  confine<l  under  the  threads,  so  us  to  make  a 
strong  rainniression  on  the  wound,  and  to  force  the  edgea  into 
their  places.  This  succeeded  completely  on  one  side;  on  the 
other,  union  was  not  so  eEitire* 

During  the  whole  of  the  treatment.  It  was  necessary  to  keep 
the  nostrils  distended  by  small  tubes.  The  substance  which 
answered  best  fL>r  this  purpose  was  the  barrel  of  a  qiiill,  the  end 
which  remained  in  tlie  nose  being  aloppiJ  up  with  melted  sealing- 
wax,  and  a  small  aperture  cut  in  tlie  side,  dirough  which  tlie  air 
cuuld  paaa  freely.  Tiie  tendency  to  contraeticn  whh  very  great, 
so  tliat,  at  one  period,  the  tubes  being  lefl  out  during  the  night, 
it  required  considerable  force  tu  rephice  them. 


EIHDJOFLABTIC  OPERA-TIONS. 


S9 


As  tlje  new  nose  waa  formed  entirely  of  akin,  it  will  per- 

ps  be  eupj^Bed,  that  tlic  integuments  camposin^  it  wera 
id»  and  the  form  of  it  cM^ily  deatroyed.  Thia,  however, 
ircm  reasons  easily  appreciable,  was  not  iJie  caae.  Tlie  integu- 
metkte  of  tlic  scoly)  bein^  natarnlly  of  trreiit  tliioknoss,  by  the 
Guppur^tion  which  took  pkcc  ii-om  the  inner  aide,  assumed  a 
H|£rmneft0  almost  fiimilnr  to  fibro-cnrtilage ;  and,  at  the  root  of 
the  nose,  the  internal  surfitces  coming  in  contact,  contracted 
adiieeions,  eo  aa  to  m^ike  it  perfectly  aolid  at  that  part.  The 
Golumnii  alao  formed  a  round  and  solid  pillar  to  support  the  tip 
of  the  nose. 

Great  precautions  hod  been  tnken  to  guard  against  exposure 
[to  cold,  which,  by  atopping  tlje  circulation,  might  at  once  de- 
feat the  whole  object  of  the  operation.  Aa  aoon,  however,  as 
ndhcsiau  had  taken  plaoOi  it  was  perceived  that  no  danger  irora 
tbia  source  was  lo  he  apprehended;  anJ,  although  during  the 
winter  he  slept  in  a  room  in  which  water  frequently  froze,  and 
■waa  repeatedly  exposeJ  during  aomo  of  the  ccldeat  days,  the 
tenjperatui^e  of  the  organ  was  never  greatly  diminished. 

The  cicntrization  of  the  wound  in  the  forehend  was  retarded 
~by  the  cold  weather,  and  Ich^  rhan  half  the  lime  would  have 
been  required ,  had  the  ojxiration  been  performed  during  a 
wtLrmer  aeason-     When  it  had  diminished  to  a  small  size^  and 

»  cicatrization — -aa  ft'cquentiy  ia  the  ease  in  the  lilling-iip  of  large 
wounds  —  seemed  to  have  beer  arrested,  great  benefit  was  found 
from  the  uae  of  an  ointment  composed  of  siic  dropa  of  creosote 
Kta  an  ounce  of  simple  ointment.  On  the  application  of  this  to 
1  the  wouml,  the  effects  were  at  once  apparent-  A  small  pellicle 
formed  ovi?r  iis  whole  surface,  which  was  shortly  replaced  by  a 
£rm,  consistent  cicatrii. 

In  one  or  two  caacA  operated  upon  by  DiofFenbnch,  much 
ewollin^  took  place  in  the  new-forniefl  Tiose  the  day  after  the 
opemTion,  ariaJng  Irom  the  difficulty  with  which  the  blood  wns 
conducted  off  by  the  veinB-  In  one  case,  the  noae  became  so 
enormously  distended  that  it  was  fe:Lred  the  adhesions  would  be 
entirely  destroyed  ;  and  it  waa  only  by  the  repented  applicition 
of  leeches,  fleventy  or  eighty  being  employed  in  the  course  of 
forty-eight  houre,  that  this  w:ls  avoided.      In   the  present  caae. 


so 


THE   FACE. 


from  tlie  citcnHon  given  In  the  indsion  on  the  left  eide, 
Lehig  tjiki:n  Lli:it  trurtinn  siiuuUI  lun  he  madi.^  tou  trt'iUy  ijn  ihe 
part.  BO  aa  to  coinpresa  the  pedicle  at  its  baee,  tLe  circulatioo 
wa^t  from  the  firat,  uurjbf^tnictetl. 

Tliia  case,  liavinj?^  Leen  tike  first  succraflful  one  m  thiH  oomtr 
try»  has  been  mr>re  fully  relateil.  It  must  be  remenibtred  diot 
it  wad  done  before  tlie  dayH  of  etlier.  \vbicli  gn^dv  facilitatcJ 
Bubsequent  tedious  o|ieratiu[i!4  uf  this  dcsuriptlon. 


Cabe  XIV.  —  IlhiHfipliL>*lle  Oj/KrtUion^  by  ik^  Method  of 
Taliacotius.  ^  This  wuh  a  cajie  of  lupua  of  fifteen  jeara'  stand- 
ing. The  commenceniCDt  wae  by  a  spot  on  ihe  very  tip  of 
the  noee*  which  gradually  e:^te[ii1ed,  becoming  fiuitLly  of  a  livid 
nal  oolor,  and  having  its  Hurfiu'e  (covered  by  imiiicrona  elevationa 
of  a  tuberculu.r  apjicarauue.  In  his  ordinary  state  of  health,  and 
when  jiicrfectly  quiet,  the  only  Henaatioii  in  the  affected  part  wa« 
thiit  of  heat  and  itcliing :  hnU  on  the  slightest  derangement  of 
the  fiystem,  and  upon  any  extratjrdinary  exciiiun,  ain  intense 
burning  and  atJiiglng  was  felt,  nut  only  in  the  noae  itself,  hut 
in  the  surroiiULliJig  integuments;  and  oflen  so  int^upportublc  as 
to  oblige  LliEi  tu  desist  from  hiti  work,  and  bavc  recourse  to 
cold  applications,  for  Icmpofary  relief.  lie  submitted  to  a  great 
variety  of  treatment,  continued  for  ii  number  of  ycar^,  hnt  with- 
oiil  the  {«ljghtefit  hent-Gt.  A  cuubtiu  bad  been  ap|ilicd,  a.  year 
before,  nhich  destroyed  a  pitrt  ol  the  tskin.  and  the  eubjacenl 
cartilage  ;  most  of  the  disease  remaining  undisturbed- 
He  came  to  Doston,  dcLonuuicd  to  have  the  uflcctwl  part  t&- 
moved,  and  the  loss  of  Huhctunce  supplied  hy  ihc  Taliueotian 
upcnitiua.  At  tlus  time,  tlie  nose  had  a  very  pinched  appear- 
ance, the  skin  being  of  an  intense  red  towards  tl»e  tip,  and  liav* 
lag  in  ita  substance  a  number  of  hard,  tuherculnr  bodies.  A 
slight  reduces  extended  o\er  the  ida  naKi  uf  tiie  right  aide.  In 
the  centre  was  a  dej)reas]on,  and  loss  of  substance,  where  ihc 
caustic  had  been  used. 

The  operation  was  performed  on  the  8th  of  April,  16-40.  The 
diseaae,  which  eAtendcd  up  na  far  aa  the  na^^al  bones,  waa  recy 
carefully  removed;  and  the  cartilages  below,  not  dtistroyeJ  by 
the  caudtic,  were  founJ  to  be  In  a  pcrfecdy  healthy  state. 


IU1IN0PLA9TIC   OPERATIONa. 


81 


[iTDCn^iona  of  the  flap  were  carcfiiU}'  taken,  and  marked  out  on 

he  fore-firm.     The  traces  were  maJo  on  the  radiitl  side  ol"  the 

;ft  arm,  about  two  inches  from  the  styloid  proccBS  of  the  m* 

LLUfl.     Thia  3rtp  was  ilia^ectcd  up,  iududing  with  Uic  ekin,  tho 

[mb-cutAQcous  celKilar  mcmbrrLDc,  and  woe  eccn:\^d  in  its  new 

^*itnntion,  in  conlatt  with  tlic  fiice,  ljy  five  etituroa  ;   the  arm  being 

finnly  fixed  in  thia  position  by  ftpproprialo  bfl-ndngcs.     Nour- 

it<hni(.'nt  wn^  ia  be   taken   through   an   cliLstic  tube  ;  tbc  mouth 

^^jcin^  BO  covered  up  aa  tu  pi-evcut  the  direct  introduction  of 

^Bbod>     He  woa  pinci-d  in  bed,  and  supported  in  a  sitting  poa- 

Hturc  by  a  common  bed-ehairp 

'  On  the  tbilowing  day,  the  !Jih,  there  was  some  a[>pcarjince  of 
errsipclatouE  uiflommation  on  the  bridge  of  the  noec :  iie  had 
been  pretty  quiet,  and  had  slept  a  little^  but  required  constant 

I  watching  to  prcv<int  him  from  i^lippin^  down  and  doubling  him- 
self up  in  tJie  bc<l.  He  cumplained  much  of  a  want  of  solid 
support  to  tho  olbow;  and  iliereforo  a  wooden  apparatus  whb 
conntmcted,  and  placed  acro&e  the  Ixx),  wliich  aervcil  aa  a 
firm  renting- place  for  the  *utq,  and  enabled  him  to  maintain 
more  eaaily  the  pn>[>cr  poeition.  The  pulae  wae  sixty;  and, 
throughout  the  whole  period  of  hie  confinement^  it  remained 
^  below  the  ordinary  standard,  On  the  lOtiii  he  complained  lesa 
H-of  hifl  arm,  but  wne  exceedingly  reatieas*  During  the  <\Ayt  bo 
HwAd  removed  to  an  eaay-ebair,  and  the  change  afforded  great 
Bxclief. 

■  The  state  of  things  varied  littler  from  that  already  dceeribcd, 
iiniil  tiie  iiftb  day,  the  period  appointed  for  separating  the  coa- 
ne<'(iim  fMitwecn  the  ftfm  and  face.  On  ihia  dayi  the  base  of  the 
Hap  wuf*  di\-ided  :   a  perfect  adhesion  had  taken  place. 

The  wound  in  the  arm  was  dressed,  and  a  small  portion  of  tho 
pkin  which  projected  bound  down  in  its  place  by  ndhcaivc  etra]*a. 
The  irregiilur  portions  of  skin  atlnehcd  to  llio  nose  were  ro- 
moved ;  and  a  sVv^Ui  compression  made  on  the  cd^jca  around  the 
noftriJif,  witli  atnpa  of  ndhesivc  plaster. 

The  arm,  on  being  relieved  from  its  continomenlf  was  not  so 
pHjnfid  OS  might  have  been  cjs  peeled :  tiiorc  was  an  almost 
entire  loss  of  |wwer  in  the  rttxor  muscloBr  In  the  course  of  a 
few  days,  however,  it  rc^'ained  ite  hcalUiy  etate  of  feeling  and 
mutton. 


32 


THE    FACS:. 


By  the  20th  of  April,  the  newly  tranaplunte*!  skin  h«d  con- 
triiGte*!  Ut  nearly  the  natural  kjzc  ;  lite  line  of  union  wflli  the  ekiii 
of  the  nose  was  perfectly  Hneai;  nil  the  al^rupl  and  useJe^'fl  j>or- 
tions  of  akiD  on  the  lower  &\ge  uf  ihe  no/sc  had  h|i>ughed  off, 
teAving  u  jMrrfccdy  even  and   rDiinJed  edgi^  tu  the  nastril«. 

On  the  23J,  I  w^a  auqiri^,  on  removing  the  green  f^i 
whidi  covereJ  the  JresatngSt  lo  find  that  the  whole  cuticle  cif  the 
reat<ireil  jiart  hiid  peeled  iiK,  leuving  the  aurfftce  quite  raw,  und 
covered  hy  the  green  (xiloring-niatier  of  the  *ilk-  This  at  firal 
scemeil  likdy  to  jiruhing  the  period  of  recovery,  but  h  jirovEd 
of  niiiterlal  heDcfiL :  :i  flight  su|ifiura,tiiin  conimeuced,  which 
hroiight  dov^n  the  skiti  to  a  natur^  ihieknef^i^,  aud  rounded 
off,  in  the  moat  periecl  nianncr^  every  ineqniility ;  and  eeemed 
itlHin  lo  melt  tlie  akin  ljlIu  die  luljiicent  inlegunieiiHK,  so  t\s  ahnnsL 
to  dt^troy  the  tr,u:ee  of  the  Viae  of  union.  A  new  cuticle  ra|^ 
idly  formed;   liud,  by  the  end  of  the  month,  he  wu^  ^uite  wdL 

HubACiiucntly,  havia^  c\|io^  luuiself  to  the  fluu»  he  vk&a 
troubhil  with  itching  in  the  right  ida  o|'  the  none,  where  a  flight 
redness  reniaintd^  He  ciiuie  to  me,  very  du:^iroua  lo  huvc  the 
akin  c>f  thii^  pnrt  nl  once  removed,  lie  vma  miAJoua  that  tlie  ex- 
periment should  be  tried  of  cutting  a  picec  of  akin  from  the 
urni,  and  ininie^liately  placing  It  ju  the  wound,  lo  supply  the  lofi* 
of  ftubBtance.  Although  I  did  not  consider  this  part  of  the 
operation  necesaary,  I  yichlcd  (o  hla  deftire^  and  made  tlie  at- 
tempt. The  diae.x^ed  tikin  was  removed,  aod  itd  place  supplied 
hy  11  piece  fn>ni  the  fure-iwni,  kept  in  place  hy  Ihil  moistened 
in  hlood.  On  removing  tlie  drefifiing,  al  the  end  of  four  flays, 
a  GOitd  uniim  h^d  taken  place. 

It  will  he  perceived,  thiit,  in  this  caaef  the  old  operation,  aa 
performed  by  Taliacotius,  of  taking  the  der^Lrcd  inte^^uinenb  from 
another  part  of  the  body,  wiib  prefen^l  lo  the  Indian  methrxl, 
tn  whicJL  tlie  &kin  la  horroivcd  from  the  forehead  and  hairy  ^csilp. 
The  reasDua  are  perfectly  obvioua.  The  loss  of  aubHtaucc  to  be 
HUpplied  waa  email.  By  tlie  course  rcaortL'd  to,  a  M!Jir  on  the 
iJjreliead  was  avoided;  and  that  on  the  arm  waa  of  no  impor- 
nmce. 

The  operation  was  not  precisely  that  of  the  Itjdiim  surgeon- 
Taliacotiiii^   preferred   taking   the   skin   fnmi   the   arm   near   Uie 


isfrtion  of  the  ddtoiJ  rajsde;  and,  by  adoptirg  this  mothmlt 
limb  caa   he   much   more   ecGuroly  Bscd  in  contact  with  tho 
lead-     In  llie  present  caee,  llie  patient  bcinf*  a,  niuacular  man,  the 
arm  could  only  be  brought  to  that  position  with  great  difiiculty. 

■      It  alar>  differed  from  that   of  Tnliacotiiia,  ia  the  early  scpara^ 
tion  of  (he  transplanted  skin  from  its  connection  with  the  arm, 
on  the  fifth  in^ti^ad  of  the  fourtoonlh  or  fiflccath  day ;  and,  as 
tLe  princ7i)>al   o^jeciion  tu   hie  method  la  the  poeitioo   in  which 
^tho  arm  is  eo  long  and  painfully  confined,  rhie  is  ccrtninly  a 
^t-Tory  important  consideration-     The  Italian  surgeon  raised  the 
Hflnp   gradually,   allowing  it   to   suppurate   and   contract.      Tho 
"most  iuapoptant  poiut,  however,  the  adheniye   process,   must   by 
thifl  means  have  been  rendered  much  Jess  certain. 

The  accompfloyinff  print  will  atJbrd  Bome  idea  of  the  position 
if  the  patient  while  tlie  arm  wns  confined  lo  the  face. 


Gabb  XV.  —  Rkinoplaxtic  Opertstwti.  —  A  young  woman, 
17  yeara  old,  from  Maine,  applied  to  me  ia  163da  having  loat 


d 


Zi 


THE  TACE. 


her  Doae  in  ibe  followinp  manner  t  Sixteen  montlia  before,  hav- 
ing a  wjirt  on  her  nose,  she  wna  induced  by  her  frienJe  to  appW 
for  mlvice  to  one  of  those  quac^ka  fityletJ  cancer  doi^torsj  who 
eaeily  perauflded  ber  (liac  the  nflcction  was  of  a  cflnceroua  na- 
ture, A  i^aastic  wna  usQtl,  wlilcli  produced  bo  grcni  a.  degree 
of  inflammation  as  to  akrm  her,  and  cbli^  ber  iigiiin  to  Luve 
recourse  to  him.  His  Einswei-  was  that  the  npplicaiion  should 
be  continued,  not  only  to  the  witrt  itself,  but  over  the  adjacent 
parts,  "so  that  none  of  the  roots  of  the  diaejwe  mi^dit  GEcap«." 
It  wna  therefore  [persevered  in  ;  mid  ao  cfiectuiJIy,  thnl,  at  (he 
end  of  n  fortnight,  all  tbe  tiesb  of  the  nose  sloiij^lied  off,  leav- 
ing her  in  a  must  deplorable  condition.  On  rt-ap|jlieniiod  to 
the  quack  as  to  wbat  was  to  be  done  under  those  cipoum- 
Btnnces,  he  assured  her  that  it  was  a  most  hnppy  lernoinatioii 
of  the  di^ense,  which,  by  tbeee  means,  bad  been  wliolly  eradi- 
cated ;  and  that  the  noee,  in  the  course  of  time,  would  ffi-ote 
out  again,   nnd  be  perfectly  restored. 

These  aeauraneea,  ns  may  welJ  be  conceived,  were  not  dei- 
tined  to  be  realized  :  [he  cd^es  of  the  wound  gradually  cica- 
trized, leading  lior  in  the  state  in  which  I  saw  her  siAteon  months 
alter. 

Her  condition  was  much  as  follows:  The  tip  of  the  noae, 
together  with  the  ala>  nasi  and  corresponding  portion  of  the 
septum,  was  entirely  destroyed,  leaving  the  nasal  paseagea  ei- 
poffod :  the  oflsa  nnsi,  with  a  araiill  portion  of  skin  covering 
thcmi  retrained  entire,  tlieir  edges  being  lined  with  a  Riin  mid 
eoniewbnt  vasculnr  cicatrix.  In  other  reflpecta,  she  was  ri  good- 
looking  woman ;  und  her  henlth  as  little  disturbed  as  couid  have 
been  expecteil. 

The  o|»er!Uion  was  done  on  the  ITlh  November  of  the  same 
year.  The  patient  was  placed  In  a  recumbent  position,  with  her 
hcail  well  sup|Kiried  by  pillows.  The  dimontions  of  the  flap 
were  traced  on  the  forehead,  nearly  ooe-third  larger  than  was 
necessary  for  the  formation  of  the  new  nose,  ThiB  was  dis- 
sected up,  nnd  evory  precaution  t.aken  to  leave  the  pedicle  of  skin 
between  the  eyebrowa  sufficiently  large  to  allow  free  vascular 
communication.  Care  was  also  taken  to  leave  the  angular 
arteriea  unwounded,  aH  upon  these  depended  the  principal  meonfl 


R  HI  so  PLASTIC    0PEKATION9, 


35 


\ 


support  to  the  Hup.  Before  proceeding  fardi^r,  (lie  odp;ea  of 
the  wound  in  the  fareliejul  wore  approilnijilcd  by  the  twisted 
mjtarc^  Tliis  wua  ficilltatetl  by  the  incision  in  the  eciilp  being 
proionge<l  to  n  jjynimidiil  form. 

Tlie  cicjitrix  covering  the  nasal  bonos  was  now  romoved,  iho 
flap  twiste4l  round,  !tod  secured  in  its  place.  The  etrip  whidj  was 
to  fonn  ihe  cohimna  of  the  nose  w^  deeply  ini|]iantod  in  the 
upper  lip;  (lie  whole  was  supportetl  by  amoll  atrip&  of  ndliesive 
pUtril4?i%  unJ  cuvercd  with  Hnt,  to  preserve,  as  njuch  as  jtoe^ible, 
lU  lemperniiire;   smnW  tiibea  were  intro4]ucc-<l  into  eneh  nostril. 

The  pali*>rit  \rjia  direi-led  to  keep  in  Led,  to  remain  perfectly 
etill,  nnd  to  brcnthe  througli  the  mouth. 

On  the  following  day,  the  nose  wae  swollen  ;  pnlse  eeventy- 
two:  she  waa  rather  rcBtloss.  On  the  Sflst.  the  sutures  were 
removed  ;  eotiro  union  bad  taken  place.  The  fieiiJ*ation  was 
nearly  nittural,  and,  as  in  the  previous  case,  but  slii^'btly  referred 
to  the  pfirt  from  whieh  the  skin  Imd  been  transjjlaated.  The 
form  of  the  noae  was  good,  uirh  a  regular  curved  outline;  the 
alar  nasi,  also,  were  well  defined.  The  no&lrils  were  kept  open 
by  means  of  tiie  small  tubes,  which  were  removed  dnily,  and 
cleansed.  The  wound  in  ilie  forehend  was  dressed  daily  with 
creoeoie  ointment.  She  aldu  derived  much  comfort  from  a  creo- 
sote gargle,  for  purifying  the  mouth.  On  the  columua,  which 
ivns  L-iken  from  the  scalp,  hair  continued  to  grow;  hut  was 
ciuily  removed  hy  seii>sorfl,  so  as  to  be  ficiircely  perceptible- 

From  this  time,  she  gpidiiaUy  p:aiucd  m  stren;^lh,  r\nd  was 
Me,  in  a  few  daye^  to  sit  up.  The  wound  in  the  forehead 
slowly  cicatrized,  nnd  the  noae  assumed  n  more  natural  stppciir- 
ance.  In  the  following  Bjiriiig,  I  performod  the  comparatively 
trifling  operation  whit'h  was  required  for  confining  the  pedicle 
in  lis  phice-  The  cicatrix  of  ibe  furchead  wna  then  quite  tirm, 
nnd  easily  concealed  by  the  hair. 

The  operation,  in  thla  cjue,  with  some  slight  exceptions, 
resembled  the  first.  In  the  6ret  operation,  the  twisted  suture 
was  used  fur  coikfiiiiii;r  the  new  nose  in  lis  place-  Jn  the  present 
instance,  however,  Tho  interrupted  suture  was  enhstilutcd,  and 
pnswered  a  much  better  purpose;  tlie  points  of  ulcerzuion,  on 
the  removal  of  the  thi^ads,  being  less. 


w 


THE   VXCE, 


Case  SVI-  —  Hhinopfastic  OpemihUy  bif  the  Alethad  of- 
Tafi<icotius. — In  tlua   cnee,  the  operntion  waa   performed  wv. 
eordiag  to  the  mcthcU   ref^ommouJetl   by  Talkcotiua,  rariJifiel, 
bowover,  by  the  expi>rieiioe  wliioh  niorlcrn  prnrtitro  haa   siiggeal- 
ed  ;  the  sktn  beinj^  bon"oweJ  from  uvor  the  hictjpi  muscle,  as  in 
tlie  Talidctitian  operation.     It  is  more  interesting,  from  iU  beingf 
30  fiu   na   we   know,  the  only  one  which   hsid  been  suc(*essfully 
performed  by  this  niethud  far   twenty  yertr»  previous,  the  aepa- 
ratioQ  of  the  tliip  being'  xumle  nt  axt  eai'her  penod  than  in  anyl 
enee  on  record. 

The  union  was  thonij;hl  sufficiently  perfect  nt  the  end  of  sev- 
enty-two hours,  or  three  dnyg,  to  wnrnint  the  ^epamtion  of  the 
new  flcip.  In  earlier  cfwes,  reported  by  Graefe,  Delpeck,  and 
uthers,  ten  to  fourteen  Uaya  were  thonnlil  necessnry  to  secure 
union.  The  advantage  of  this  ejirJy  tlivision  of  the  pnrta  will 
l>e  ensily  perceived.  The  preference  of  this  method  ih,  that  no' 
acar  ia  left  on  the  forcheiwL  At  the  pnnie  time,  it  must  h6 
flcknowledg«l,  thnt  the  skin  of  the  arm  ilues  not  possesa  sufficient 
firmneaa  or  elnsticiiy  for  the  construction  of  the  noae,  wJiere  tha 
Gubgtrneiure,  aueh  us  the  bonea  and  caniliiges,  have  been  do*, 
Btroyed, 

The  patient  was  a.  femnle  30  yenrs  old-  Hnving  a  warty 
excreecenc^e  on  the  na§e,  glie  iipplied,  as  in  the  previous  caae,  to 
A  quack,  who  enjoye<l  uoloriety  in  the  tretitment  of  onncers,  aiid 
■who,  ns  usunl,  nt  once  informed  her  fliai  the  disense  was  cancer*: 
ous,  and  ndviaed  its  remaViil-  A  can)*iic  wa^  applied,  but  soj 
badly  managed,  that  nut  only  the  djaease,  but  n  portiun  of  thti 
nuse  also,  wus  destroyed,  lenvJng  the  unfortunate  eubject  id  h 
most  distressing  HituaEion.  H 

It   looked  e3(ac(ly  as   if  the  nose   hnd    lx?en   neatly  excised  i 
the  skin,  a  portion  of  the  cartilai|;e  forming  the  septum  naai^  and_ 
about  one-tliird  of  the  cnlumna,  were  wanting.     The  nasal  cavi-B 
ties  were  exposed,  and  the  deformity  produced  of  a  very  striking 
»n<]  disagreeable  :rharneter. 

The  loBs  to  he  snpjilied  wna  not  Bufficient  to  justify  a  resort 
to  the  Indian  method,  especially  ns  the  lady  was  not  so  stout 
AS  to  render  thai  of  Taliat^rtius  insiipportP.ble, 

I  advised  ber  to  return  home,  and  to  have  a  bandage  madej 


B[n?JOPIA8TI0  OPEIUTlOV6> 


37 


V 


ftach  aa  is  described  and  depicted  m  the  work  of  Talmcotiua, 
aod  to  exercise  herself  daily  fcir  a  few  weeks  in  keeping  the 
arm  in  eoniact  with  ibe  Ince,  in  the  jxisition  wiiirh  it  would 
be  requisite  to  maintain  after  the  operation.  The  operation 
WM  performed  on  the  21rt  of  October,  1840,  Jn  ihe  presenee 
of  Dr.  Ed,  Reynolds,  Dr.  S.  D.  Townsend,  Dr.  FT.  B.  Inches, 
and  a  nmnber  of  oiher  molicnl  gendeiiien. 

The  ciuQtrix  iMivcring  the  eilge  of  the  notitrils  waa  first  re- 
movedi  and  die  apei  of  the  septum  nnd  nnhininn  nasi  made  into 
a  raw  surfat^.^  A  flap,  nparly  drjublo  the  size  required,  wna  now 
Olsseelefl  out  frora  over  the  upper  part  of  the  biceps  miisele  of 
the  ri^ht  E-rni,  its  haae,  which  presented  downwards,  beincr  left 
attache"!-  The  bleetllng  having^  censed,  iinil  the  flap  hnving  con- 
Iracied  nearly  one-hnlJ'»  the  :irm  wtis  brought  up  to  the  faee, 
and  the  edges  of  the  flap  contined  in  contact  with  the  raw  sur- 
fu%  of  the  nose  hy  aix  sutures-     The  bandage  of  Tidlacotiua, 


38 


THE   FACE. 


of  whi'^h  the  flccompiiij'iDg'  ivoimI-cuI  gives  a  gtM>d  idea,  as  well 
u  of  die  getiertil  nppeiirance  &nil  poBliiDD  of  llm  pntlenl,  ^tba 
now  .ip|»lii^il»  mil]  servcil  to  iiniiutaiti  iIig  arm  iniinnvalilv  fixed  Id 
contact  with  the  head.*  The  whole  of  thw  pinfiil  opt^ralion, 
which  wiw  before  the  daya  of  ether,  waa  BUjijjorted  wilh  the 
most  derermiiied   fortitude. 

Out,  '22d.  Since  jeeterdayshe  has  remained  in  an  arm-flmir. 
preferring  tlie  fiitlirig  posture  afe  the  nioHt  couifurlubic,  both 
for  breathing  and  for  taking  noumhmenl;.  For  an  hour  or 
two  ahcr  the  operalLinu  the  tkrm  was  qniiu  numb,  from  it«  con- 
Atrsiiiied  potiitiun  and  the  pressure  of  tlie  bauda^.  This  grada- 
dly  changed  to  a  puiTkfid  ^ensntion, 

25d.  She  complains  t<>-day  of  severe  pnin  in  the  wrist, 
wliich  wjiA  very  so(>n  relieved  by  wellin;^  die  bAindarre^  wjih 
kiidaniim ;  and  almost  im mediately  al\er  each  nppli [Ration, 
flhe  was  nonnmseil  io  sleep.  Tlie  bandsiges  were  relaxed  a  little 
from  being  wet,  but  not  ^o  nmuh  as  to  do  injury. 

24di.  To-day,  i^eveiily-hvo  liuiirs  nfter  t!ie  cjwnilion,  I  pro- 
ceeded, ill  presence  of  u  number  of  medicnl  gentlemen,  lo  divide 
the  pedicle,  and  releiise  the  ami  fmni  IIa  pidiiful  position.  On 
fir.'^t  letiinjf  it  douti,  it  appearwl  qtiite  pandvKed  ;  i>ut  by  gentle 
frictior^  tlie  power  of  motion  and  sensation  was  gmdunlly  re- 
stored. 

A  [jei-fecl  Jidheeion  hiul  Ijtken  place  between  the  new  flap  and 
the  ri^ljt  side  of  the  nose>  On  tJic  other  ^ide.  the  «kiu  waa  so 
wrinkled  np  from  the  preamire  of  the  head,  that  it  waa  not  poa- 
sil>le  to  determine  what  was  the  state  of  liuioii.  Out  of  the  new 
Il't[j  a  ]x^liele  wfu  now  shapeil,  Iii  serve  fur  the  coinpIeUon  of 
the  ciihLrnna,  and  wafl  cunGned  lu  contact  with  what  remained 
of  the  old  one  by  a  e<Lngle  anture. 

Tlie  patient  wa^  in  good  spirits,  and  appeared  but  little 
fadgiitxl  from  tlie  painful  pouitiun  in  which  she  had  been  conSned 
for  fiuch  n  length  uf  tiinc.      Iler  eufTerin^rig  had  certainly  been 


I 


*  t  fltn  inil^brcd  to  th&  kiiirin&iH  of  Tcy  fl^aarl  Dr.  Ia?h«  fat-  a  ca^y  ai  the 
ori^nal  fuliu  uilitioii  of  TnliJiL^oEiiLs.  WiLrin^  t}tc  JaEc  of  ]5*JT,  Irom  nliJoh  tlkia 
wixwl-uiit  i»  cori'itd^     Tills  v(.»rj  mrv  anJ   Lununs  wurk  "as  ablaincd,  will*  mucli 

dimrirlry.  in  Italy;  luid  bac  Ibv  copiet  htb  to  be  fountl  In  prcBerTAtion  m  ibo 
pr«eni  d»y- 


grcally  nl  1  e vi ntod  hy  tho  possibility  uf  hcmg  nLIc  to  move  aboul 
the  room  witliout  mtcrtVno^c  ^vJtli  ihe  adliodivc  proccBSj  owing 
to  llic  ptn-fect  retentive  powor  of  ihe  ljftiida<^cB. 

25llk  Quite  uotnrortablc  ;  the  tip  of  the  noao  looked  well; 
the  cdjjca  on  one  ^iilc  somewhat  livid,  but,  on  being  couchccl 
ii'ith  iLe  knife,  bled  freely ;  a  portion  of  the  new  uolumna  in  & 
eloughin;^  i^tnte. 

Sov,  11th.  A  email  picL^e  of  the  elfin  which  formed  the 
ecplum  havin;:;  elou^^hcd,  the  rcmninder  hoa  settled  djwnt  und 
ot  present  i»  iirmly  united  in  its  ettuiLtioni  Tho  nose  bos  n 
good  shnjKj,  but  ifl  aVill  a  little  awollcn. 

Dec,  l:^lh.  She  rotunied  boina  wall.  Her  no&o  hnd  cr- 
tircly  henlod;  ita  form  waa  pood;  tlie  tip  was  slij^htly  turned 
Dp,  and  the  whole  orp;nn  a  Itttio  shortened  when  compared  with 
1(3  t>ri^nid  Jimcn^lonaT  but  was  KtiK  ni^cnblo,  and  presented 
nothing  rcmiirkfible  to  a  oji^ud  observer;  the  line  of  union  bad 
so  melted  down  into  the  surrounding  pnrta  as  to  be  acareely 
pcrceptihlc. 


I 


Case  XVH.  —  Mi-e.  F,,  30  yenra  of  age,  waa  treated  by 
me,  for  a  number  of  yeurfl,  nt  my  hous(>  and  at  the  Hos|>itfll, 
for  nn  uleeration  of  ibe  noec  looking  like  lupus,  but  probjibly 
epceifie,  which  oho  fiaye  Hrst  attneked  her  breast.  The  dlecose 
of  the  breast  eommcaeeil  ci^ht  years  before.  The  whole  nose 
waii  nttucked  and  destroyed ;  the  vomer,  the  left  turbinnlcd  bone, 
and  the  orbit«r  procefis  of  the  Hupcrior  maxillary.  Th<j  whole 
poaterioT  nflroa  was  exposed,  And  the  opening  of  the  Euatn- 
rhiun  tubes  distinctly  vieiblc.  The  pnlnte  was  thrown  up  in 
the  iiet  of  ewallowin^'.  The  left  miixiUnry  siniia  was  quite 
open  on  the  inner  eide-  The  defltruetion  of  parts  waa  much 
3»rcntcr  than  I  havi  ever  Ix'fore  eccn,  and  the  openin;^  on  llic 
fncc  larger.  A  euro  was  tiiiallv  elfeetal  by  the  persevering  use 
oftJie  iodide  of  pota^^ium.  When  the  opcrnlion  wuh  peHbrmed, 
—  Marob  28,  1855,  —  the  ulcer  had  been  healed  up  for  eight 
inonthfl*  Tlie  flap  wne  taken  from  the  foi'cbead,  as  in  two  of 
ihe  previous  eases,  being  somewhat  nnHlilied  in  order  to  cover 
the  iiregular  aperture.  The  part  to  form  the  septum  wns  taken 
fnmi  the  aeulp,  previously  ahaved,  and  wns  an  ineh  and  a  half 


40 


THB   FACE. 


long.  It  was  twisted  siround,  and  nicdy  ndjuslod  in  Its  p!i 
wilh  euturcG  ;  tlie  edges  of  the  Kkin  on  the  Fnce  having  been 
made  rnw.  She  w^  much  depressed  hj  the  0{>eracff>n  ;  ^4^B 
thj?  skin  imiied  well,  and  she  ultimately  rewH'ered,  aftpr  th^^ 
usual  protriLclcfl  treatment  which  these  cases  require,  with  ■ 
most  excellent  nose,  and  &  very  slin^ht  scar  on  the  forehead.  A 
small  aperture  was  allowed  to  remain  nt  the  left  *ide  ot'  the 
nose,  at  her  own  reqiipst,  to  fiirilitate  the  renioviil  of  the  Ion] 
blaek  hair,  whieh  continued  to  grow  from  ihe  septum, 
direction  down  the  throat,  causint;  considemblo  irritation, 
aperture  referred  to  was  covered  with  court-plaster, 

Tfjis  cftse,  as  most  of  the  others,  ha*  a  touch  of  romance 
its  suhsequent  history.  She  called  on  me  some  y^^ars  af\er,  and 
said  that  her  good  Looks  hnd  been  so  fur  restored,  llmt  she  had 
nttraeted  the  nttentinn  of  a  soldier,  and  hnd  been  a  second  time 
married.  The  marriage,  however,  lumed  out  an  unfortunate 
one  ',  as  I  hav'e  lately  learned  from  mv  hrotljcr,  Mr.  J.  S.  War- 
ren (who  was  called  on  to  administer  charity  to  her),  that  her 
husbflnd,  in  a  fit  of  intoxication,  had  threatened  her  life  in  ibe 
tniddle  of  the  nijrht,  and  so  alimied  herns  to  make  her  jump 
from  &  window  in  the  tliii'd  story,  which  nearly  terminated 
career. 


Case  XVITI. —  A  gentleman,  49  years  of  age,  a  tall,  han 
some,  and  powerful  man,  wrote  to  me  in  the  early  part  of  t 
year  1657,  to  know  if  any  thing  could  be  done  to  restore 
nose,  the  greater  part  of  whi^^h  he  had  cut  off  in  a  temporary  fi 
of  insam'ty  some  vears  hcfore.     1  described  to  him  the  nature  of 
the  opemtion^  ns  being  a  very  painful   and   fatiguing  ooe,  and 
requinng  a  giiod  part  of  the  whin  of  the  forehead  To  he  uswl   in 
the   mannfatture.      T   i-ejirest'iiled   tho   very   worst   side  of  tlie 
picture  to  him,  fearing  a  person  of  his  situation  and  npjiearanc© 
would   hardly   he  salisfie4l  with  the   rough   substitute  made   fi 
one  of  the  mont  imporlant  features  uf  the  fiiee,  however  su 
cessful  the  surgeon  might  be.      lie  answered   me,  tlail  he  w 
determined,   at,  any  rl^k,  tii  ha\~e  the  operation  done;  nnd,  iQ 
the   month  of  Octid>er,  he   came  to  my  house,  having  made 
journey  of  frooi  one  to  Iviit  tijousand  miles. 


1.e 

i 


limyOPL-VSTIO  OPERiTlONSn 


41 


tcr  ttn  exnminjLiion  of  the  case*  ami  fimlin^  how  miu'li  of 
tlie  skin  of  llie  foruhcnd  It  would  tuko  ta  EuppJj  llic  luj^t  orgjin, 
I  felt  gjcut  Jie^italiou  ac  tlie  undertaking,  lie  stuted,  Jiowevcr, 
that  lie  had  come  n  great  dUtflnce  for  t\m  purpose,  that  he  plarjcJ 
LimSflf  (\i\\y  under  my  dirfitlion.  and  wouM  wait  any  Ica^tb  of 
tiDie  till  1  hnd  fuUr  matured  mv  |ilau». 

Having  fiooJIj?  determined  to  do  tha  operation,  it  was  pei^ 
fomjod  on  OoC.  25th.  with  th(?  ivtsistauce  of  Dra.  Bri;;^e,  Hay- 
^':ird,  and  Slflde.  Tho  ranutin^  of  tlic  old  nose  were  first  slit 
cpen  in  tlic  ocntre ;  mid  the  lateral  ilnpe,  which  had  partially 
cave^l  in,  wore  dissectod  up  from  their  itdhesions,  A  lar;::e  tii- 
BJigiditr  flap  of  skin,  involving  nearly  llie  whole  forehend,  waa 
LOW  digsc^lcil  up,  with  a  Bmall  goIuqid,  taken  from  the  hairj 
I,  to  flcrve  for  tfie  eoptutn  of  the  nose.  This  tlap  wns  eii- 
in  n  cloth  imtii  the  wound  in  tho  foreliead  had  hcen 
The  operation  otherwise  waa  conducted  tu  described 
la  the  previous  cases. 

From  the  tur;^id  etate  of  the  veeacle  of  the  fjice,  the  operation 
waa  noeeseiinly  n  very  hloody  one.  For  this  renson^  flnd  from 
the  necessary  delays  in  determining  tlio  Aize  of  die  flupp^  und 
filting  them  niooly  hi  their  jilaces,  it  la^rCed  nearly  three  houra. 
The  patient  drclme<l  to  tnke  cll»er,  and  bore  the  whole  of  thia 
'long  nud  painful  operation  with  the  most  unflin^ihin^r  firmno-^s, 
Bti  that  a  bv&tnndor  could  hanlly  h:ivc  dolerruiiicd  whether  tho 
'SLirpcon  WHS  opor;itiiig  on  a  living  or  dead  euhjoet. 

Jle  p:t#Hed  a  quiet  night.  The  next  d.iy  his  pulse  wiia  eighty, 
Jind  he  hml  vary  liltie  uneasincsa  in  the  nose  or  forehead-  On 
tho  li.Hili.  the  ftfrclkcjid  w!W  dressedj  and  all  the  an^^lcs  nnd 
pro^Linule  jjarta  connirtrted  by  euiui'oa  found  to  biivo  united  by 
Itlie  iirat  intention. 

On  iJie  29lh,  the  new  nnso  waa  dreaded,  and  the  flaps  were 
ffto  well  united  to  the  cheek,  tbat  tliey  seemed  to  have  melted 
ico  it. 

On  Nov.  1st,  the  phiga  were  removed  from  the  nostrils;  the 
LtJcnt  noe  up,  and  ftl>out  the  room. 

Nov-  32d-  He  had  been  ont  of  doors  for  two  weeks  in  per- 
fect henlih.  The  womid  in  the  foreheitd  was  hoaied,  lenving  in 
illie  centre  n,  scar  scarcely  perceptible.     The  noee  looked  well, 

0 


42  THE   FACE, 

the  seTisibilit}'  wqa  natural,  perhaps  a  Jittle  dull,  not  referred  to 
tlie  forehead.  The  twiet  in  the  pedicle  had  become  effaced  hy 
a  most  remarkable  transposition  of  the  parta ;  tlie  ecar^  which 
originally  commenced  on  the  right  eide,  being  drawn  over  to  the 
left  by  contraction  of  the  tissues.  Tiie  small  apertures  which 
remained  on  tliis  and  tlie  oppoaitc  side  of  the  pedicle  were  eaailj 
obliterated  by  aubsequent  inanccuvres. 

The  patient  was  extremely  elated  by  tlie  eucceas  of  the  opera- 
tion, and  by  the  very  natural  appearance  of  the  Bubatitute-  The 
rc-action,  after  this  long  period  of  retirement,  brought  on  con- 
siderable excitement  of  feeling.  Notwithstanding  roy  repeated 
precautions,  and  advice  to  him  to  return  home,  he  indulged 
in  a  very  free  course  of  living ;  which  ultimately  terminated  in 
an  attack  of  apoplexy,  which  destroyed  him. 


OPERATIONS  rOR   THE   RESTORATION  OF   THE  LOW'EB 
ETELID. 

The  difficulty  of  repairing  the  cversion  of  the  eyelid  after 

burns  and  other  accidents  attended  by  destruction  of  the  integu- 
ments is  well  known. 

Since  the  introduction  of  the  autoplastic  mctliods  for  the  res- 
toration of  lost  parts,  the  transplantation  of  cutaneous  flaps  for 
a*ipporting  the  remains  of  the  everted  eyelid  lias  been  attended 
with  euccetis-  The  two  following  cases  are  gi\'cn  in  illustra- 
tion ;  — 

Case  XIX. — The  subject  of  this  was  a  boy  12  years  of  a<re, 
from  Weymoutli,  Mass.  When  an  infant,  he  was  dropped  into 
the  fire.  The  couseijuence  was  an  extensive  bum  of  the  left 
side  of  the  face,  and  a  paitial  destruction  of  the  lower  eyelid. 
As  the  wound  in  tlie  cheek  cicatrized,  the  reuiains  of  the  lid 
were  completely  everted,  and  the  tarsal  cartilage  witii  ita  cilia 
firmly  bound  down  to  the  lower  edge  of  tiie  orbit. 

The  effect  of  this  was  a  constant  epiphora^  cauJsiug  much  irri- 
tation of  the  integuments.  From  the  exposed  state  of  tlie  con- 
junctiva, it  had  become  thickened,  having  the  appeai'ance  of 
epidermis ;  and  the  cornea,  from  exposure  to  air,  prescntcil  an 


OPEltATlOVS   OS  LOWKR   EYELID, 


43 


opnciCy  which  wns  Jiiily  inorcaainfr,  nnd  thi^cntcncd  iIp?tnjc*tion 
of  vititm.  UnUi;r  Iheec  cirpunistnn<'es,  the  foilowin*^  opcmtion 
tvaa  pcrfurmcd  *fn  tlie  12tli  of  June»  1841 :  — 

All  incision,  iibmtt  an  inch  mid  !i  h.ilt'  in  length,  wiis  made 
pnrallc;]  with  the  (jommiEj-ure  of  the  eyelids,  and  nbout  two  linea 
Lic]t»vv  ihe  ]Hdpo!jr,il  mnr^in  ;  nnd,  ailer  u  onroful  direction,  the 
remains  of  (he  eyelid  were  aepiirated  fi"om  llie  ed^e  [>f  the  orbit. 
Til*  disaocCiim  wns  then  continued  upwards  between  the  tarsal 
Gurrildgc  and  the  conjunotiva^  and  the  connections  so  fur  dea- 
troycd  na  to  allow  the  lid  to  be  reelore<l  to  ite  natural  position. 
Tho  ihU'koDcd  !tnd  diseased  subcutaneous  cellular  membrane 
was  then  comijletoh'  removed- 

By  the  ec|>ai"aiion  of  the  ed^s  of  ihc  skin,  a  large  ovnl-shapeU 
wonnil  now  presented,  nnd  this  xvas  to  be  tilled  by  a  portion  of 
ttin  Inken  from  a  neiprlihorin™  pnrl.  To  ctfeet  thia,  an  ini'ition 
H'B.6  commcTicod  from  the  outer  an^rlo  of  the  wound,  and  carried 
in  n  jeicicircular  direction  over  the  temple,  at  which  point, 
nndcr  the  hnir.  wai*  the  only  poi'linn  of  sound  skin  which  had 
not  *urtered  troiu  the  effeL-ts  of  the  burn  :  an  oval  flj»p  was  here 
diasccted  out,  ahour  one-third  larp:er  in  eize  than  was  reqnii-ed, 
ami,  bavinn;  fully  relractod,  was  twi^te*!  round  and  mninfained 
in  ita  situation  by  means  of  sutures,  aod  n  alight  jiressure  eser- 
GLSod  upon  it  with  a  roller  bandage.  Before  terminating  the 
operation,  the  thifUcned  conjunoiiva,  whioh  formed  a  priijeeliciii 
henealh  the  lid,  so  as  to  prevent  jt^  perfect  application  to  tlie 
eyeball,  was  raised  up,  nnd  entirely  removed. 

Tl>e  lemiination  of  tbia  eaaa  was  quite  sueecssfuL  At  the 
eod  of  f  n;r  days,  die  dreaaings  were  removed^  nnd  the  arlhesiou 
of  [he  tlrip  was  ahnosl  complete;  a  slight  ^u[jpuraiii>n  only,  at 
ila  inner  an^le,  baring  occuri'ed.  The  parts  were  all  much 
swollim.  At  the  end  oE'  a.  week,  the  pedii^le  which  eonnecto'l 
the  newly  iransplantctl  flap  to  tlie  neighboring"  pjiTts  was  divided, 
and  bled  freely.  The  patient  was  sufficienily  well  in  a  month 
to  return  home. 

About  three  months  afier,  he  gave  the  followinQ^  account  of 
himnelf :  He  was  able  to  close  the  eye  perfectly,  and  the  tears 
had  resumed  iheir  proper  channpls.  The  newly  formed  lid 
seemed  to  ftdfil  all  its  functions,  and  there  was  no  disposition 


44  THE   FACE. 

to  evcrsion.  The  opncity  of  the  cornea  had  so  far  disappeared 
as  to  be  Hcarccly  perceptible.  The  only  circumstance  which 
required  n  remedy  was  a  disposition  in  the  new  lid  to  stand 
out  from  tlio  eyeball,  as  if  from  a  swollen  state  of  the  conjunc- 
tiva :  this  was  remedied  by  the  repeated  application  of  a  pencil 
dipped  in  sulphuric  aeid,  so  as  to  destroy  a.  narrow  strip  of  the 
conjunctiva.  The  transplanted  skin  at  first  protruded^  but 
gradually  settled  down  to  the  level  of  tlic  Burrouading  integu- 
ments. 

Case  XX.  —  The  second  ease  was  a  young  lady  19  years 
old.  The  accident  which  produced  the  deformity  was  very  simi- 
lar to  the  preeeUIng  one;  having  fallen  into  the  fire  when  aa 
infant,  she  had  been  badly  burned  in  the  face.  From  this 
resulted  a  very  extensive  cicatrix,  affecting  nearly  the  whole 
skin  of  the  face,  and  tn  some  }iai-ts  impliojiting  the  subcuta- 
neous textures.  The  left  eyelid  was  drawn  down  and  everted 
at  its  external  angle,  leading  the  eyeball  exposed.  From  the 
destruction  of  the  intcgutnetits  of  t!ie  cheek,  the  left  angle  of 
the  mouth  was  drawn  upward  in  a  direction  to  meet  the  external 
angle  of  tlie  eye,  there  being  about  an  inch  and  a  half  distance 
between  the  two.  A  large,  firm  band  of  indurated  and  thick- 
ened integument  extended  from  the  forehead  perpendicularly 
across  the  bridge  of  the  no,se.  The  external  edge  of  the  right 
eye  was  also  slightly  drawn  downward  by  a  cicatrix;  but,  the 
cheek  of  this  side  having  partially  escaped  the  effects  of  the 
bum,  there  was  no  ever^ion  of  the  eyelid.  The  following  opera- 
tion was  planned  and  cxecutetl  on  the  7th  of  November,  li540. 

An  incision,  two  inches  in  length,  commencing  on  the  cheek, 
midway  between  the  eye  and  upper  lip,  was  carried  with  a 
semicircular  sweep  in  a  direction  upward  and  outward  towards 
the  ear,  its  convexity  beiug  downward.  The  skin  was  then  dis- 
sected up,  both  above  and  below,  so  as  to  relieve  the  traction  of 
the  integuments  in  either  direction ;  and,  on  this  being  accom- 
plished, no  difl^eulty  was  found  in  restoring  tlie  eyelid  and  angle 
of  the  mouth  to  their  natural  positions. 

From  the  separation  of  ita  lips,  the  wound  on  the  cheek  now 
gaped  widely  open,  being  an  inch  in  the  perpendicular,  and  two 


OPERATIONS   ON   LOWER   ETELID- 


45 


iphca  in  the  tmnavcrac,  tiiMnct(*r;  nod  tliia  wn3  to  be  fillet!  up 
by  hoiTowtMl  intcguincDt.  The  oUbuts  of  ihc  hum  Ivning  peuii- 
trat<;<l  iiil(]  ihu  niuficular  ftub^tuncc,  it  wns  ncccfiaory  fii-at  to 
rcmoi'o  all  Hie  indiimtcd  eubt^tanco  covering  the  iloor  of  ttid 
vound-  A  largR  oval-ehnpcd  flap,  one-third  Inrgcr  thno  wna 
iK-foesHry  to  fiJi  the  wuund,  wati  diti^eijlpd  fVuai  the  tcTXi[dc, 
■twiatcd  round,  and  without  difficulty  adjuelcd,  and  eocurcd  ia 
lis  new  situntion  hy  mcana  of  Putiirc*,  as  in  the  preceding  caeo- 
Xhe  wouad  on  the  temple  was  drawn  together  by  euturea,  and 
in  A  direetioi]  to  favor  the  tronii^plantcU  J^kin  ia  remedying  the 
deformily. 

The  uneccmly  cicatrix  on  tho  bridp;c  of  tlic  hosq  waa  nuw 
completely  dissected  out.  The  vcpacle  ivhieli  were  divided  during 
the  opcraCioa  were  allowed  to  bJecd  until  they  ceaecd  Yoliuitarilj, 
ijt  being  dej^imblc  to  ovoid  ligaturea,  Tho  wound  was  di'c^eed 
with  f;raduiited  eoniprCHapa,  secured  by  n  bflnilngo-  Quiet  was 
tinjuincd  :  notwithstanding  which,  from  talking,  n  ^ight  hemor- 
rlui^'o  wjii*  proiluecd,  which  partially  prevented  the  union  of  the 
trunH|>lntUtd  ik[i. 

Hitt  httlc  constitutional  irritation  followed  the  operation.  On 
ihe  fourth  day  the  UindaLxe  was  reitujved,  and  two-ihirdfl  of  tho 
WJis  fuund  to  liavc  united:  the  inner  portion,  tovtards  the 
I,  was  raxecd  up  by  a  oon^ulura  of  bJood,  and  the  union  at 
'^thid  pojntf  of  course,  defeated.  The  wound  on  the  temple  hail, 
in  A  great  rucaeurc,  united  by  the  iiret  intention.  On  the  sixth 
iJny,  the  ligatures  wei'e  all  remuve<i.  and  the  inner  portion  of  tho 
flnp,  which  showed  a  dispoBition  to  Glough,  was  cut  away;  the 

»^viiund  at  tbi^  point,  where,  foitunntclvi  the  support  waa  Icufit 
revjuircd,  U.'ing  allowed  to  heal  by  the  eeeoud  inlcntioa. 
At  iLe  end  of  eix  weeks,  the  wounds  hud  all  healed;  and 
ehc  returned  h*>me,  greatly  improved.  There  wae  ro  di^ipueition 
to  emersion  of  the  eyclidT  aiid  its  functions  were  well  pedbraied- 
The  nii'Ulh  was  also  restored  to  nearly  its  natur:il  appearnnce. 
Th<^  liicini  rxprewioQ  wiu^'greaily  improved  by  the  removal  of  tho 
uoeighlly  band,  wliieli  prejeeted  out  over  the  bridge  of  the  uose. 


The  above  ensee  are  selected  from  among  a  great  number 
of  iiimllnr  instancea ;  the  operations  of  a  pla^tie  character  about 


46  THE  FACE- 

the  face  bcingf  as  a  general  thing,  tinueually  successful.  What- 
ever operation  ia  used  for  restoring  the  eyelid  or  the  mouth  to 
Its  position  when  drawn  down  by  a  cicntriXf  it  is  important  that 
the  intogumeut  ehould  be  freely  dissected  up  from  the  subjacent 
jMirtfl,  so  aa  to  allow  tlte  eyelid  or  mouth  to  be  restored  to  its 
po^'ilion  by  bringing  the  intcgunient  on  a  different  plain,  as  re- 
gards the  subjacent  parts,  from  that  wliich  it  occupied  before. 
A  simple  di^tsiim  of  the  scar,  and  allowing  the  edges  to  separate, 
even  if  a  flap  ia  introduced,  would  not  remedy  the  difficulty. 
In  the  eyelid  particularly,  tlie  dissections  must  be  very  thorough, 
and  curried  quite  up  to  the  edge  of  the  lid. 

During  the  past  year  I  have  operated  on  two  children,  a  boy 
and  a  girl,  both  about  8  years  of  age,  in  which  the  integument 
of  the  lower  lip  ond  entire  neck  had  been  destroyed  by  fire; 
the  mouth  being  open,  and  tlie  edge  of  the  lower  iip  in  contact 
with  the  sternum.  In  one  case,  tlic  jaw  had  been  completely 
deformed  by  the  tension,  the  two  middle  ineisora  being  some 
distance  in  front  of  the  lateral  ones :  tlie  whole  fiicc,  in  fact, 
with  the  lower  lida,  was  on  a  stretch ;  and  the  eyeball  was 
strained  upw^ards,  in  oitlcr  to  allow  the  patient  to  see  objects  in 
front  of  him-  In  these  cri^csj  hy  a  semicircular  cut  at  the  base 
of  the  scar  on  the  sternum,  and  subsequent  dissection,  the  head 
waa  liberated,  and  restored  to  \ts  place :  the  wound  being  cov-> 
crcd  by  akin,  slipped  along  from  the  sides  of  the  neck,  in  one 
case;  in  the  other,  two  tunnels  of  skin  running  beneath  the 
sear  supplying  the  requisite  integument.  In  the  ease  of  the 
boy,  which  was  the  most  estrcme,  it  was  difficult  for  him  for 
some  time  to  get  accustomed  to  the  new  position  of  the  head, 
which  felt  to  him  as  if  about  to  tumble  off  backwards,  the  sup- 
port in  front  being  lost. 

The  cure  of  bnt  few  of  these  cases  can  he  completed  hy  & 
single  operation ;  a  series  of  operations,  extending  sometimes 
through  a  number  of  years,  being  required,  if  the  destruction  of 
the  integument  is  great,  and  the  deformity  implicates  a  nuntber 
oforgana.  The  organs  interested  in  the  health  and  nutrition 
of  the  patient  must  be  first  attended  to  ;  the  finishing  touches, 
afTeciing  the  ajipoaranee,  being  left  till  a  later  period. 


Ki'tXriKLtAL    CAHCEK    AfiV    KODE^\T    LLC'EK. 


47 


EPmiELIAL   CANCEK  AND   RODENT  tXCEEp 

TJiere  nre  three  kitiJs  of  morbitl  afFecliuns,  ejit-h  aroompitniod 
wiih  iili'i-niiicm,  iind  fticuntod  upon  naain  portioti  of  rho  fiwrp, 
wliu'-h  it  U  net^eAsnry  to  flisimgiuHli  IVom  each  oilier,  —  ephholial 
canctT,  liipii*,  nml  rodent  ulcer. 

KpifkfUal  cftncer  is  g-oni^rnlly  foiiml  upin  the  ekin,  iind  (?fl- 
j>cciiJlj'  upon  die  lower  lip,  though  it  is  not  conlininl  To  thia 
8itU!)tif>n,  but  ocours  upon  other  portions  of  the  hody,  as  the 
tiinjrue,  till'  at'rotnm,  the  Inhiii,  anniiul  the  nniis,  nnrl  cvmi  in 
the  laryin  or  |iliaryns,  [jjkiii  the  itteriiw,  and  in  the  hludilt^r,  I 
bbre  never  aeen  ii  cme  of  It  in  tlio  upjH^r  lip- 

Al  rh('  njmnicni'ctuent  i»f  the  tliaease,  thrre  [b  notk'ptl  n  swell- 
ing, with  ii  round  or  oval  hard  hiu^u;  ^^r  a  wart,  uitli  a  [in^ 
jffcting-  dark,  dry  summit ;  or  ftitn|>ly  a  scale  of  a  drirk  color, 
mu*t  generally  seen  on  tlie  clicck,  whidi,  a(ler  rtpcarod  remuv- 
al?*,  periiMpfl  ihruiigh  a  aerit^a  of  yeni's,  nlnmately  Itrniimitea  ia 
ulecmticiii :  iIiIh  cxtt^ids,  InvoKing  die  jjdJiLcent  tissues,  till  n 
large  nlctr  is  furim^d,  with  the  edges  evertc4l  and  eswivated  ;  the 
hjuiv  h  rciMiiih,  concave,  and  bleeds  cuially  ;  it  difichnrguu  a  thiu, 
HLuii.>u«  liijoid. 

The  difll^rent  appearances  dependent  upon  the  variety  of  sitiia- 
tjon,  or  the  [jLiinner  in  nhii^h  the  pernli.ir  rpithtlinl  relliii  are 
eituatul,  is  fidly  and  minutely  deacribetl  hy  Pngetj  who  slIao 
give;*  a  dtiscriptiun  of  the  mii^rorscopiL^  uppearanees. 

Them  IB  no  tendency  Inwiinls  healing;  nnd»  if  leH  to  itself, 
ihe  drstnictiou  of  siihslanee  betomea  mere  excennive,  the  iyui- 
jilmliti  glands  connccltd  with  tlie  diwaHed  part  eiiliirge,  Kiiully 
ulet-ndc,  und  dciitb  ia  the  r<isult.  Ejirly  exciaiou  wdl  usually 
nrre.'it,  and  fftotnelimes  defitroy,  the  dbeaae,  though  it  may  return 
in  the  nelglilforing  ti^^^uea. 

In  regJird  to  cancer  of  the  li[j,  the  disoaee  u  so  fVetjuent  that 
IS  Id  hiirdly  worth  while  to  addut^e  casea.  So  far  hh  my  L»xpe- 
ntncc  goes.  It  J*  more  geuerallv  aitimted  on  the  left  diiin  on  the 
nght  side  ;  having  its  origin  in  some  irritating  eauac  fi'equenily 
repeated,  suiih  us  the  flteuj  of  a  clay  tohiirei)-pipe,  or  tiie  pM>is[ige 
over  (lie  lip  of  the  saliva  ealuiiited  with  tubiiwo,  in  lohaeeo- 
cbewcrj^. 


48  THE  FACE. 

I  have  been  much  Btruck,  in  removing  cancer  oF  the  L'p,  to 
find  how  far,  in  almost  every  instance,  the  real  cancerous  de- 
posit extends  beyond  the  apparent  disease  on  the  free  surface. 
Too  great  caution  cannot  be  urged  in  regard  to  giving  the 
ulcer  a  wide  berth;  and  it  will  be  found,  on  dissection,  that 
the  sound  parts  have  been  seldom  sacrificed. 

After  removal,  it  perhaps  may  be  advisable  to  enjoin  on  the 
patient  a  simple  and  uuirritating  diet,  avoiding  animal  food,  and 
all  alcoholic  stimulants,  for  a  limited  period  of  time. 

Dr.  Walshc  says,  "There  is  only  one  affection  which  may 
easily  be  confounded  with  cancer  of  the  lip ;  viz.,  venerenl  uloer- 
atioQ,  with  nn  indurated  base.  I  behcve  it  will  be  admitted  by 
all  persons  who  have  had  occasion  to  observe  much  of  diseases  of 
tliis  nature,  that  it  is  oflen  impossihb  to  determine,  from  the 
local  characters  of  the  ulceration,  whether  this  be  syphilitic  or 
cancerous,"  ' 

In  tlie  cases,  however,  which  I  have  seen,  the  chancre  was  on 
the  upper  lip  instead  of  the  lower,  a  circumstance  which  I  have 
never  met  with  in  regard  to  cancer. 

Jjupus  generally  appears  £rst  upon  the  nose,  or  the  check, 
near  the  nose,  aa  a  small  tubercle,  yellowish  on  the  summit,  and 
reddish  around  the  base.  The  ulcer  wliich  forms  is  rather  more 
superficial  tlian  in  the  preceding  variety,  with  less  swelling;  the 
edges  are  rn^ged,  not  indurated,  and  soinetiuiea  everted  and 
excavated.  Lujms,  after  ulceration  has  commenced,  is  not  con- 
fined to  the  integuments,  but  may  also  involve  cartilage  and 
ligaments,  destroying  large  portions  of  tlie  face.  Sometimes  it 
heals  epontineously,  though  it  is  tJien  more  likely  to  return  in 
the  cicatrix ;  but,  if  extirpated  by  the  knife  or  caustics,  it  sel- 
dom returns.  Cicatrization  commences  at  the  circumference. 
The  cicatrix  is  peculiar,  usually  being  crossed  by  elevated  bands, 
and  ha\'iug  knobs  scattered  over  its  Hurfuce,  at  first  quite  livid, 
eubsequcntiy  becoming  wliite. 

The  last  of  the  three  diseases  received  from  Lebert  its  name, 
—  rod€t}t  ulcer,  —  which  has  since  been  adopted  by  the  best 
autliorities.  It  is  most  fre<juently  situated  upon  the  eyelids, 
sometimes  upon  the  ciieck,  or  more  rare/y  on  other  portions  of 
the  lace.     I  have  never  known  it  to  occupy  the  lower  lip.     As 


ErmiKMAL    CANCRK    AND    nODE^TT    DlXElt. 


41* 


llir  JjHon^u  is  nu  ifiti?ri?sUii*;  une,  and,  in  its  dingrosU,  ooinpara- 
lively  11  new  one,  I  will  vl'IITui'i;  to  lyitulc  tlie  fblJowIn^r  oxcclloat 
"ijktioQ  of  it  from  Pa^C:  "It  is  of  irroguliir  slmpts  bat 
genrriiJiy  tmils  luwiirtls  ovjij  or  nrcular.  The  Uh^g,  hciwever 
dccj^ly  mid  mioqiiiUly  I'jccnvntod,  id  iLsanlly,  in  niusi  p:irt,  not 
warly  or  ntnlnlnr,  or  even  plainly  grimuktcJ  :  in  comnist  whJi 
r4uux^m!i  ulcer,  one  may  esjjecially  observe  this  nbsenfre.  or  Ips* 
amount,  of  U[T-^-(m"di.  It  is  :tl*o  compamtivelT"  *\vv  nnil  glossy, 
yitUlinij,  fi.hr  ili  exlcu^  vprv  Uulo  it^lior  or  otlior  tlt^cliiii't.'e,  s\ui\ 
has  rommimly  a  dull  reddish-yt^lluw  tinl.  Its  burder  i«  uli^rfitly. 
If  at  iill,  plevnfed ;  if  <?lovata.1,  it  is  not  ironinionly.  or  inu<"ii. 
t'lfJiur  evertcti  ur  umiortiiined,  bnt  \r*  sinoi^tiily  rouinled  or  luwly 
Cuben!ulLitL\].  Tbe  immediately  adjacent  ekin  u^unlly  njjpears 
fjuito  Keidrhy.  The  biise  and  border  silikc  fen]  touy;li  and  hnM^ 
iw  if  Ijonnded  by  n  layer  of  induruted  Tisfiue  ah\ntt  n  line  In 
thickness.  TbU  Inyer  does  not  tnncli  inerea^^e  in  thicknenfl  »>< 
the  ulcer  e^Etendr^ :  ^md  herein  is  unolbcr  cliief  cnntrx'it  witli  vnn- 
cj^roiis  nlo^*n^Lio^  t  in  tho  pr^^rcea  of  rodent  nicer,  we  see  more 
desinicEton  ;  m  the  ennc^erou?*,  we  *ee  deytnietion  witli  t'liim-idenC, 
and  Eisually  more  tban  commensurntc,  growtk.  It  is  imly  in  the 
nu^st  ensee  that  a  i^rovvtfi  'is  sHSOciatpd  with  rodent  ulr^v-*' 

Mr.  Hiiiehin^on  liaa  also  published  an  cxi;t'llent  nrlicit?  upon 
tHU  disease,  in  the  "MediL^al  Timca  and  Gazette"  for  Sept.  311, 

Kiident  ul(^er  i^nires  complete  extirpation  by  the  knife  or 
eiuutiefi.  It  ift  veiy  likely  to  reium  j  but,  in  the  following 
ttiws,  did  not  rttiim,  like  cani-er,  in  the  exaet  spiit  :  the  difieaiw 
F^eemed  to  follo^v  on  at  one  >^ide  uf  il  :  ihere  wn>i  no  glimdcilar 
rximpti<'JLi]{Ui.  (The  tew  caapfl  which  fullow  will  ft^rve  to  illiia- 
trate  aunic  poinu  In  rcgsuvl  to  lliesc  ditien»eH.) 


Cakcei:  of  niE  Lir.  —  The  four  followiirg  cosea  of  i^anccr  of 
the  lip  nre  principally  intcrestin;^  from  being  all  iliat  have  oc- 
Cvirred  nmnni;  females  nt  the  Masaai-hiiHCUs  riciicnd  Tlnspitid 
for  a  period  of  over  forty  yearn,  iind  fnun  the  faei  that  ihrec  of 
the  four  were  naeerlained  to  have  »moked  a  pipe.  They  are 
quoted  from  ilie  Hospital  rccoTNis :  — 

7 


Case  XXI,  —  Otmt^r  o/  L^tt^rr  Lip  in  FemriU. — ""  P-  G,. 
aged  62t  nianicd  ;  bi>ru  m  Maine.  Entered  the  Ilo^jiiuiij 
May  4.  1852. 

"A  heidthy-loDkinjj;  old  Udy ;  knows  oF  no  hereditary  l^ii^ 
dcttcy  to  tuiUig'ikatit  di^caee^  Two  years  ago  tu^t  auiumer,  tke 
Buffered  irom  ^caiiker'  in  the  moutli  imd  inside  of  lipa,  upon 
recovering  from  which,  n  enudl  ulcer  was  noticed  on  the  under 
lip,  which  wafi  soon  followed  by  a  smnll  hard  'ivart/  not  pain- 
ftdf  hut  troublesome  from  constant  itching.  Last  aumaier,  this 
'wart*  become  detached,  and  woa  followed  by  an  uJcer,  which 
has  prop-e^eed  to  present  apijeaitancc. 

"At  about  the  centre  of  lip  projects  a  red,  fungous  maaH,  at 
the  haJHj  about  one  inch  by  tlu'ec-fourtha  in  diameter;  while  the 
everted  and  protruding  fungus  measures  in  cither  diameter,  over 
ita  convejdty,  one  and  one-half  inches.  Tlic  maw  b  soft,  red> 
and  tlic  baae  ia  not  indurated.  One  or  two  enlarrfcd  lympbatic6 
are  felt  Lcncafh  the  jaw,  lender,  but  not  painfuJ.  Tumor, 
thoijf^h  not  tender  nor  painful.  giYCft  a  seni^ation  of  wcigUt,  and 
maked  epecch  fiitiguing.  She  haa  amokcd  a  yipc  for  years. 
0[^erate<l  npon,  and  diachiu-ged  'well.'" 

Case  XXII. — "E.  C.»  aged  80,  widow;  bom  in  Irclaad- 
Entcred  tlic  Hospital,  Oct.  3,  ]S53,  with  qntheLial  cancer, 
which  waa  removed  from  tfic  left  side  of  lower  lip. 

'''  Being  an  out-patient,  the  history  of  her  disease  is  not  known, 
except  that  she  haa  been  in  the  habit  of  emoklng  n  ptpc  for 
many  years.     ShG  was  di^barged  well." 


Case  XXIU.  —  ''B.  S-,  aged  60  ;  bom  In  Ireland;  marric*!. 
Entered  the  Uoapilnl,  June  (>»  I860. 

'^  Tlufl  woman  haa  an  ulceration  on  lower  lip,  which  was  Hrst 
noticed  about  bvclvo  months  since.  There  ia  aotac  induration 
around  the  base.  No  enlargement  of  glands  about  the  nceJci 
Otherwiec  bculthy. 

"  She  haa  been  in  the  habit  of  amokiog  a  pipe- 

*  SKe  waa  oi>eraled  upon,  and  waa  iii  a  few  dnys  difichar^ccl 


KPITHKLLil.  CAXCEft   XST>   EODEXT   rLCEB, 


51 


» 


_  ^  XXI\''.  — ''K.  L.,  widow,  act?d  70,  bom  in  Ireland; 
■40^8  the  Hct^pital,  ^laroh  9.  I^t56. 

"Xine  moDths  ago,  a  smnll  "scale"  appeared  on  lower  lip,  at 
the  ruargin  of  the  mucous  meiobiUDe^  upon  reuioviii^  wliich  a 
filight  'cratk  '  wa*  noticed.  The  scale  wad  in  a  short  time  rc- 
Eicwed,  nnd  be^n^ii  ^^  a^unte  the  appciu'aucc  of  a  scab,  vrhicb 
inereflfcd  in  size  till  now. 

"At  present  it  resembles  a  wart  the  eixc  of  half  of  a  largo 
^wrry,  circiihir,  finn,  ed^-cs  ^haqjly  ilctinet);  surface  ron^h, 
aad  of  a  brown  color;  eurroundia^  [issue  not  Indurated.  It 
ia  about  oDO-third  of  an  inch  in  diameter,  unU  i^  miscd  one- 
twclfth  of  an  inch  from  fiurfnce  ;  bleeds  easily ;  not  tenJer  nor 
painful.      \o  hcredilary  lendencv  of  any  nature. 

"  She  has  never  emoked  a  pipe  cor  chewed  Mbaeeo.  Other- 
wise henlUiy. 

"Tumor  was  removed  March  10th;  and,  on  the  IVth,  the 
wound  haling  perfectly  umicd^  and  all  the  suturcA  being  re- 
moved, ahe  wa«  dLsoharged  well," 


. 


Rrairdi'ii  CtUGt  optrait'.d  on  tU  tka  M<iasfich*is«tta  Of-n^raJ  ffospitfiL 

WholvnombcTofcAses  of  cancer  of  loner  lipu|i  to  Jan.  11,  1861  37 

Ma[u 73 

Fctnitki     .,.«..-,.......,..  4 

Addicted  10  smokiD;;  a  pipe    _.....,.,...  44 

Not  ia  thci  bnbtt  of  etuukiag .  7 

Not  a«c«rlaiacd 26 


Case  XXV,  —  CAa}tci'e  of  the  Upper  Lip  j  resejMiuf/  Oan- 
etr.  —  Tn  June.  18*>4,  a  aervant-^rl  was  lulmittoil  into  the 
Hoepitnl,  with  a  tumor  of  the  upper  and.  left  side  of  the  tip« 
which  was  eupposed  to  be  cancer,  an<l  whi<^b  she  entered  to  have 
remored,  She  stated,  thai,  during  the  previous  winter,  she  hail 
noticed  a  tisfiure  oa  the  let^  side  of  her  iip|>Gr  lip,  but  did  not 
pny  much  atteniion  to  it ;  nor  dkl  she  think  it  nny  ihing-  serious, 
until  in  May  it  enlarged,  and  the  Bwelling  ini^ilieated  di4>  juljoin- 
ingpnrtfl:  ^upjjuratiun  also  commenced,  Ujjon  entrance  there 
was  an  oblong  ulcer,  with  an  everted,  fungous  eurlacc,  about 
two  inches  by  one,  having  a  soft  ba^e,  djjw'barging  m<x]ernte)y» 


52  ^^^^^  TIJE  FACE, 

ami  (vii;j<ing  pnin  ;  ^ircsenting,  IniU'Pil.  ti]\  ihc  Ji|i|ienrnjirc*  cH»r- 

hHe!  tlmu^liC  &\ic  uiiglit  Imvc  cuD[i'iiGtc!d  it  wLile  iloing  cliambor 
woi'k  Ht  ibc  lic>icl>  lleUiLiil  bcr  rl^^lit  cnr,  there  wns  a  herpctit; 
ufTccliuii  irf  (be  akin. 

Tim  unUtiun  of  tlic  parta  waa  Grst  relieved  by  a  p(niJtii;e. 
and  f^lic  was  put  on  a  gi'ain  of  tlic  protiudide  of  mertiiry  tLtod 
lime?  a  Oiiy.  A  week  aflcr  her  entrance,  sUe  wiis  ctlieiiKed,  luid 
Llie  dlscaae  tljuro uglily  ciiuteiiiccd  ivilh  iIil-  hciJ  iiitratfj  of  mer- 
cury. It  uhnust  ftt  ont'e  put  qd  an  improved  j^[i[)C!jni[ici;,  aod 
preecDted  u  liealtby,  granulatm^  enrface.  Ou  the  4lh  of  July, 
she  began  tt>  complain  oi'  sure  throjit,  iiriuttiou  altouL  tlie  *:]aiifU 
of  the  iieek,  and  Iter  Iiair  began  to  flUl  out.  Tlie  sore  gradiudly 
luaJeil,  and  llie  diasiii  made  by  the  gival  desijuetion  of  [larlj 
waa  almost  entirely  oljiiterated.  She  contiiined  for  aoun;  tluic 
afterwartls  under  medical  treatment  aa  an  out-patient. 

CAi^E  XXVI.  —  Ej:tcnsivc  litvirrent  EplthclUd  Cdnctfr 
of  tht  Nom^  and  part  of  ihe  Fact.  Op^rntiitn.  Cure.  — A 
rfrfpectabie  Irishwoman,  hi)  years  i>f  age,  entei'eiil  tlie  Ib».^pilal> 
in  May,  lS[ti\  for  a  formidable  cpitlicIiiJ  cancer,  which  nicen- 
pied  ceiirly  ihe  wbole  n(»se,  and  i;xtenJcd  on  the  It^tt  /side  of 
the  cheek  to  about  the  middle  of  the  lefl  orbit-  The  nostiils 
were  completely  ['iMniclcd  by  the  tumor,  "hlch  pre«;nled  tUc 
ninet  singnlar  appcarnnce,  ne  of  a  round  catdiHuwcr  niaaa  placed 
upon  tbc  nose,  with  the  two  eyea  peering  over  it,  Slic  anid  that, 
about  dx  f»r  eight  ycara  previous,  the  diflease  had  commeneed  by 
a  long,  narrow  wart,  growing  from  the  letl  side  of  tbc  nose. 
This  biul  been  rtraovcd,  by  aonie  improfei^eional  man,  with  a  ligJ»- 
ture.  Kcturtitng  aguin  tivc  or  six  yeara  afterwards,  it  waa  cut 
out  by  a  aurgenn.  lt«  however,  vci-y  slnTtly  re-appeared,  and 
aoon  a.*^umcd  fbiimdafhlc  dimciisioiiB,  Her  health  waa  good, 
and  tbc  princiiial  fluftcving  waa  from  the  irritiiting  dlecharge 
supplied  by  the  extensive  gnimdating  surface. 

Tbc  tumor  covering  the  left  nostril  woa  held  aaide,  and  the 
ala  nafi  cut  through  cloae  to  the  face.  All  of  the  remaining 
portion  of  the  niaaa  was  now  encircled  by  an  incision,  and  ihc 
tumor  dissected  ofl'  rapidly,  in  the  nu(l&t  of  llic  moet  pi-ofuse 


EPITHELIAT.  CAVCER  AlOl   ROl>KXT  ULCER. 


53 


hcmorrlia^.  The  vetisela  bciug  ?ecurcJ,  the  inrj^'c  wound  was 
narroiA'^  \tj  pacing  fuiarc»  About  tm  Inch  apiirc.  and  lying 
tlic  wuuud  up  in  ^cgnicnl^,  wo  as  to  oMitcratc  niiont  hnlf  of  it. 

o  the  remainder  was  npplic<l  aorapcd  lint,  wliidi  was  allowed 
to  liry  on.  She  suffered  very  little  pain  at^er  tlii^  operation, 
thon^  eotncwhnt  Ihchlc,  and  in   a   tew  day6  was   i\h\c  to  ha\G 

er  bod.  The  wound  gradunlly  cieatrued ;  and,  eo  lon^  ne  I 
lept  her  in  view,  fho  romnincd  pedcetly  healthy,  and  tlicre  wiw 
DO  rccurreuce  of  tlie  diacaac. 


RoiniNT  UlcbKh^Case  XXVII.  —  Rodent  Uh^r  of  ihe 

3^o*e,  K^diih*  and  Globe* — J»  C.,  5U  yo.ira  of  ngc,  npp!ic<l 
lo  me  in  IJJ^IJO,  for  an  nicer,  which  implicatcii  nearly  llic  whole 
^B  »ido  of  tlie  noac.  the  lower  eyelid,  and  the  cycbnli  of  the  rijrht 
iidc,  Hia  father  wae  living  at  the  nj;e  of  tfO  yenr^  :  hid  mother 
iliwi  of  consumption.    Thirteen  rears  licforc,  wliiJe  cutting' Avood, 

I  A  chip  flew,  and  struck  hira  on  llie  cheek  under  the  eyo.    A  pcd- 
Itr,  in  the  ynrrl  at   ihc   rime,  Jipplicd  ft  mixture   of  gTin-fottifn. 
A\  ni^dit,  hi^  IJice  ^uJled  ;  and,  subsequently,  the  wound  nleer- 
•tcd,  and  s]>rcud  to  ^omc  dUtanec  down  tlie  cheek.      For  aevend 
ycivrg  it  kept  its  plaec  in  the  check ;   hut  g;radunlly,  in  apitc  of 
treatment,  it  invatlcd  the  eyelid,  and  finally  nitocke*!  the  eonjunc- 
y       tiva,  and  ptnctnCed  to  the  pcriu^tcal  membrane  liehind  the  eve- 
^I^U.     Dr.  James  C.  White,  by  applicationa,  had  kept  it  at  bay ; 
^^T>ul  finally  referred  him  to  me  for  opcmiioii.    The  appennince  of 
the  ulccrntio:!,  which  now  occnpicd  the  eiJc  of  the  iioac,  and 
had  destroyed  the  left  eyelid,  and  conjunctiva,  covering  the  eye- 
ball, wa*  unlike  cither  the  mi^^ed  disease  csillcd  epithelial  can- 
^^ccr,  or  liipu^,  \vii)i  jta  cut  edgca.     It  had  nioi-c  of  the  look  of  a 
^Hdried  ulcer,  adhering  firmly  lo  the  deop-aeatcd  parta,  and  with 
'       Iml   little   anbMaucc.      It   answered   i'ully  to  tlic   description    of 
"  Uudent  I'lecr/' deaeriftdl  hy  Mr.  llulchinaon  in  his  diffcren- 
j      tial  diaynoeie  of  the  diacaaea  mentioned  abovcp     I  removed  the 
^Bvholo  di^eahC  ^virh  the  cycbidl,  cut  itwiiy  the  cd^  of  the  upper 
^^cyclidt  with  the  la!*hca,  dissected  up  the  &kin  of  the  cheek,  and 
hrought  the  raw  edgca   of  the  eyelid  and  cheek  together.      He 
ft  good  recovery  j  tlie  Boeket  being  gradually  entirely  filled 
lip  with  an  Ldvcntitinus  tissue^  and  tlic  skin  heinr;;  stretched 


u 


TIIE  FACE. 


across  its  eitemal  Aperture.     The  tioee  cic&tmed  well,  and 
scar  aftcrwftrda  remained  heal  thy. 

On  Oct-  10,  1^«*>3,  a  Bruidl  ulcer,  the  eizc  of  the  head  of  ft" 
pin^   nppeQrcd   on   the   cd^o  of  the   f^ockot.      This   occnaiom 
ejirciid,  und  was  ohliteratcd  Liy  grinding  into  it  nttrate  of  silvcTi 

ThJa  ulceration  did  not  extend  much  iu  hrcatlth,  but  sccmi 
to   penctnitc   backwai-Js  very   slowly :    cerebral   eympComs 
rurrcd,   followed   by  general  deterioration   of   tlic   hcixlth : 
he  diedf  about  a  year  af^erwardsi  with  very  littlo  external  mi 
fe^totioo  of  disease* 


Case  XXVIU.  —  Tforfen^  ITtcer^-  —  H.  R.  C.  was  opci 

on  by  nic,  Feb.  8,  lB(;i>,  f^>r  the  lihovo  cliecat^e*      He  waa  60 
ycura  of  age.     About  twelve  ycura  ago,  he  had  a  Hmidl  pimple 
on  the  right  cheek,  near  the  nofle»     This  renwuned  quiosc<?nt  for 
Boinc  years,  vh^hen  he  applied  caiidtic  Ut  it,  under  which  it  di||^H 
appeared.      It  was  followed  by  an  indurated  tumor  under  it^" 
Abo^it  four  months  eiiicei  Bnding  thia  inet^asing,  and  involviiig 
the  akin,  he  made  repeated  applications  to  it  of  the  acid  nitrat^H 
of  mercury,  which  cou&ed  a  Oecp  niecratiom     Thia  inercafic^^ 
atYer  tfje  applicatioLB  were  ettip|)ed  ;  and,  when  I  perfonued  ih^ 
operation,  the  base  of  the  ulcer  was  fonned  by  the  |ierioatoi 
of  the  malar  bone^  and  its  aidea  (which  felt  almo^^t  bony)  wci 
of  considerable  thicknees*     ToworJa  the  mouth,  only  the  ini 
coua  membrane  covered  the  indurated  parts.     The  oritioe 
the  chcak  was  about  the  size   of  a  ton-eent   piece.      The  edg;cfl 
were  rather  deprcsacd  tlian  elevated,  not  red,  and  very  friablo. 
The  whole  of  thia  dii^cnee  waa  dieaected  out,  and  peeled  ofi"  troi 
the   bone,  leaving  it  bare,  and  with   a   lar^c,  deep,   ^[>ii 
wound.      By  eome  lateml   cntd  and  a  little  diesection,  tite  skill' 
could  be  slid  ^o  aa  to  cover  about  two-tliirtia  of  the  wound, 
without  tension.      The  microacopic  nppearaneea  gave  no  indico^H 
tion   of  a  cantcrous  affection,      I  «aw  this  pati<inl  in  May  ;  the 
wound  on  his  ta<'c  wati  entirely  heal(*d,  and  no  tnarka  of  di^flse 
there.     An  uleerution,  however,  aiill  oiiatcd  on  the  nose,  and 
aecnjcd  disposed  to  extend   on  the  inside,     A  eharjj  crayon  of 
iiltrnte  oi^  aiher  was  freely  ground  into  it  eo  as  to  doatroy  thoj 
tieaueti  as  deeply  us  possible. 


the 


THK   ETEh 


S5 


Case  XXIX.  —  nad^ut  Ufcev.  —J,  O.  S.,  fiO  yesrs  t>f  nge, 
a|)plii?il  to  ml*  in  August,  ]8fi3,  for  an  ulceniLhin  at  the  root  of 
t]ie  alu  of  dir  nght  side  of  the  ddag^  whiuh  wa;)  the  continu^inn 
«f  a  ili^eai^c  of  tim  or  fifu^en  yeiirs  hUMiding,  It  hiicl  ctJinmenrcd 
with  an  ulttr  on  llie  ujjjier  lip^  ivhich  gra<Iii!LtIy  EKlPndetl  W  ihe 

»prt»ent  t^i^ut^  healing  faehmd,  and  coiitracting  the  lip  bo  that 
the  eilge  wjt«  uuw  LiiujFcd  up,  and  nearly  in  contact  witli  the 
nose. 
I  made  various  ap[ilicatiunfl  to  the  ultier,  hoth  cau»itic  And 
others,  which  only  served  to  ag^iivjite  It ;  and  I  finnlJy  Ue<<UI<^ 
to  operate. 
^^  The  loop  and  hardened  (liratrix,  together  witli  the  ideer,  were 
^B completely  sLud  tlioruiighly  ext^iaed.  Tlie  edges  of  the  lip  were 
^■brought  together  ;<□  as  1o  rL-atore  \t%  uri^fiial  Lirendth.  The 
^«  ■wound  hejdetl  rapidly,  :Lnd  the  paticut  aeeined  Lo   he   entirely 

cured. 
^K  About  a  year  aftcrwai-da,  he  applied  to  nic  again  with  a  j^mnll 
^HuleeraEiunT  jn^t  witliiu  tlie  iila  of  tlie  no.ne.  After  ViU-iouri  rippli- 
^HcatloiiH,  withuut  sui^ce^Hf  it  W!V*  cut  out,  and  at  unee  h^Eiled. 
^HTwu  montluf  afterwitrdr^,  it  rc-^ippeitred ;  and,  extending  f>oih 
^^laleralTy  jind  In  ilepth,  a.  third  apcrjithKi  wa*i  [icrformwl,  more 
1^  esten^'ive  ihiio  those  preceding.  Tliin  wus  fcJlowed  l>y  an 
^Beryeipelntous  atfeetion  of  bis  fiioe  ;  and  tJiis»  fiuhAiding,  by  albu- 
^^  niinuria.  He  grachmlly,  in  the  course  of  80fne  weeks,  fell  into 
,a  cauiito^e  suite,  and  died. 

Tlii*  patient  waa  of  a  very  florid  <iomplejtion,  hia  skin  very 

licit,  and  easily  dispoj^eil  to   inflame.      Half  of  every  year,   he 

m  A  hot  clitnate.      The  edgCH  of  tlie  nicer  presented  no 

|(if  tumor,  iU6  in  cancer  of  tlie  *kin.  but  were  fiLarp, 

id  hiid  a  mealy  look,  eaoily  broken  down  by  the  probe. 


THE   ETT5» 

Iaj^C  XXX,  —  CdPceroas  Tnun/r  ttf  (hn  lifghl  l^ifH.  I^fl- 
\vqL  lieeoveiy.  —  A  gerillemau,  73  ycara  old»  applied  to 
le,  April  14.  18S2,  on  B<:c(uiiit  of  a  tumor  projecting  friim 
ithL^  right  eyebilU  l)etween  the  lids,  sprijiging  from  the  mir- 
fiww  of  the  globe  juhc  l>elow  the  iria.      lieiwccn  Iwo  and  three 


56 


THE   FACE. 


ycara  before,  he  hod  what  he  auppoeed  to  be  a  cataract,  wlu?li 
dcBtroyed  t}ic  B>'\g\it.  of  tlic  eye.  Aftorwarde,  he  ^criLlclicd  the 
conjuiielivn  widi  hia  nail.  This  wne  followc^l  hy  n  smali  pimple, 
which  aJowly  dcvelojieJ  hito  the  tuniori  He  wa^  finely  Icii  ta 
ask  advice,  hy  the  recurrence  *if  fre<]uent  and  ecrioua  hl^eding 
from  the  eurihc'C  of  the  tiiinor,  Hiid  (d^o  by  n.  acvi-rc  imiti  over 
the  eyebrow,  which  preventctl  iiim  from  attending  to  bia  huai- 
ticije,  anil  iJiaturbed  hie  rc^t  at  nii;rht.  On  acpiiratin^  the  lide, 
the  ghfbo  was  tbnnd  to  be  cnlarge^l,  and  protrudwl  from  tho' 
socket;  the  pujiil  filled  witli  a  ycJIuwish-wbiLc  fluhjstftnee.  Very 
Urge  vcine  ran  fioni  tho  cunjuncliva  upon  the  tijnji>r.  ilc  t^aid 
he  had  liad  on  apoplectic  attack  about  three  montlia  bcforCi  at' 
wliich  time  he  fell  upon  the  floor,  striking  the  tumor,  and  eauaing 
a  copious  bcniorrbn^e. 

Operation.  —  An  ineiBion  was  made  at  the  external  ftngle  of 
the  eye  :  the  cyebull  was  seized  by  double  houka,  and   removed 
liy  tho   ftculpcl   and   aeisaorJ*.      The   hlL-eUinLf  waa  ft'cCt  but  wna  ^ 
checked  without  phi^^gin^  the  orbit;  two  or  three  vesacU  were-| 
tied.    He  gradually  and  |jcvfcctiy  recovered,  and  hved  a  number 
of  ycnra  ullcrwardf^,  and  died  gf  other  di^eo^e. 


Case  XXXJ,  —  Meluno^is  of  the  Riffht  Etfc  Removoii 
lir-covrr'/.^^^  ti..  27  ycard  oF  age,  entered  ihc  Ilo^pititl  on 
March  10»  1S5U,  for  a  tumor  of  ilie  riyht  eye,  ^vhlch  coiiimcnccil 
ei:c  years  before  as  a  flight  opacity,  attended  with  neutttlgio 
pains  ;  and,  nfxtut  four  years  after,  a  tmuor  appeared  juat  hcicw 
the  cornea,  seumini^  ta  aprin^^  from  the  conjunctiva-  Caustics 
were  apphcd,  hut  tmly  aggravated  the  diacjwc. 

Wlicn  he  entered  tlie  Uoqiitid,  the  globe  wivj  enlarged,  irregu- 
lar in  eliape^  the  anterior  f;bumbcr  was  obhtcrated,  and  behind 
the  pnpil  a  dai'k-culored  ^uhdtauec  wns  seen.  Ju^t  hilow  the 
cornea,  two  irregular  tumors  projected  from  the  hull,  between 
tho  Vnh,  surmounted  by  a  tranBpnrcnt  membrane,  dnd  con- 
taining dark-colored  contents.  Tho  wbolc  eye  was  the  seat  of 
intense  pain ;  and  an  o|)cration  For  its  roinoval  was  doeided  upon 
on  tliia  account,  iVom  the  great  irritation  produced  on  the  eye- 
lid*, and  from  its  probably  mohgnant  character. 

An  incifiioji  an  inch  long  waa  made  at  the  cstcmal  angle  of 


THK    KYK. 


57 


i-lid  ;  tlieglol)^  of  ilie  eye  was  seized  by  tiie  double  liooks  j  a. 
inted  bistoury  was  plunged  in  at  one  eide,  and,  tlie  eye- 
ball being  tnrcumscribed  wiih  ilie  knife,  tlie  temoval  was  com- 
Ipleteil  by  dividing  the  aerve  vritb  strong  curred  scissors.  The 
use  of  the  etroiglii,  shflrp-jjoiuted  knife  in  tlie  operation  in  niuuh 
preferable  to  the  blunt  bistoury  uaunlly  employed,  which  ia 
tnanceuvretl  with  difticulCy  among  the  dcep-sented  tissues,  end 
prolongs  the  oper^ition.  In  the  present  case,  after  the  removal 
of  the  tye,  the  tissues,  which  ftn'mod  llie  bed  of  the  glohe, 
were  oleflrcd  away  with  seiseors.  The  opemtioa,  as  is  often  the 
ease>  wjis  followed  by  very  pi'ofuse  hemorrhngGT  which  whb 
te?isily  Btopperl  by  furring  one  or  two  sponges  into  tJie  socket. 
Experience  generaUy  shows  that  aa  attempt  to  seize  the  ves- 
selfj  with  forceps  i»  useless,  where  the  hemorrhage  cornea  frotn 
^■uch  an  obscure  **itimtlon  as  the  loose  cellLhir  membrane,  deep 
^■in  llie  sncket. 

The  compressing  hninljfcgo  was  remoyed  on  the  followinjj;  day  ; 
H  on  the  third  day,  one  of  the  epongee  ;   and  on   the   fourth,  the 
^KremjLining  one^     The  patient  lelt  for  home  in  about  ten  days,  in 
^tw  goikd  state  of  beallh,  and  entirely  free  froQi  pain. 
^B      An   examination   'if  llje   disease   tiy  the  microscope  disclosed 
^Bcaneerous  matter,  wkh  a  melanotic  cclorlng- 
^^     The  patient  presented  himself  at  the  Hospital^  between  one  or 
^Etwo  years  after  ilie  operation,  in  a  good  state  of  heiJth. 
^1     These  two  cases  *;Ik>w  that  rJiis  formidable  diHcasc  may  bo 
^p^moveil,  witli  a  prospect  of  prolonging  life,  and  ivith  great 
t«lief  to  Bufiering. 

Case    SXXn.  —  Tawor  of   the    Orhii.      liemavaL  — 
lb,  IflfiO,      This  caae  was  that  of  a  gentleman,  09  years  of 
who  had  been  healthy  previous  to  the  commencement  of  his 
Four  ye^irn  hefore»  after  expotiiu^  to  a  current  of  cold 
IT  on  his  face  while  sitting  at  a  lecture,  he  felt  a  soreness  at 
M*  upjier  [mrt  of  tlie  orhit  of  the  left  ^y^-      Shortly  a  swelling 
ippeared  nt  this  spot,  which  gradtially  filled  up  the  soijket,  for- 
cing the  eye  from  its  aiiuation,  so  as  to  project  h  forwards  and 
:wards,  and  prevent  vision,  except  of  objects  on  the  same 


M 


THE    FACE, 


The  *iirfftce  of  the  tumor  vfus  irre^ilur,  aud  covered  by  iia- 
]nvgiid  \ciiiA.  It  WHS  tennc,  elastic  to  the  touch,  nnd  il:«  apprar- 
ance  at  first  wjlb  that  prefiputed  by  erinc[)hn]t>i(l  drspaat^  when 
mulcmg  its  vp-ay  out  fnun  thfl  interior  of  the  cranium.  It  liad 
increiLscd  one-thinl  ivithiii  two  niDiithtf.  On  a  Citrefiil  exploni- 
Tiun,  Jill  iiidislinet  fluctiialiou  was  [lerceptible,  Tliere  als<i  pro- 
jf('t«.I  from  iho  iipjier  put  nf  tfie  sfK^ket  n  s/Tiall  slicif  of  hone, 
which  cnU'i'Cil,  anil  wjts  in<zorporatixl  wilh,  itj*  pn.rietes-  Thia 
led  me  tu  the  belief  ibiit  it  niiglit  he  a  c&se  of  perio^tOBis,  and  tii 
jwlvise  tin  ejtplomtory  aponillnn. 

All  mci^IoiL  wan  niaik  througli  the  akin  and  orbicular  muede 
of  the  eyelid-  This  at  once  diKclosed  a  hony  aac,  which,  on 
lieing  punelurcd,  dlscharg^cd  about  four  uirnt-es  of  fclid  pus. 
Thia  ffiiCy  n&  fnr  as  jwi^isibic,  w.is  dwsocted  out.  On  carrying 
Uie  iiTiger  upwards.,  no  lusiplance  was  encountered  fur  two  inrhes 
above  the  niEirgiik  o£  tbc  orhit.  The  pressure  of  the  fluid  hatl 
npfiarcEilly  cuu^ed  an  abt4orE>lioii  of  the  lower  wall  of  the  ii-t>ntal 
RiniiM,  and  forced  upwards  Lh;it  porljon  u|ri:in  which  the  anterior 
lol)ea  of  the  brain  repose.  Two  opciiln;rg  could  he  distmguished 
williiu  ihc  cavity  ;  one  leinling  iiiUi  the  right  fmntjd  rsinus,  the 
other  communicalin^,  by  a  very-minute  opening,  with  ihe  uaeid 
cavitiea  :   the  interior  wue  lined  witit  a  delicate  iiiciubranc. 

After  being  once  empTJed,  the  cavity  was  a^hi  filial  with  pus, 
coming'^  as  was  supposed,  from  the  otlicr  sinus. 

It  was  eatuniLtcd  that  from  bix  to  eight  onucea  of  pus  escaped 
from  the  tumor  Ju  the  course  of  the  duy.  His  physician  in" 
formed  nic,  tluiE:,  for  some  days  after  the  i>|>or;itio]i,  the  dlsi^ijir/^ 
was  "iiujucudL' i ''  but  it  theu  gradually  decrcused.  The  eye 
neitrly  retrained  its  natural  {lositioii,  and  the  sight  waa  as  good 
OS  ever.      Ilia  health  was  uiiimpaire'K 

I  have  once  or  t^vice  eccn  ca^^ee  eimUar  to  the  above,  in  whicK 
iJic  eye  has  bceu  pnrttidly  forced  from  its  bucket  by  &  bony  cyst, 
aucceesfully  treated  by  a  free  incision,  and  removal  of  a  portion 
of  the  parlctes  of  die  cyst. 


THE   EAE. 


59 


THE    EAE. 

Care  XXXm.  —  EpithcUal  diricer  of  tfts  Him  of  the 
Jiifihl  Ear.  —  A  *^i»llcji]an,  15  ycnrs  of  a^o,  ivho  luiJ  aJwnyH 
leiJ  a  vi'i-y  leiu}^:"™!^  lito,  but  h^i  been  cspnticU  n^  coiiiai.iader 
of  a  s\x\\t  at  iBCn,  iLpplicd  to  mc,  iu  JMnj,  1859,  with  n  lnv^ 
ovtrhan^'in;;'  t'|»ithelinl  riwicor  of  llie  u|>j)or  [mil  of  tlif  rim  of 
llie  i-ij^lil  ear.  It  Wi  h>Ilowc<i  proUy  luiteh  llit?  course  of  (jiiiicer 
of  the  lip,  and  very  much  roeemblt-U  it.  It  ciiuKtHl  nu  very 
Bcrious  inconvpnieiioe.  For  hiilf  tin  iudi  on  ench  *iidc,  the  tkiii 
•was  ecalyy  thickuneU,  and  dnrk-culured,  as  it  appears  in  the 
coniiD<?nucDtcnt  of  this  afJcctioTi. 

With  Bciasora  I  remuYod  the  tumor,  topetlier  with  Jt  portion 
of  the  cartiian:G  of  tho  ear,  eo  ita  to  be  aure  li>  indude  tlu-  wimlu 
tJiBende-  I  aUowcd  tho  nouiid  to  blued  freely  for  ^oittc  titnc, 
without  attcDiplin;^  to  arrcHt  Jt ;  for  I  liave  otien  ohaetwdt  in 
operations  about  the  ear,  but  loore  especially  in  tho^o  involving' 
tlu?  lifbt^,  thiit  a  very  8lj<|;ht  irritiilion  of  the  wouud,  ftiieU  a^^  in 
by  the  application  of  foreepj^f  seGms  to  rouse  up  the  erectile 
tjttfluef  and  Jfi>'c  rise  to  troublesome  hemorrlia^^e.  In  removing 
licndulous  tuaiors  produced  by  the  irritation  of  carringa,  and 
vrbcre  «uture«  huve  been  iip]jlieil,  I  have  been  called  to  ]>ati(.'iitti 
Bome  hours  afterwards,  and  fouod  the  cur  in  tho  neighbor- 
hood of  the  wuund  "reatly  swollen,  the  hcriiorrhfi^  proluae, 
and  isming  Ir^im  the  whole  surface  ol'  the  wound  ett  nttppf ;  nn<l 
have  been  obIi;:je<l  to  remove  the  tbremU,  and  make  eootldn^' 
&nd  cooling  applieatioua.  In  the  present  instance,  it  wan  ncoes- 
»ary  lo  lie  a  number  of  arteries,  and  ^pply  a  little  fnvpui-ed 
fliuc,  which  haa  been  found  very  useful  in  obccking  slight  hleed- 
inpt.  and  a^  an  abdorljeut  for  dreaaiug  wounds- 

This  patient  did  well> 


Case  XXXIV. — Ilecurre^\f  J^Arovs  Tnmor  of  thr.  Eur. 
JiemoL'ah  — June  9,  1805,  a  young  man»  25  yenrB  of  age,  was 
Btnirlc  by  a  biUi  in  the  left  ear,  in  October,  LStSO,  eiiuHing  a 
fleah  wouiLil,  to  which  adhesive  ploj^ier  w:is  applied.  AtVer  two 
weeksT   a  small,  hard  rumor  appeared  at  the  seal  of  injury. 


60 


THR    FACE. 


When  this  was  the  size  of  a  pea,  it  wns  removed;  nnd  he 
experienced  no  ineonvonicnce  whacever  till  1863,  when,  from 
the  srriLtfh  of  a  etipk,  ihe  tnmor  re-appoarpj.  It  wm«  n^tdn 
removed  in  &ii  months  aftpr  the  injury  ;  and,  in  three  montKit, 
re-appen.red  for  the  third  time.  It  was  about  the  size  uf  a 
cherry,  hanlT  well  defir^eclT  emfinicing  the  heliK  of  the  enr,  and 
apparently  eneoTHlnimatnns. 

Tt  VMS  removeil  hy  a  V  indaion  with  9<;w9ors,  TVo  hleeding 
-veGvela  were  tied,  and  the  edges  of  llie  wound  bronght  to^rether 
hy  sutures.     A  microacopic  examination  showed  it  to  be  jibrous. 


nofwa. 


4 


In  thp  conrse  of  my  pi"ac[ice,  I  have  had  nn  opportunity  of 
observing  ri>nr  or  five  cases  of  horny  auLstnnreft  deiclope*!  on 
differenl  parts  of  the  hoily.  In  1836  I  bronglil  home  from 
Paris  a  wiLX  model  of  Uie  hejul  of  n  woiniin*  with  a  homy  esere*- 
eenee  of  from  eight  to  nine  inchefi  in  length  growing  from  tlic 
foreheiiil.  It  was  removed,  bj  the  celehnited  Br,  SoiiherbipIlF, 
from  ihti  head  or:Ln  old  woinun;  nnd.  ni  \i\y  rcquehl,  the  opera- 
tor wrote  out  II  denL'riptinn  of  the  viit^fit  he  ifien  heitig  over  ninety 
years  of  Age.  Thin  case  —  to  whieh  I  would  refer  aa  one  uf  the 
moat  pplehrated  cases  on  record  —  has  already  ijeen  puhlishefl 
ill  the  "  Transactions  of  the  Boston  Sueiety  for  Medical  Iiuprov 
ment." 

T>T,  WiUiiim  R.  Lawrence,  who  ohtained  this  occount  for 
writes  underneath  it  aa  follows  :  "  Dr.  Souherblelle  rjilh'd  upon 
me,  Jind  ieft  the  followin<r  deaeription  of  tJie  womun  with  th^i 
horn.  Tt  seeni.><  thnt  he  hoA  never  puhlii^heil  nn  aceount  of  i^^| 
Dr.  Souherbielle  is  a  eiiriosity  of  hhnself:  hi;  is  92  veura  olJ,^^ 
and  is  still  an  ofieinlmg  surgeon,  in  foil  IkealEli,  and  does  not 
wear  glasses  ;  waa  an  intimate  friend  of  Robespierre;  and  Bays  i 
tliat  he  once  examined  Fninkliri  for  stone  in  the  bladder.  He 
6ayH  that  he  has  pej'formed  the  high  operation  for  fttoue  i^etween 

fourteen  and  fifteen  hundred  tiuiee  ;   and  tbiit  that  ii  the  only  one . 

which  rijght  to  l>e  [lerfonned,  esccpt  in  children."  ^^^ 

M.  liayer,  in  his  work  on  diseases  uf  tbe  skin,   mentions  tn^^^ 
case  of  a  woman  under  llie  care  of  Dubois,  at  tbe  Hospice  do 


HORN! 


61 


"■crTcctlomicniciit,  who  hnr]  a  horn  occupying  tLo  ForcScmJ  eix 
inches  in  diameter  un<i  aix  inches  in  height.  It  was  very  bnrii 
nt  its  summit,  raid  wiie  cmhmced  at  it£  bnao  by  u  ring  of  epi- 
dcrmi*,  euch  as  ie  seen  at  tho  root  of  tho  nnils.  This  tumor 
hiallj  incrciLacdi  £0  j\a  Anally  to  pufiK  down  the  t^kin  of  tho 
itnd  and  cover  ihc  cyeliila :   a  fctiJ  odor  arose  from  It- 

I  have  aocn  ono  or  two  eases  of  tiimora  reecmbling  tlieee 
homy  uroiiiiRtioQfl  ;  one,  on  the  fneo  of  an  old  lady»  bolwoen 
two  and  three  inches  in  height,  with  a  baae  of  nn  indi  and  n 
haH  or  two  inchca  in  diameter,  of  b.  dark  brown  coJor,  and  of 
come  years'  ddmllon.  Upon  ueinj^  elight  force,  it  caino  off  in 
my  hand.  leaWng  at  ita  base  an  ulc?crated  Burfaco.  The  excres- 
cence wna  evidently  composed  of  dried  layers  of  pua,  originating 
in  a  chronic  ulcer. 

The  following  caae  of  a  true  horn  of  email  size  I  operated 
Ml  ID  1^63  :  — 


SE  XXXV. — Horn  on  the  FacG.  —  An  Iri^^hman,  fiO 
old,  \vitli  rather  a  Jricdt  ehrivelle*.!  akin,  presented  hiLiisolf 
nt  the  Hogpital,  June  ti,  l^l>^,  having  a  homy  excrescence 
win^'  from  the  skin  of  the  face,  on  the  right  eide,  ami  on  a 
1  with  the  edge  of  ihc  lower  jaw.  The  horn  itaeJf  was  rather 
more  than  an  inch  long,  situated  on  an  elevated  b.iac  or  tumor 
nbout  half  the  size  of  tL  amall  EniiltBh  walnut.  The  whole 
growth  waa  removed  by  two  incieiona,  leaving  the  healthy  cellu- 
lar membrane  below,  A  j>er|Tendkulur  seelion  of  this  tumor 
displayed,  —  first,  at  tbo  taec,  fat,  forming  the  mats  of  this  part 
of  the  tumor;  eeeond,  this  was  surmounted  by  thrce-fourths  of 
an  inch  of  c^rnpnct  epidermic  tissue,  on  top  of  which,  waa  the 
horny  structure,  disposed  in  cup-like  Uyere. 

I  have  also  lately  removed  from  the  forehend  cf  a  Female,  just 
between  tho  eyebrows,  a  homy  tumor  of  nbout  three-quarters  of 
ui  inch  in  lenj^'thT  and  of  between  one  and  two  ye^rs*  growth. 
It  had  at  tirst  the  apj^arance  of  a  wart,  this  being  g«Ldually 
BUrtnounted  witli  a  liorny  ^>roduciion.  It  was  removed  aa  in  the 
former  case  ;  and  healetl,  hai-dly  leaving  a  scar. 


fiS 


TilE  FACE* 


DEVIATION  OF  TUE   SEPTOi   oF  THE   NOeE. 

We  seldom  cbserve  in  bouka  on  eur^ry  nny  reference  lo  ll 
queaLiun  of  tbe  treiituiEiut  uE'  thia  a.1tbi:tJon  ;  it  l^mg  piiiinpnlj 
notlccfd  iti  conubCtlon  with  tlic  difTcreDtia]  di^gnu^ia  of  pol^|in9, 
niid  mucous  tlilckenlu^'  of  the  un^^d  cnvitice.  It  i9,  1i(nvcvei-,  an 
nffectiou  of  ft£>me  iuiportiiiice,  iujd  oue  in  cotieefiuencc  uf  whiuh 
patic^nta  oflen  i^pplj  ior  trcntuicitt-  It  would  be  sujtpuaoi!,  llia£ 
wlmt  {[»  lutit  in  frc^duui  uf  rt^spiration  hy  the  ubaLrucLiun  uu  udM^H 
«!de  would  be  made  up  on  tlte  other ;  but  this  is  uct  tlie  ciue^B 
Tlie  (ibetriicted  &ide  becomes  cougcatcd.  and  this  congestion  setati 
to  be  tnuiaiuittcd  in  pjirt  tliroui;rhout  the  whole  extcot  of 
nnbiil  ciLvitle^,  caui^iii^  difficulty  ia  breathiiij^.  iuordiuate  sec 
tloii  fruiu  the  noitriU,  more  or  less  congestion  about  the  Lea 
nnd  A  general  disturbance  of  the  health*  Patients  with  thia  di 
eujic  often  a[il>ly  fiJf  advice,  eupposing  it  lo  be  polvpus  \  an 
flomctiuics,  from  the  grettt  buji^^u^^'-down  of  the  ppongj  and 
ttiickened  mucous  mcmbriine  of  the  aeptum  on  oac  side,  it  ivould 
Bcem  ciiay  f^r  the  mistake  to  1^  made.  But,  on  examining  t 
tumor,  it  will  be  found,  fir^l,  always  to  belong  to  the  inn 
instead  of  the  cuter  aide  of  the  na&al  pafif^c;  Aecondlyt 
prcsMiig  ou  it  Willi  n.  prohe^  or  with  ihe  little  finger^  it  will 
found  unyieldjiig ;  and,  thirdly,  by  pii&aing  a  probe  ioto 
other  noalril,  it  will  f:tll  into  the  cavity  made  by  the  dcvlfttloit 
corresponding  to  the  [irominence  on  the  olher  eidc- 

Thc  method  which  1  have  adopled  for  the  treatment  of  theso 
caaes  will  be  best  illustrated  by  one  or  two  exiimplcSf  which  mny 
fierce  to  represent  quitQ  n  number  of  others  wliich  have  falJen 
under  luy  ohacrvation. 


Ca9B  XXXVI.  —  Deviation  of  the  Septum  of  tit  o  ^o^e, 

A  child,  12  years  of  age.  of  a  scrofiiloLas  hahJt,  was  brought  to 
me  by  its  parents,  having  an  extreme  dcviatiun  of  the  acpCum  to 
the  right  side,  coni[detcly  obatructing  the  passage,  and  giving 
rise  to  the  train  of  symptoms  already  mentioned  as  belonging 
to  tlie  severe  forma  of  the  uili^etion-  I  commenced,  with  much 
diflicuity  and  greikt  resistance  on  the  piut  of  the  p;itient,  b^ 


% 


DEVTATIOy    OF    SEPTUM    OF    VOSE. 


f;3 


• 


VII I J 


pfieeing  a  amnU  bougie  into  tlie  obstrucLod  noBiril,  koGpinjj  It 
upon  the  iloof  ol'  the  cavity,  so  aa  to  prevent  il«  pcneii-.illng 
either  in  nn  upward  or  lateral  dirocTum.  After  tliis  had  been 
June  for  several  dnjs  in  suoopssion,  a  narrow  pasange  wns 
opened.  Into  this  was  pmssetl  a  piece  of  prepared  sponge,  well 
oiledf  about  an  inch  lung,  of  a  cylindvical  shape,  and  pointed  at 
jt9  cxtremilT-  This  wos  aecured  on  tbe  outride  with  a  string, 
whieh  witA  fiatenffll  around  the  ear.  The  expansion  of  the 
apcnge  at  first  caiiaed  great  irritation,  whicli  wouhl  }jave  gone 
oil  to  uJcerfltion,  had  it  not  been  removed  after  twenty-four 
hours,  Afier  ihe  irritation  \ind  subalded,  the  sponge  was  again 
introduced;  and,  by  pi-o (deeding  with  caution,  nnd  removing  it 
^oiD  time  to  time,  an  opening  wiis  made  large  enough  to  allow 
tn  iVee  a  passage  of  air  as  upon  the  other  eJde. 

Cask  XXX\1L — Deviation  of  the  Septum  of  the  J^o^e . — 
A  young  genileoi-aa,  18  years  of  age,  with  marks  of  a  Btrumous 
(lifithe^Uf  eoiitulteil  me  on  account  of  a  deviation  of  the  Bepium  to 
llie  rigijt  E'ide.  lie  could  breallie  frecdy  througli  the  lefl  nostril ; 
but  cu  the  right  side,  he  could,  with  great  effort  ^  force  through 
only  a  #mall  porfioo  of  air.  The  tumor  formed  by  ihy  aejitinn 
looked  much  Jike  a  jMfh-pus,  forced  duwa  to  the  external  opening 
of  the  nostril.  I  first  passed  a  bougie  along  tbe  lower  eido  of 
tumor;  tijen  the  little  finger,  well  oiled,  woe  VQvy  slowly, 
with  much  dirtieulty,  inainnaled  into  tlie  pasesij^eT  forcing 
the  septum  over,  and  guided  nt  the  same  time  by  a  finger  in  the 
other  nostril-  On  withdrawing  the  finger,  he  breathed  freely 
tlirough  the  right  aide.  He  waa  now  a'lviscd  to  introduce  twice 
II  diiy  a  bougie ;  and  at  nij»l]t  to  wear  a  little  instrument  con- 
structed witli  a  spring,  so  that  it  could  l>e  closed  by  pressing  the 
blades  tugi'thor,  imd  then  allowed  to  exfiand  after  introducing  it 
into  th&  nostril.  After  this  course  had  hcen  pursued  for  a  short 
time,  the  paaaage  seemed  to  be  fully  diluted;  but,  on  ita  being 
neglected  for  sevenU  months,  the  difficulty  recurred  in  part,  ao 
&0  to  rei^uire  a  rejietition  of  tiie  treatment. 

Casi:  XXX\TII,  —  Det'iitfwn  of  (ht  Septum  Nasi,  ftith 
apparent   Ctthnveons  Dejxtsit  on    the   extemni  end  of  the 


64 


THE   PACE- 


Cartilage.  —  A  boy,  aged  12,  was  brought  to  me,  June  2-i, 
18li<j,  by  hifl  phyaidan,  i'or  wbnt  appjiared  to  be  a  tumor  in  tiie 
ri;;lit  nostril,  and  which  bulged  out  the  eide  of  the  nosG.  It 
hrtd  couie  on  gradually,  fionliy  completely  obfitructiBg  the  breaih- 
iiig  througb  that  noatrilp 

I  found  it  to  be  the  affcclion  mentioned  aliove,  Tbo  surfaec 
of  the  tumor  hud  on  it  one  or  two  streaks  which  looked  like 
uketntion,  but  wlLich,  on  being  examined  with  die  finger, 
proved  to  be  cnlcareous  deposit  on  the  end  of  the  cartilage, 
where  it  pressed  on  the  mucous  mcuibninen  At  first,  there 
eeeuied  to  be  no  visible  opening  iuto  the  nostril ;  and  it  wa*  with 
come  difficulty  and  with  gi-eat  rofietanee  from  the  pntieot,  tJut  ■ 
the  probe  eould  be  ind[nuaieLl  alon^  tlie  floor  of  tlie  ni^stril* 
This  was  replaced  by  ft  conical  gmn'clastie  eathcter,  through 
whieh  he  breathed  fi-eely,  I  ai]viscd  the  O'eainieut  pursued  in 
the  former  easea. 


TIIMOK8  OF  THFh  JAW-BONK. 

In  the  substance  of  the  superior  and  inferior  ma^Ufle  are  found 
tumors  of  vnrious  character,  myeloi*!,  cystic,  cancerotie,  fibroue, 
cjirtilfl^inouH,  and  osseous;  more  superEeiidly,  and  springing 
from   the  bone,  may  occur  e}mhtf, 

O|xsruttona  for  the  removal  of  large  tumore  of  the  jowa  were 
formerly  very  rare,  and  were  eunsidcred  highly  dangerous.  By 
the  use  of  improved  cut  tin  rf- forceps  of  large  size,  the  upper  jaw- 
bone nmy  now  be  removed  with  but  little  trouble  or  daoger; 
being,  in  faet,  a  less  f'oi^mldable  operation  than  tJie  excieion  of 
the  JoAver  jaw.  The  deformity,  loo,  ia  mut?b  less  than  might  bo 
expectoJ  ;  ys  the  cavity  ia,  in  a  measure,  filled  by  adveniitioufl 
tissue,  and  may  also  bo  partly  closed  by  artiltcial  coiitrivaneca. 


Myeloid  Triions  of  the  Jaw,  —  Myeloid  tumors  in  the 
ja^v  are  rai-e,  anJ,  at  a  late  stage  of  their  exUtenee,  are  orten 
djfitinguished  Avith  didieulty  from  that  external  affection  caUed 
"  epuUs."  The  following  caaea  characterize  well  the  history  and 
appearance  of  iliis  disease. 


MYELOID   TCHORS  OP  THE   JAW. 


65 


C\eE  XXXIX.' — Mffeloid  Tumor  of  the  Loii'ct  Jftw.  —  A 

Ilftdy,  ^L  jcara  ofa^e,  applied  to  me  In  iWVj  with  u  hanl  tumor 
en  the  ri^'Lt  siJe  of  tiif  lower  jnw,  in  front  of  the  socket  ^jf  iJto 
■c^ortd  moUr  tooth-  wliirh  had  bi?pn  estrooted  n  couple  of  yoara 
before-    Sim^  its  cxtmctioii,  she  haJ  had  ncurol^i^c  pains  in  that 
•ide  of  the  fauo-     The  tumor  hnd  aonjet^hat  tho  fcding  of  a 
cyatic  growth.     Th«re  waa  no  dieense  of  the  gum.     I  cut  dowTi 
Upon  it,  and  remorcd  it  even  off  \\\i\\  the  jiiw  with  the  bono 
forceps.     The  wound  rflpi<l]y  henlod  ;  nnd  I  did  not  see  her  for  a 
yew,  when  a  elight  buJ^'^in^-out  of  the  .jaw  was  perceptible  At. 
tJiat  spot,  but  not  sufficient  to  demnnd  eurglcal  intorfcron^^e. 
ijn  November,  18*15,  she  consulted  me  for  a  fuu^'oid  ;:rrowth 
*emhlia^  epulis,  occupying  moat  of  tho  horizontal  portion  of 
itJie  Jaw  on  tho  H^ht  side,  ^hicli  had   appeared  wifJiln   the  hn^t 
iroe  uumtha.      The  lower  ed^^e  of  ihe   bone  etill   preserved  a 
^-clenn  margin.     It  wati  decided  to  expose  the  diy&ise  hy  a  free 
extemal  indaionf  and  to  be  goTeme<I  by  cin:iimstanees  aa  to 
Texuovin;*  tho  whole  aubetttnco  of  the  jaw,  or  leaving  tho  lower 
1^^  riiu  of  b*Dne,      Thia  wa-s  done  in  tlic  maMner  related  in  tJje  next 
^B<oa«e,  and  the  tumor  exposed  to  view  :   tho  facial  nrtcry  was   tied 
^^  before   bein;;  cut,  to   avoid  the   f^it   and  troublesome  flow  of 
bJood  whidi  UBUully  takce  plaee  wlten  ihat  vessel  \&  divided, 
tooth  was   now  removed   in   froTit   of  tho   diaeaflc,   and   tlic 
tii^dom-tooth  behind  \  an^I,  it  hcin^  fbund  possible  to  preeervo 
iihe  ed^  of  the  jaw,  peqjcndioular  incisione  were  made  with   a 
iidl  haudaaw,  a  honzontal  ^^roove  underneath  the  tumor  with 
[ey'e  saw,  and  the  diviflion  was  complelcd  with  powerful  bone 
rrcepe.      On  romovint^  tlie  tumor,  a  emnU  cup-liko  depression 
[i^midned  in  the  cenfrc  of  the  jilace  from  which   it  was  tukon; 
tdr  althou^^h  this  appeared  quite  healthy,  ae  a  matter  of  pre- 
miion  it  was  eeoopcd  out  with  a  chisel. 

On  making  a  scetion  of  the  tunior,  the  bone  wiis  found  ex- 
faiided  to  a  ^hell,  and  contained  a  sofl  material  similar  to  that 
|lo  which  the  name  of  myeloid  has  l;een  pveu,  of  a  ^otX  uniform 
appoarnnoe.  ami  which^  on  examination  with  the  microscope, 
I  proved  to  be  a  Rue  epccimcii  of  that  ditfeaae.  It  had  broken  out 
^^^m  ita  osseous  envelope  on  the  outside,  and  then  hiul  sproiLd 
^^papidJy  over  the  gums  in  tlic  vicinity. 

L 


6e 


THE  FACE- 


Tbe   wo'tntl  was    brouglit   t(>p;cther    by  quite  a  number  of^ 
autnres,  ami  unifed  nearly  throughout  by  first  mteiition. 
patient  haxl  scarcely  any  const  itutioniil  disturbance- 

Case  XL- — Myeloid  Disease  cf  Loicer  Jnw^ — A  young 
married  woman,  19  yeare  old,  whoBO  p;oncral  heallt  hnd  been 
very  g;ood,  oonaullcd  me,  in  June,  1865,  for  a  tumor  of  die 
lowor  jaw-  It  Iind  commcnccHl,  two  years  before,  with  pain  m 
the  first  molar  tOf>th  of  the  ri^lit  lower  jaw,  which  was  thoitglit. 
nt  the  time  to  be  due  to  an  "ulonrntion  of  the  t(>oth,"  A  swell- 
ing, which  made  ita  appeurtiuce  a  year  imd  a  lisdf  after,  gradn*; 
ally  increased.  The  looth  was  then  cstrut'ted :  in  the  course i 
of  six  weeks  the  tumor  doubled  in  size.  It  was  easily  felt 
extemidly,  extending  from  an  inch  from  the  anglo  of  iht*  jaw 
to  the  canine  tooth-  On  the  inside  of  the  mouth  it  bulged 
out,  and  protruded  upwiirds  through  the  eavity  formerly  occupied 
by  the  tooth.  Sh:^  hjid  little  or  no  pdu.  and  experienrcil  no 
incouvcaicnce  from  it.      Her  general  health  was  very  gixvd, 

Op&ration.  — An  IncUion  was  made  from  the  zigoma,  sweep- 
ing around  under  the  ramu;*  of  iho  jaw,  atid  t<^rminnCod  near  the 
Up  iu  front  uf  the  angle  of  the  mouth.  The  fadal  artery,  wliich 
woa  now  cjLjToeedj  was  aeiacdj  with  two  piurs  of  forceps,  above 
and  below,  divided  between  them»  and  the  two  ends  tied.  The 
mucous  membrane  was  now  cut  through  into  the  mouth,  and 
the  tumor  esposed.  The  teoth  in  front  and  behind  being  ex- 
trnicted,  the  juw  waa  flawed  through  with  a  smaU  saw,  and  waaj 
theu  dissected  out. 

On  examining  the  tumor,  the  walls  of  the  jaw  were  foundj 
expanded  by  the  growth  from  within,  and  deficient  at  the  uppec 
portion,  where  it  protnided.  On  milking  a  longitudinal  section, 
the  gross  appearauwa  were  fijunJ  to  be  characteristie  of  myeloid 
disease ;  being  compact^  uniform  iu  appearance,  with  a  few  of  the 
characteristic  "  blotches." 

Under  the  raieroscope^  there  were  found  chmgated  and  many 
nucleated  cells. 

The  wound  healed  rapidly  j  but  her  health  remained  delicate 
for  some  months  afb^warda. 


SrVELOID   TUMOIie   OF  THE   JAW. 


C7 


Case  XLL  —  licmovftt  of  Upptr  MaxUhiytf  J]one  for 
^i/el<ftd  J}ij*ea^€.  Pal/iatcuG  Opf^ralion  two  i/cars  ht^J'fn*. 
jiriijicial  Substitute. — A  young  man,  10  years  ol'  ago,  en- 
tered the  HoapitrJ,  April  7,  1864.  lie  was  formerly  a  aolilit-r* 
A  ytoT  and  a  hidi' beftrre,  »  small  swelliiir^  wits  iiDticciI  ii[ioutlie 
outside  of  the  guiu  of  the  upper  jaw,  neat  the  Grat  uiolar  t€oth, 
foflowing  loo  earlj  exposure  after  an  attack  of  ti-pboid  lever. 
Thinking  a  cartons  tooth  was  the  cause  of  the  awelling,  it  was 
removed;  hut  tlii^  hail  co  eflect  ou  the  tumor.  Nine  moulliD 
nhcTt  tt  begAu  to  increase  in  ^Isk  :  on  adniia^ion  to  Uie  Iloapi- 
tult  it  inejisurcd  one  and  a  \iaI£  inches  in  diiinieter ;  was  ovoid* 
hard,  not  tender  upon  prcL^riure;  pmnful  at  timea,  pain  ^'  stream- 
ing np"  the  side  of  the  iace,  and  at  such  times  the  eje  was 
jUentJy  hlood^hot, 

'April  lilh,  he  waa  etherized;  the  lip  wns  drawn  up,  expoaing 
djc  tumor.  An  incision  wud  then  made  in  the  protruding  wall. 
Through  this  opening,  the  linger  waa  parsed  into  a  csLvity  con- 
taining a  pulpy  fiibftancc,  which  partly  fiUed  the  anb'um,  and 
which  waa  ecooped  out. 

A  fraginent  was  examined  under  the  microscope,  and  Touud 
to  contain  the  many  nucleated  plntee  of  myeloid  growth,  and 
ditftinol,  isolated  nucleated  ceJla,  euch  as  are  usually  found  In  tlio 
connection . 

Sixteen  days  after,  he  ww  dir^charged,  relieved. 

Nov.  21*,  ltf05,  he  returned  again  for  the  removal  of  the 
upi^cr  maxillary  ;  the  disease  having  rceurrcd,  and  made  consid- 
crahZe  progresa.  The  right  side  oi'  the  cheek  waa  occujiied  by 
SL  liard  (uuior,  expanding  the  anterior  wait  of  the  antrum,  and 
ini|jin^ng  un  HxQ  maliir  hone.  The  apciturc  previously  men- 
tioned was  Gllcd  with  a  dark^colorcd*  fungoid  masa,  of  the  «izc 
of  a  cheetnut.  It  was  deeidcd  to  remove  the  whole  bone,  as 
afl'ordin;,'  the  only  hope  of  cure.  It  waa  done  in  the  fullumng 
manner,  which  1  shall  describe  in  detail,  aa  being  the  mctliod 
which  !  have  unlinarily  pursued  fur  ihc  removal  of  the  upper 
aiaxillury  hime,  and  which  IcjIhVcs  ua  little  deformity  ns  any  of 
the  methods  proposed,  where  llie  diaeaao  is  extensive.  Ucing 
trlheri/^l  sufficiently  to  carry  him  throu^di  the  preliuiinary  in- 
cifiioiuj,  a  puiuted   bistoury  was  plunged  through  tljc  skin  just 


THE    FACE. 


above   tlie   lygfjTiijiiic   process   of  the   makr   bone.      A   curved 
fncL^ion  WHS  then   mndc  througti    the  s\dii   unil  miiiiclea  tct  tbe 
Hn<rle  cif  the  month,     A  bit  tif  sponjje  hsul  liccn  previously  Muffed  J 
itifo  (bjLt  clicek  to  prevent  the  blotwl  fnim  fluwing  into  tlie  Tmijc^.  ™ 
WJiiin  ihe  skin  of  the  face  i^  more  fJiicci^l,  us  in  oU]   |>craoiis, 
thid  inclnion  mnj  be  {nrnmenceit   Tower  dovniT  thereby  iiivi(lin£^| 
fewer  filiurjonta  of  the  fticinl   iieTv<**  leaving  lesa   pnralysis,     A 
t(Ju   Ii:iii[f<]   iiicisiari,  however,  embarriLSPes   the  sectioa   of  the 
bones-      The   flap  waa   dieeectei]   rapidly  up,    the  right 
the  nciHG  cut  nw:ij,  anil  the  contc?mj'  of  tfie  soctet  rliflsectral  pa 
tiidly  iroiu  the  floor  of  the  orbit.     The  bones  being  well  d 
the  vcs^icIh   iu   the  flupj)  were  tied,  the  blood  wnii  cleAreil   awit 
from  the  wt^iiul,  and  ether  wiia  again  given.     With  a  amall  hand-' 
Haw,  a  groove  was  made  In  the  frontal  process  of  the  tnalnr  bono 
and  through  the  zygi>matic  prfH^ess^  'i"'^  *^'*^  Boction  eompleled 
by  the  cutting  foreepa,  the   former  incision  eitending  into  the 
Hphf?no-m!»xillary   fiesiire,      Tfie   nitsal   |H-ocesfl   of  the   8Uperi 
maiilliuy  hone  waa  now  ent  through  in  the  direction  nf  the  *ani 
fiasTire.      The   month   being  held  wide  open,  a  vertical   inci^iio' 
was  made  with  a  f*trimg  p(Mnred  Icnffc,  rhnmgh  the  r^iveritigs 
the  hard  pahite  aa  far  biLek  aa  the  palate  hone,  iind  a  lateral  onff 
fruni  tlie  termiiiation  of  this  behind  to  the  rotJt  of  the  hu^t  ciiolar 
tooth.      Listen's  large  cutting  forfepa  were  now  iiseil   to  flivld 
the  bone,  whiijh  tliey  cleanly  and  efliciently  did  ;   the  first  incis 
tooth  hjiving  been  prcvijuely  removed.     The  whole  mass  w 
now  seized  witJi  powerful  bookci]  fijrcepa,  and  iiii  attempt  made 
to  depress  it ;   hut  it  field  faat  at  iu  junction  witli  th(i  pterygoid 
process  of  the  wphenoid.     A  diiael  was  therefore  driven  in  Iw- 
hijid  the  bone,  and  nn  iittempL  made  to  brejik  its  nttri^^h in enta, 
but  withoot  fliKTtsw,     A  blunt  chisel  was  then  inscrleil  between 
the  two  maxillary  bonca ;  and*  by  a  prying  motion,  the  lulhesion 
to  the  bone  behind  w&s  broken.     The  remainintjr  sofl  attaeh 
mentfl  weri;  divMisI  by  hhint  curved  scissors.     The  maxillary 
artery,  which  lileU  freely,  iva*  tieil.      Wien  all  hcmnrrfia^'e  luid 
ceafeeil^  the  e*Iges  t>f  llie  skin  were  ai^curatcly  broiigixt  together 
by  Kutures,  ciire  bein^  tukcn  to  nicely  adjiiat  the  Itp ;  and  one  op 
two  sutures  were  insertrtl  inside  the  moictli. 

The  patient  waa  gieatly  depreooeJ,  and  stinmlauls  were  freely 


KYELOtD   TUMORB   OP  THE   JAW- 


6d 


ImifiistcrcJ*  Tbcrc  waa  an  oo7.in^  from  Lho  wound  rlurin^  the 
titmc  <|jiy.  For  goiuo  days  the  piUi^C  rcniuinod  fcelrk  and  the 
^trcii^L  inut-li  dcprosecd-  In  two  wocks  tfiL^  powere  of  Jife  ro- 
i^ved,  and  ho  then  recovered  with  ^eat  rnpidity.  The  imrnlyaia 
waa  Icec  ttinn  usual,  nnd  ivith  a  alt^dit  cHbrt  the  cvelida  could 
l>o  nearly  dosod.  .Sight  was  not  impnircd.  The  union  of  the 
wound  WAS  j>erfeet,  except  at  one  Bmitll  spot,  where  a  Bolivary 
aeemed  to  ihreiLten. 

On  inepcetion  of  the  diaonflcd  part,  the  cavity  of  the  antnim 
wiu  foiuid  filled  with  a  sutt,  dui-k-oolored^  apon^  mace,  which, 
iindc'r  the  mioroecope,  pref^cnte^l  the  Avell-markcil  choriictcrs  of 

Iniyeloid  grcwtli.  The  disease  waa  entirely  removed  hy  the 
opcTBfjon. 
Jievifirka.  —  The  inciaionfl  in  tlie  soft  part^  in  tliia  ea,*e  leave 
M  little  deformity  as  any  of  llioae  putr^^eeted  for  the  exoiaion  of 
tlu^  hone-  Gensoul  rocomniend^  int^iBion  of  the  upjit^  lipf  a 
^roea  cut  through  the  eh<^ek,  and  n  perpendicular  one  at  the  end 
of  tiiie,  leaving  three  very  disajcreeable  ecarw.  Fer<xiieson,  a, 
iimple  cut  throupli  the  upper  lip  into  the  nostrilj  or,  ]x)saihly, 
%  eontinuation  of  thi«  incision  around  the  mar^^  of  the  ala^  up 
the  rtiiie  of  the  ni>eG,  and  alon^  the  ed^e  of  the  orbit,  if  necee- 
»Aary.  In  regard  to  the  boaea,  it  has  been  advised  to  make  one 
cut  Lhrou|:!h  the  maxillary  proee^  of  the  malar  bone  into  the 
»pheno^mnxillary  figaitrc,  instond  of  riividinj;  the  zyp^oma  and 
the  frontal  process  of  ihe  malar  bone.  The  objeetion  ih,  that  the 
M  tumor  rpenerally  oceLj[kieft  the  whole  cheek,  and  prevents*  the  exes 
^■cution  of  the  plan  propo^cfl-  The  trying  point  U  the  iidheslun 
^Hof  tJic  iimKillary  t)one  to  the  ptLTv;;*>iili  made  more  firm  by 
^Birtflommatitry  aotion,  Eo  that  in  malignant;  diai^atiGB,  in  attcmpt- 
^■in^  depreiffiiou  of  tlie  hone,  the  front  pan  of  the  nntrum  is  apt 
1^^  to  break  a^vay  from  the  posterior  portion^  retiinring  tlie  back 
|^_  port  to  be  flubBeqnently  removed. 

^B  The  ellght  deformity  Ict^  tiMm  so  extensivo  an  operation  ia 
remarkable.  There  la  n  flight  parulyjtie  in  the  cheek,  and  at 
firpt  a  confuftion  in  tl^e  speech  and  aome  difliCiUty  in  dep;lutilion, 
'Vhich  COD  he  almost  (Completely  remedied  hy  artJfieiaJ  appllaneea 
,ofpold,  i^itta  pereha,  or  hard  India-rnhber, 

With  a  little  mnn^>nient,  a  mneh  luri^^er  portion  of  the  £oft 


70 


THE   FACE, 


[inrlA  Govermg  the  piilitLt;  mi^'bl  be  8&veil,  as  iiwy  peel  ofT  cfteily 
when  the  buiii;  is  ciepreased- 

Tliis  patient  rec(»vereJ  ppTfi^ftly.  Tin-  salivary  fie^tula,  whidt, 
it  WHS  feareil,  woijUl  be  pcrniaijent,  dospil  iiftor  two  or  three 
jiljpliuiitionrt  of  caustic-  The  voice  and  deglulition  were,  of 
course,  veiy  much  iin^mireil  by  the  gre&t  cuvlty  lefl  nilcr  the 
removal  oPtlje  bone*  These,  however,  were  completely  i-cdtored 
by  tlic  iiigeiiiimF^  ron^lnictioD  of  u  ha.nl  nibl>cr  ohtiirnior  uuil 
^lahitt*,  Dijule  by  Dr.  Rufria  !C  Dieki^oD,  ilentiat.  lie  now 
r4[ieaks  well,  aud  IjcjujcIm  nu  luogfir  regurgitate  throu^di  tbe 
DUfiLrlle. 

Kpclis,  —  It  IH  TH^cpsaary  to  iliHtinguisb  epulis  from  niyiJold 
Jiaease  uf  tlic  jaw.  The  hitler  iH  UBuidly  a.  disease  uf  the  alie- 
nor tif  the  hniie,  which,  exleudlug  Diitwards,  after  a  while  pre- 
aents  an  a[>pertninee  similar  to  the  former.  Myeloid  dLscaac, 
involving  the  Muh.sUinee  t'(  the  bone,  and  changing  entirely  the 
rttnictiire  of  tlic  p:trt.  as  lei  well  deHeril>?d  by  P^gel,  itjipiirts 
the  cicie-ion  i>f  tliat  portJou  of  the  jaw  whii-li  ia  attach«l» 

Epnltti  ifl  comparatively  siipcrfii^ial.  Ii  arises  from  the  peri- 
ofttLrunj  aiid  ^^rows  outward  ;  is  more  coiiimoTt  in  young  persooe, 
ihongh  it  fre^jucntly  oecwrs  in  advanci^l  HfeK  If  the  gum  is 
reiuoverl  with  ihe  woeke^s  of  the  teech  from  wliieh  it  sprin^fs,  die 
diaraae  in  c.m-eil ;  tiut  care  should  he  taken  to  cut  deeply  enuiigh 
iiitii  tlie  boae  to  remove  the  whole,  us  otl]erwi?*e  it  will  be  likely 
to  return. 

In  ihe  case  to  Ihj  adduced,  the  disease  \\m\  lieconie  so  dee[dy 
BeJited,  and  attacked  to  such  an  extent  the  neighboring  parlj>, 
tliLit  removal  of  the  wJuile  Ujne,  which  wa«  very  small  iind  ileli- 
eate,  was  £nully  required. 


Case  XLII.  —  Removal,  throurfh  a  Sinnll  Qpenhuj,  of 
IJtilf  of  the  Lorrer  rJafr^-httn^.  EpuU-^.  —  A  married  lady,  30 
years  of  age,  considteil  mo,  in  June,  lyGO,  for  a  fungous  ex- 
creseenoe  occupying  the  alveokir  processea,  aud  aockeLs  of  the 
three  \i\i^i  molar  leeth.  Tlie  disejiae  rjo  up  a  little  on  the  ramus 
of  die  jaw*  and  lapfted  over  on  each  side.  A  yc.ir  previous,  whe 
laid  buhmitted  Lu  the  removal  uf  a  uiolar  tooLhi  and  tlio  jaw  had 


EPCLB. 


71 


'Dot  nncQ  been  in  a  flound  etnto.  A  phort  time  aftenvnrdj?,  a 
fungoua  growth  from  the  di&eJiscMl  aoclitl  wjie  retnured.  It 
gflvc  h«r  \ery  littlo  pnin,  but  wag  iccrcitj^ing,  hnd  tnken  in  the 
muooua  membrane  on  the  ouUlcle  of  tbe  jatv-bnuCf  luid  was 
^m  creeping  up  on  tho  as^enilinjf  pnrt  of  it.  She  was  Uesiroua  te 
^K  huvc  nn  ojierntiou  dono  at  uncr?,  so  tiiat  sha  miglit  ii^turn  home 
^Bthut  day.  Tliia  I  did,  as  thoroughly  us  pog^ible,  in  the  ordinfiry 
^B^n,  with  the  cutting  forct^pfi,  going  dceji  into  llie  jaw,  and 
^^HBiov'ing  the  disease  ^o  far  ns  it  4!oijld  Ix'  JpU.-ctGd.  Tlic  blood" 
ing  for  the  moment  wiifl  profuse,  obsf^iiriug  the  after  stepa  of 
t}io  operation,  a^  ir  always  dooH  when  an  nitciTi|]t  is  made  to  out 
away  pleees  of  the  jaw,  without  making  an  oj>eniiig  iJiiough  the 
clieek  ;  and  on  thi^  account  the  subaequcut  safety  of  the  patient 
^Aften  sacrificed  to  tlie  natural  desire  of  avoiding  si  deformity, 
le  liemorrhago  wjis  eliecked  by  tlie  local  u^e  of  porcbloride  of 
imQ«  In  a  fortuiglit  I  saw  her  again,  every  thini;  apparently 
bavitig  done  well' 

On  a  very  careful  extuoination  at  lius  time,  I  detected,  deep 
in  the  jaw,  rennuns  of  tlie  diseased  tissue,  and,  knowing  tlint  any 
ilelay  would  be  fital,  proposed  to  the  patient  an  opemtioa  for 
the  exposure  of  the  bone  by  an  exlcnial  incision  \   and,  if  it  was 

I  then  found  nDceaaary,  ihe  removnl  tti'  the  whole  bone.  Being  a 
person  of  great  courage  and  decision,  she  at  once  consented 
without  hesitalion  to  submit  to  any  operation  that  was  thought 
tiucessttry. 
On  the  20th  of  June  the  jaw  was  exposed.  What  was  left 
cf  it  was  found  to  be  very  narrow^  and  icTaJed  by  disease,  which 
nm  up  on  the  ascending  ramus.  It  was  at  oncfe  decided  to  di«ar- 
ticulutc  iIjc  bone,  which  was  done  in  tiie  uaiiid  manner. 
Tlie  wound  united  by  the  firjft  intention.  The  constitutional 
Irritniiim  was  sli-^ht.  On  the  fourth  <]ay  &he  eat  up^  nnd  on  the 
i^^  ilxlh  waa  out  <if  doors  ;  on  the  eighth  eIio  returned  home,  a  dis- 
^BtftDce  of  eighty  mileH.  A  daguerrotype  likeness  taken  at  thifi 
'"^'     time  scarcely  shows  the  marks  of  the  operation. 

November,  18ti.^,  being  in  town,  she  called  on  me.  She  wns 
in  fiill  hcaldi,  and  was  free  from  disease.  She  talked  plainly  ; 
»nd  used  the  remaining  portion  of  the  jaw  well  in  mastication. 
The  gap  caused  by  the  removal  of  bone  was  filled  up  witli 


71 


Tin:  FAOE. 


dense  fibroue  tJesiies,  which  accmed  to  ana\7cr  oU  the  purpose  of 
bone  for  atcatlying  it.  The  ladaor  Iccth  above  and  bclf>w  wero 
in  Eippoeitian.  Thctc  vraa  no  pamlyai:^;  and  the  murkd  of  tlie 
operation  wore  ^^carcdy  vbiblc. 


Cystic  Toiojis  of  the  Jaw.  —The  appearance  of  tL( 
tumors  ia  pcncroJly  very  iorraidalile ;  and  tijc  practitt, 
tJic  most  part»  when  the  wliolc  subetanco  of  tbe  l>onc  b 
dilated  into  a  mere  aao,  almoet  entirely  deprived  of  oe^fiuu^  eub- 
etancc,  hns  been,  until  very  recently,  to  remove  the  portion  of 
tlie  Jaw  involved  by  tlie  tumor.  Wlieo  the  tumor  hiw  ^towh 
simply  at  ttic  expeoac  of  the  outer  table  of  the  bono,  cither  of 
the  upper  oi-  lowor  jaw,  without  iuv<jlvinR;  Jte  whole  Bubelnnry, 
it  liofl  been  eu3toiuiiry  ti>  es|jlore  tlie  cyi^t  and  remove  a  portion 
of  it,  causiug  ioHammution  and  oblitei^ation  oF  the  cavity,  oa  in 
tlie  cafio  of  cyata  oceurrin^ir  in  eoft  purt^.  Diij>uytrcn.  in  hia 
cullectcd  artielofl  on  Diaeaaes  of  the  Hones,  has  attnoheJ  mure 
importance  to  tUie  question  than  any  odicr  writer;  aud  illus- 
trates, by  cafica,  the  effect  of  caposin^  the  tumor  by  cxtcroal 
disaection,  removing  a  portion  oF  the  sac,  ami  by  applicntioua 
cfFccting  lU  (»U iteration.  I'roleasor  Marclii  of  AlUmiy,  hn* 
written  p.  volua^ilc  paper  on  thia  subject  in  the  " Tranaaetions 
of  tlic  Jlcdical  .Society  of  the  State  of  New  York,*'  Profet^eur 
Groea  and  otlicrd  have  au^^eated  the  idea,  tUat,  iu  the  birgG 
CTBts  wlucli  involve  the  whole  bonoi  and  wliicli  formerly  were 
known  uniler  the  name  of  "  apina  ventojea,"  the  treatment  ahoulil 
be  the  same,  Iu  one  of  the  eaaca  cited  by  the  former  gentle- 
man, the  extirpation  of  the  bone  wua  finally  found  ncccaaory 
after  this  plan  had  been  tried. 

Afi  to  the  enuscti  of  these  diseaacs,  they  are  vnriou£.  In  tlic 
jaw,  they  probably  ariae,  in  moat  inatancea,  from  irritation  at 
the  roots  oF  the  teeth  ;  in  the  long  boues,  the  head  of  the  tibia 
for  inatance,  fwntx  blows, 

In  ltiG2,  I  published,  iu  the  ''lioston  Modical  and  Surreal 
Journal,^  a  case  occurring  in  an  elderly  woman,  of  a  eyat  whieh 
involved  the  aacending  portion  and  condyles  of  the  jasv,  and 
wliich  I  removed;  not  tliinkln^  it  eafc,  in  a  person  of  her  agc^ 
wlica  tlic  didorgiuiizatioa  of  the  jaw  seemed  to  be  so  complete. 


CYSTIC    TUMOIIS   OF    THE    JAW. 


73 


run 


tlie  risk  i>f 


expoi-imentnl  moile  of  trofltmonf.  Since 
that  lirnt?,  I  h.ive  hat]  tin  Of>[)ortunky  of  trying  the  eon acr rati ve 
^an  (jf  treatment  irk  two  lii^tanccst  which  I  pro[iu«L'  sliortly  to 
relate, 

Nuhdthi^tamling  llic  principle  wluob  Las  been  su^^esied  or 

[luntcJ  at  for  the  treatment  of  large  cyalic  tuniora  of  the  jaw, 

me  of  llie  wi'ittra  on  tlie  aiihject  have  pi-esenied  enaee, — where 

Jete  destnnrtion  of  the  hana  hns  taki?n  phice,  le:mnfr  nothing 

delicate  cyu, —  as  having  been  s^neeessfully  treated  by  the 

icuifxl  adverted  to.      Dnpuytren,   in   hia  work   t>n  DisenHea  cf 

B[>nes,  g-ives  several  cases  treated  witliout  excMunj  some 

uf  them.  ln»vevfTt  nnsiiccessfully.     M.  Nthiton  hns  nU\i  written 

the  Hithject,  referring  for  caacB  to  ihe  work  of  Dupnytren,  and 

vlvHin^  the  pnnoture  of  the  cyst,  aud  the  ^tuflintf  of  its  csivity 

^with  Jim.    Mr-  Krichsen  wiya.  that,  "  when  the  cysts  arc  ao  largo 

Lat  they  have  destroyeil  the   integrity  of   the  Lone,  nr   when 

ley  are  iLS^ueiiiteil  with  a  hirge  rjuantity  of  fihnms  tissue,  eo   us 

iMnslLiute  True   fibro-cyslie  tumors,  eTcision  of  the  di^caswl 

jnc  ini]>it  be  practise<l."     Mr.  .Stanley,  hi  his  "  Tn?iitise  on  the 

tiecHitea  of  the  Bones,"  deacrilrtjs  perfectly  the   affei'lioii,  hut 

JiM?«  nut  allude  m  any  other  op(*ralJon  than  the  "removal  of  the 

^Luinor,    aiid    of   the   portion    of   the    horn;    from  which    it.   has 

isen." 

Ill   the  rollowing  cjwea,  the  treatment  consisted  in  the  piin(v 

ire   of  the   ^ae   withbi    the    month;    cvneua(i:ig   il8   coiitcnta, 

d,  at  the  same  time,  obliterating  the  cavity  by  t^rui^hing  in  itfl 

wnWa ;  and,  liwtly,  in  keeping  up,  by  injections,  &c. ,  a  anfficitnt 

Ilegree  of  irritation  to  f;ivor  the  deposition  of  new  bone-  The 
ompamtiTe  mildness  of  this  moi^e  of  treatment^  and  the  excel- 
eni  ehanuTter  of  the  reaulla,  combine  to  award  tJie  pnifercnce 
or  this  operation  over  eseision,  or  even  tlie  large  external 
ipctson  adopted  by  Dupuytreu. 

XLIIL —  Ut/iflic   Tumor  nf  the  Lowgt  Jaw^^A 

woman,  aged  ^5.  with  light  hair,  blje  eyes,  and  delicate 

^n,  applied  to  me  in  the  opriug  of  1863,  on  account  of  a  largo 

tumor  invoKingtlic  whole  ri;,^ht  aide  of  the  Jaw  ahnvc  its  anjj^lc. 

lie  tumor  was  of  a  globulur  dhapc>  extended  boAik  under  the  lobe 

10 


Lun 


u 


TITF.    FArE. 


IC 


of  thp  our,  Torwimls  en  an  t.>  cncmacli  ii[mn  tho  iruvity  of  tl 
nioiali,  ami  upwirdit  8u  tn  Ut  pru*<  ii[»o»i,  ninl  soniewlint  to  over- 
lft[],  the  Kj'^fniia.  Tlie  eil^mnl  surface  of  Uie  tiinifjr  was 
Brnrjcilh  nml  «Lin!n;j;,  slightly  mlpnitttoua;  u.iti1  slie  *iuifti\il  fmiii 
its  pre88urti  i]|)oii  the  surntuudiiig  organs.  It  tiud  ciimmcuL;^^, 
floine  jeara  Iiefore,  by  a  swelling  nt  tlie  root  of  tlie  wisdom- 
tOiilTi  of  ill e  right  side;  nnd  the  i neon v tin iencc  naij*je*l  liy  iU 
|ir(*ssurc  hatl  l)eci>ine  eo  great  us  to  leiul  her  to  take  niea^urea 
f(ir  Its  rnnKtvjd- 

Upon  coi^flultatioD,  tt  was  Jui^iJl'J  tluit  a  portion  of  tljc  jiLW 
would  probably  rtquirc  removal ;  tljc  tumor  having  been  first 
exposed  by  an  incitiion  mitde  inside  of  the  mouth,  to  vtrJfy  ita 
character . 

TKi;  fulluwijig  operation  wu»  pe:'fonncd  under  tho  influence 
of  ether.  An  iuijifiloii  wils  ui^dc  in  the  umsi  prommcnt  part  oi 
tbc  tumor  in  the  mouthi  upon  wbich  a  hirg^e  quiiDtlty  of  gluiiy 
Huid  escnped-  Upon  pulsing  iJio  fitiger  into  the  opening,  it  was 
foi^nd  that  the  whole  Jaw  at  tWt*  point,  with  (be  artluulatmg  and 
coronoid  proee^^aes,  wa.s  ozpacidtid  into  a  mcru  bhell,  at  some 
parts  us  tijiQ  aa  parchment,  and  destitute  of  osseoiiii  aubatance. 
It  watf  witliont  aolld  i.'oiLtents.  Under  Llic^e  eircumstanceri,  and 
cou»!derhjg^  tlie  good  bejiltb  and  youtli  of  the  patitrut,  it  wau 
determined  ti  make  the  attempt  to  aave  the  jaw.  A  portion 
was  thi^refore  removed  from  the  aric;  and,  with  tlie  fingura,  the 
aided  of  the  cavity  were  made  to  tolln[ifle,  au  an  to  eume  in  eon- 
tELct  with  eiich  otber.  In  order  to  excite  »till  fuilber  irril.ition, 
a  bit  of  cotton  cloth  waa  fojv^  iuto  the  interior,  and  tl^e  end 
left  pi-ojeeling  intL>  the  uiuuth.  A  moderate  dogioe  of  irritation 
followed;  and,  at  the  end  of  a  day  or  two,  Uie  pledget  was  re- 
moved, suppuration  baviug;  commenced  in  the  sac>  The  aper- 
ture was  dilated,  from  time  to  time,  by  the  introduction  eitlier 
of  the  finger  or  of  a  bougie,  and  the  sac  iiijectcd  witli  tincture 
of  iodine.  At  the  eud  of  two  or  three  wcckd,  she  left  the 
Ilospllal,  with  the  tumor  reduced  to  about  otio-hnlf  lU  origind 
size.  From  that  time  until  tlie  prescul,  f\iG  has  occasionally 
visited  me  at  my  liouae  ^  and,  by  keeping  the  extcrual  opening 
free,  and  occasionally  irritfiting  the  interior  of  the  sac,  a  ao!id 
ma^3  of  bone  has  been  deposited  anew,  aad  the  Jaw  hue  resomcd 


CYSTEC   TUMORS   OF    THK    JAW- 


75 


Brnncirniit  of  it*  orip;innl  shape.    Tho  sac  ia  in  the  way  of  becom- 
ing; entirely  oblitoraled. 

In  November,  1863,  I  ofrain  saw  the  palient,  who  camo  to 
coDfiuit  me,  not  about  herself,  but  about  a  frienJ.  All  bi^s 
of  the  tumor  had  dianjipcaretl,  anJ  the  jaw  had  rogained  almost 
iU  nntunU  »hape ;  but  n  small  apcrlure  siill  cxUted  at  the  dite 
of  the  tbrmcr  opening  into  tlic  mouth,  and  A  filairy  fluid  wae 
fifeft*iiornlIy  difieharj^Dd  from  it.  She  wriB  i^nilo  well,  and  all  the 
iunctic^n^  of  the  jaw  were  perfectly  performed, 

SuhFcpicntly,  abu  ajiplieJ  to  me  with  a  tumor  of  a  smaller 
I,  whiuli  liad  ftppcarc<l   in  the  jaw  anterior  to  tho  ftilo  of  the 
^nt  one.      It  wa^  treated  in  a.  eimilar  mB.nncr,  with  a  aimllar 
result. 


Case  XLIV.  —  Cj/slic  Tumor  of  the  Lov^cr  Jaw.  —  May 
23,  1863,  Dr.  Bennett  of  Uxbridfje,  Maaa.,  brought  me,  as  a 
patient,  a  ^jemlleman  56  years  of  age,  with  a  large  tumor  on  the 
ri^'ht  Bide  of  the  iaee,  oeenpyin^  the  parotid  region.  He  was 
pale  und  Ballow,  mudi  cinauiatcd ;  and  hia  aspect  at  first  etruck 
inc  9a  that  of  a  pereon  entering  from  maUgiinnt  dlBcaae.  He 
Btud  thai,  five  yeare  tn;forc,  while  earing*  he  bad  the  fieneation 
of  fiomething  giving;  wj*y  in  the  neighborhood  of  tho  ascending 
nittiUB  of  the  lower  jaw,  Sh*>rtlT  after,  a  tumor  appeared  in  that 
region,  which  had  flowly  incrcn^oil  to  ita  present  size.  Before 
making  an  cxaminationi  it  wa*  not  easy  to  say  wheOier  the  In- 
Ki<iT  was  connected  with  the  parotid  gland  or  with  tlie  jaw. 
From  the  commencement  of  the  diflcaac  to  the  prcecnl  time,  maa- 
tication,  and.  for  a  good  part  of  the  time,  deglutition,  liad  been 
much  interfered  with.  The  tumor  hajl  been  examined  by  many 
pliyei^'ians  of  experience,  and  by  moat  of  them  coneidercd  as  a 
parorid  lumur,  and  aa  the  patient  infcrrcii,  althtiu::h  he  was  not 
direetly  told  eo,  of  a  malignuut  character.  It  CKleitded  baok- 
wtirdd  into  the  parotid  region,  upwards  upon  tho  faec,  and 
iDwarda  so  aa  to  occu|*y  the  ri;^ht  hulf  of  tlie  palate ;  and  was 
covered  with  a  highly  irritable  mucous  membrane,  somewhat 
fi^lcmatous,  and  similar  to  tvJiat  we  olVon  see  inve^tiTig  malig- 
nant tumors  in  tltc  moulh,  whieh  have  mode  their  way  throu^^h 
irom  tlic  neek.     Duiing  un  exanunation,  the  patient  said  there 


76 


TUG    FACE, 


liad  been  of  late  a  sli^lit  di«clt;ir<,'t;  of  fluid  into  tlie  mouth; 
iuhI,  on  making  a  Careful  inapct^tioo,  a  minute  aperture  wm 
detected  nt  the  point  wlierc  tlic-  la^^t  tituW  tuoth  iirul  ^jtxa 
removed. 

t)n  introducing  a  probe  nt  Ihia  point,  a  jet  of  eenim,  miKcd 
with  tiakea  of  Innph,  was  projci'tcd  to  Q,  considerable  dis- 
tam-e,  I  immediately  enlar^'cd  the  opening  with  the  knife, 
80  llittt  I  could  intruduce  the  fin^'er.  Thid  wua  a  ninlter  of 
aorao  ditficultj,  however,  oa  Uie  patienl*s  jflwa  had  been  for 
a  long  time  nearly  closed  in  consefjuencc  of  the  liiseaeei  The 
finder  pcnctnilcil  into  a  lar;;c  aac,  extending  far  out  of  reach : 
and,  on  investigatLon,  it  aoozi  bccnmc  evident  that  the  whole 
tumor  wna  fitrmcd  by  the  cipnnsion  of  the  jaw,  irom  the  de- 
velopment within  it  of  an  ininicndc  cyet.  On  withdrawinp:  the 
finger,  a  harrier  of  bone  was  felt,  citcnding  iicroaa  the  jaw; 
and  behind  it,  under  the  first  molar  tooth,  another  amnllei'  sac 
waa  discovered. 

I  now  decided  to  treat  thia  case  in  a  mmiiar  monner  to 
the  preceding  one-  An  obl^^ng  piece  of  about  aa  inch  in 
length  and  half  nn  inoh  in  width  wuh  removed*  by  eciaaora,  from 
tlic  wall  of  tlio  cjfit ;  and  with  a  fiogcr  of  one  hand  in  the 
mouth,  and  a  finger  of  tho  other  on  the  outside  of  the  face, 
the  pidea  of  the  cji^t  were  bn>ken  down,  giving  way  under  the 
preeaure  like  i>arehrncnt,  witli  a  crepitating  noiac-  The  pro- 
jection of  the  tumor  on  ^ic  face,  oa  well  bb  within  the  mouth, 
became  in  i\  great  measure  cfJiiced.  There  was  a  alight  but  un- 
important clfupion  of  blood.  The  patient  returned  home,  under 
ihc  eliargc  of  hid  physician,  with  the  intention  of  pursuing 
pretty  much  the  same  eourec  aa  wafl  adopted  in  the  former  in- 
atan'.'c.  On  account  t»f  hia  age,  and  the  debility  aiiised  by  the 
want  of  proper  nouriahiuL-nt.  owing  to  tiie  diHieidty  of  ma^tica- 
laon,  he  was  ordered  tonics  and  a  nutritious  diet. 

About  four  weeks  hitcr,  I  saw  him  npnin,  K very  thing  had 
irone  on  well :  the  tumor  was  not  more  tiian  a  fourth  iis  larcrc 
as  formerly,  and  oeaitication  had  commenced  In  the  wnlU  of  the 
eac.  His  health  was  witaderfully  inipr*)Vedt  and  hia  complexion 
bad  tiaf^umed  a  iiealthy  hue. 

Dec.  ^,  l^G3,  1  caw  him  foi'  the  third  timci   ao  altered  for 


cirsTic  TUMOns  of  the  jaw. 


77 


the  hotter  its  scari-cly  to  be  rcco;;ri>JZ^  ae  tho  Pfiinc  peraon- 
The  jnw  cxtcvnsilly  hiwi  resuiue^l  iis  nitural  *Lape  ;  antl,  cii  ex- 
muinatioii  with  tliQ  fiDi^er,  its  Jislini^tive  anatomiciJ  markg  and 
pi"o<:csses  ccmld  be  felt.  On  llic  iosidc  of  the  jaw,  wliore 
the  incieiop  hiid  been  ni(ule,  n.  deej>  eulcua  w;w3  obeervcd,  lim:d 
mitli  mueoiis  uieiubrano.  Into  which  a  probe  could  be  paseod 
into  the  asccndinj^  emiulw.  There  was  no  diechargo  to  he  de- 
tf^eted,  nml  tlie  jiowf?r  of  mai^ticalian  wns  as  ^od  as  ever.  The 
only  troubJo  he  experiecced.  was  from  the  lody;iotnt  of  fooil  m 
thli  cavity. 

Three  months  Inter,  ho  wna  spoti  with  the  ja\v  til  a  porferfly 
healtliy  condili^'D,  performinif  nil  ila  fuiit'tiona  ;  and  ihi?  only 
cbunge  frum  tho  nornjal  «tate  Mviu^  {icthnpr^t  u  tiu^tre  soVid  and 
somewhat  tiiickened  condition  than  natunil,  witli  tho  aulcue 
oxUlio^  at  tho  har.'k  part,  whcro  tho  liimor  had  ou^nnatod. 

In  I8CII>,  he  modo  me  a  rii^itf  ^  he  s^ud,  to  show  tlie  com- 
plete auccess  of  the  operation. 


Cash  XLV.  —  Cyeiu:  Tumor  of  the  Upper  Jam.  — A  young 
lady*  16  years  of  age,  of  EngUeh  parcnUi™c,  wne  brought  to  mo, 
in  May,  1805,  on  account  uf  n.  innior  which  Imd  been  develop- 
ing for  the  liLtit  tlircc  yenra  in  tiic  alvcohia  of  the  right  u[j|ier 
jaw,  jtlBt  alx>vc  the  cnnlnc  and  bicuapid  leclh.  Three  years 
)re,  the  nerve  of  the  canine  tooth  had  been  dcetroyod  by 
lie,  and  tlic  eorious  cavity  tilled  with  i^ohl ;  the  tir^t  bieue- 
pid  being  aho  filloil  at  the  same  time.  Jrrimtinn  soon  coni- 
mtmecd  at  the  roots  of  theae  teeth  ;  aod  grv-diiidiv,  and  aliuoat 
imporcoptibly,  il  flwcllin;;  appeared  there,  A  month  before  slie 
came  to  me,  this  lamor  opeo'rd  at  it«  moat  dependent  part, 
di^chnrging  a  glairy  fluid,  which  eontinucd  to  oKudo  until  I  &aw 
the  COM. 

Tho  aperture  admitted  ft  small  probe,  which  penctnitod  into 
u  deep,  eniootL  tavity.  With  the  fin^'cr,  the  tumor  from  below 
appoarL?d  linn;  but,  when  prce^s^d  upon  under  the  gum,  a  de- 
gree of  elasticity  wtus  distin^uii^hcd. 

1  infornic"!  the  piirent^  of  the  young  lady,  that  tho  rliseaee  was 
A  ey^tie  tuinor  of  tlto  bone,  and  advised  on  o|>nrntion.  This 
wad  utiflcntod  to.     Th^  [kutiont  waa  ethcriEodj  and  a  cut  made 


78 


TMK    FACE, 


iotu  tlie  tumor.  The  mucuus  niembruTie  wan  ihen  ilUsectin) 
up  from  ite  Harfoce,  so  aa   to  expii^e  so  niiicli  of  tlie  houy 

sm  jLrt  w*)i(M  iwlmit  nf  n  free  opcmii<;  bein^  matle  mtci  it ;  and 
a  portion  of  tbe  l»onc  waB  romovetl  with  Hciissora.  Tbc  finger 
ciHild  now  lie  passed  frwly  into  tlie  cnvity,  which  was  rpjilc 
smoritlj^ancl  (entirely  lined  wi(h  tnenibnine:  itwriw  not  ponctiatod 
by  the  roots  of  any  of  the  mljicent  te*^tlu  The  cjivity  ^M^a 
8tiifti:Hl  with  lintj  iq  order  t^  excite  i]kf1:LUiiMutory  action,  lor 
the  piirpoae  of  oM[teratirg  the  sae. 

The  operation  haul  all  the  eflecT  thjit  ciiulil  have  been  iWireil. 
In  the  caurw  of  u.  eou[>le  of  i[ionlhf*,  g^nulations  filled  up  the 
the  cavityT  entirely  oblilerating  it. 

k^he  was  complcltly  relieved  of  the  dij^^yisc. 

One  or  two  oilier  canes  of  cysts  in  tlic  upper  jaw,  I  have 
ite*\   in  tlie  same  way,  with   a   similar  result. 


Case  XL VI.  —  U^tnoval  of  ih*'.  Lower  Jaw  far  a  Cf/stic 
T^nior*  Snlist'fpti^vl  Lii/'ttuff  of  f/n'  Oiimtid  AHen/. — 
Mra.  W.,  a  widow,  49  years  old,  had  had  the  wifulom  tooth  of 
tlie  riLilit  flide  of  the  lower  Jaw  eslraeted  aljimt  twelve  yeara 
l)efiire  I  ^nw  her:  the  soel^et  remained  ijuite  gore  fur  some  tiiae 
afler  the  reinovnl  of  tlie  tooth.  813  years  after,  the  angle  of 
thn  jiiw  iwgan  to  enlttrge ;  stud  the  bone  jjnwiuilly  expandeil 
80  aa  to  form  a  tumoi'  the  size  <if  a  hen'»  i^^^,  which  eneroacLed 
upon  the  cavity  of  the  mouth,  and  displaced  tiie  tongue  and 
other  orgjine.  The  tumor  was  slightly  elastic  to  tlic  toueh,  and 
had  t)ecome  a  little  t<^ndpr  on  pressure;  with  this  cxcepdim, 
there  was  no  pain*  and  no  ineoovenienee  in  niiLstiealiou.  Tlie 
disease  involved  the  an^Ie  and  azricending  ramus  of  the  jaw,  and 
extended  forwimls  as  far  as  llic  second  bicuspid  tooth. 

March  30,  18GI,  the  portion  of  the  lower  jaw  beliiiid  tlie 
second  bicuf^pid  was  removed  in  the  nenal  maoner,  though  when 
the  bone  waa  seized  with  ^t^oug  forceps,  in  onlcr  to  raise  It  from 
iltt  itdltcsions  to  the  surrounding  [jnrtH,  uu  tl^e  application  of  u 
very  slight  degree  of  force  it  gave  way,  imd  disclosed  the  fact, 
that  the  whole  angle,  the  u^cendiog  ramus,  and  the  proeesses  of 
ihc  jaw,  bnd  become  rediiccil  to  a  sac  or  cyst  conlniuing  a  thick 
yellu^v  tluid>     The  opcratli^u  waa   liEUalicd,  lor  the  mott  part,  by 


CYSTIC    TUMOnS    OF    THE    JAW. 


79 


tlio  finn:er?  ;  nn<l  t>n?  lintrual  nerve,  which  lay  close  upon  the  inner 
surface  of  the  tumiir^  wna  iliaaeeted  out  lind  saved.  Seventl  vea- 
eela  were  tied ;  and  the  ed^^  of  the  wound  were  brought  to- 
gether by  siituresi,  three  of  which  were  plueoiJ  inside  the  iiiniKh. 
No  aeverc  eonsfitutiond  disturbuncc  followed  the  operation  ; 
and  oil  the  third  dny  tJie  wound  wiie  nenHy  united.  Two  dnya 
Int^r,  the  fnce  Bwcllcd.  and  the  wound  bc*^an  te  discharge  jura. 
In  the  coiirse  of  anoihcr  fintnight,  the  w^oiind  hiid  healpil,  with 
the  exeeptioTi  of  n  jtmnll  opening  at  its  lower  an<rle.  On  tlio 
17ih  of  April,  fl  alight  hemorrhage,  of  jwrhsipa  two  ounces, 
look  phiCf  from  thiti  opening;  ?md  on  the  niijhl  of  the  !^7ih, 
^^IkcJi  iIkt  palionl  ha<l  ho  fiir  rei!o\cre(J  fniiEi  die  operation  as  to 
think  of  ^Diny  home,  profuHe  bleeding  ocfiurred,  which  was 
widi  difticaltj  c<in[ro]li?il  by  a  pponge  and  conipreAses.  Ou  the 
2nt}if  il  becjinie  evident  ibat  the  hemorrbagc  could  not  be  con- 
trolled, by  even  the  muBt  careful  phigging  of  tUe  wonnd  ;  and 
the  ligature  of  tin?  cwrolid  artery  hcemcil  to  offer  the  only 
chance  of  saving  life.  The  paiierl  was  therefiire  etherised,  ntid 
iJie  ^pongCH  removed  frum  tlie  wound.  The  finger  pnsseil 
ri'adily  from  the  external  aperture,  corres|>ontling  in  poaitii^n  to 
ihc  iingle  ijf  rhe  emutd  jaw,  H8  far  iv\  the  <rlenijid  cavity  of  the 
teiiUHira]  lir>ne,  which  iVIt  nmgli  and  cjiriou^.  Pressure  upon 
tlie  carotid  urtery  of  the  ntTccied  side  diminished  the  bleeding, 
but  did  not  entirely  check  i[  ;  and  no  <^eater  clfnet  fallowed 
llie  com|»re6»iion  of  botli  cariitids,  Tlie  arteiy  wiis  tied  nl  the 
middle  of  the  neck,  after  a  Homcwhat  tcdioua  dj8scctiunf  owing 
to  the  atleuiatoua  atale  of  the  tissues-  A  slight  oozing  of 
hloiKl  cimtinucd  ;  but  it  wn^  ejwily  nrresled  by  forcing  a  picre 
of  sponge  deep  Juttt  the  wound  i[i  the  direcLion  of  the  blceiliiig 
TPs^elti,  On  reruovin^'  the  patient  to  her  bed,  it  was  notit*ed 
that  the  side  of  the  body  opposite  to  that  upon  which  the  Jirtery 
had  been  tieil  haul  become  completely  paralyzed.  The  pitndy- 
ais  gradu&Uy  diimuidied  us  tho  strength  of  the  patient  im- 
proved;  nnd,  on  the  Htb  of  May,  the  ligiilure  of  the  carotid 
come  uway.  The  sjjongea  bad  been  pi-evioualy  renn^ved  fnim 
th&  wotind,  which  bcnied  ni.pidiy.  An  dweesa,  ivhicb  fornml 
behind  the  ear,  did  not  dehiy  ihe  ciii'e ;  and,  oti  dte  24tb  of 
May,  the  piitjciit  w.m  dirti^hurgod,  cured,  hut  «till  F^omewhat 
focblc. 


ft)  THE  FACE. 

It  Jihoulfl  have  been  remarked,  that,  pnor  lo  commencing  tltc 
opcrati^m  on  the  jaw,  it  had  l;ccn  dcci<lo<l  to  unci>ver  tfic  tumor, 
and,  if  the  cvnt  was  found  hut  partially  to  occu|>y  the  }>onc,  to 
remove  a  portion  of  it  without  rcnioilng  ilie  whole  bone.  It 
wai4  evident,  however,  as  eoon  a^  the  tumor  was  expo,«ed,  thnt 
all  the  bony  tisHue  had  dli^appeared ;  and  it^  place  had  lxtci»iJic 
occupied  hy  a  thin  and  almost  tranq>arent  oy^t,  of  the  con^int- 
cney  of  jiarchment,  the  eoronoid  and  condyloid  processes  milk- 
ing a  part  of  it.  The  removal  of  the  whole  bone  was  lliorefiirc 
|«rfonned. 

The  effects  of  the  lipiture  of  the  carotid  were  quite  rcmark- 
ahle'  The  current  of  blood  was  suflioienlly  chcckeil  lo  nlhtw 
of  effectual  plugging,  which  lM.'fore  would  not  stem  the  cur- 
rent of  hloor].  The  effect  on  the  bmin  was  certainly  very 
itin^lari  A  hemiple^^ic  affection,  three  or  four  days  afjer  the 
nature  of  the  carotid,  is  not  uncommon  ;  arisiniTt  probiihly, 
from  an  inflammatory  action  taking  place  in  the  ^^ubstance  of 
the  brain.  In  the  prewnt  ini^tancc,  the  [>am[y«is  was  imruL'di- 
atc,  and  musl  have  ariaeo  from  the  sudden  dimimilion  at'  the 
supply  of  blood  to  the  brain,  following  upon  the  great  drain  to 
which  the  system  had  been  subjected  a  few  days  before. 

The  patient  has  been  heard  from  lately,  having  perfectly  re- 
cjjvered  her  healthp 

Can<"EUol's  Tumor-s-  — Cancerous  tumors  of  the  jaw  pre- 
nent  all  the  ehiiracteristicB  of  that  growth  as  seen  el^^euhcrc  ; 
nor  are  they  very  rare.  They  arc  more  fiequently  foinid  in 
connection  with  the  upjier  than  tlie  lower  jaw,  and  generally 
commence  in  the  antrum.  Being  concealed  within  the  bime, 
th<^y  otlt^n  make  tlicJr  way  into  the  nnsal  passages,  nnd  iucrensu 
to  a  eonniilerablc  size  before  they  nppear  through  the  bone  ex- 
ternally; and  for  this  reason  it  is  difhcult  in  the  earlier  sta;^C3 
to  decide  whether  the  disease  i*  malignant :  when,  however,  the 
tumor  has  protruded  l)eyond  the  wfilla  of  the  antrum,  and  when 
it  is  nituiitcd  in  the  lower  jaw,  the  diagnosis  U  less  difficiilt, 

Tvfi>  or  three  cjibos  are  jrivcn  in  illuatration  :  — 


CAKCEItOUS  TDMORS. 


81 


Case  XLVII.  —  Ttemoiud  of  the  Upps^r  MtimUary  3one^ 
—  Mrs,  G.,  aged  41^  years,  njiplioJ  to  me  in  Septombor,  1857, 
for  ft  tumor  of  the  left  upper  jaw-bone.  She  was  a  einull, 
tliin  woman,  of  a  <Ielicatc  conBtitutioTi,  and  eoraewliat  salUw 
primplejcion.  She  knew  of  no  hcveditiuy  dUpoaitiou  to  cnncer. 
She  w."V8  the  mother  «f  severfJ  ehildrcn. 

For  Uireo  yeora  ahe  had  perceived  a  AUncee  of  the  cheek- 
bone, anj  there  was  nt  tlie  sftnie  time  a  elicit  nnd  conatant 
dfschnrgt"  t'fum  th*-  noiitrU  of  ihul  side.  TliL^  continued,  and 
the  f^welling  inci'ensed,  until  July,  1857,  when  eho  Buffered  so 
nnieii  from  it,  tliac  her  physician  jiuneturoj  ihe  antrum,  after 
hiiving  extrflotod  a  tooth.  At  the  time  tliete  was  a  elight  hem- 
orrhage \  but  diree  ^f^y^  afterwanla  a  copious  diftcharge  of  pua 
tDiik  pluec,  which  continued  in  varying  qunntitles.  Wlien  tlie 
discharge  wag  etiudJ,  there  wna  much  fulness  nnci  pressure  about 
the  antrum,  which  wa*  reliovoiJ  hy  an  increweed  flow. 

Thtf  whulo  upper  jaw-bone  si^Qtnt'd  to  be  enlarged.  The 
tumor  bad  not  made  its  way  into  the  mouth,  but  seemed  dis- 
poned to  do  so  into  the  cheek,  die  integuments  of  wbiili  were 
reddened  and  a  Httlo  d.-dematous,  I  aJvised  an  operation  as 
iiffonling  the  only  ehance  for  relief  from  auffering,  thou^rh  iia 
ultimate  siicc&^  was  doubtful ;  letting  her  nnd  her  friends 
understand  fully  its  advantages  and  dJead vantages.  It  was 
that  the  operation  ahoulJ  be  drme. 
"waa  performed  in  the  usual  mauoer,  aa  has  been  before 
related,  the  palatine  bono  and  soft  palate  being  preaerved.  In 
depressing  the  botie  after  ili^  attachment  hai]  been  divided,  a 
|)orlion  at  its  posterior  part  was  found  adherenij  and  wna  left 
attjiciied  to  tlie  pterygoid  pn.icess  so  jis  Lo  recjuire  removal  by 
the  chiGel.  This  circumstance  I  have,  once  or  twice,  seen 
happen  in  removijl  of  the  superior  maxillary  hone  ;  the  natiiifil 
fidhesion  of  tlic  part  being  almost  increased  tn  anchylusis  hy  the 
inflammatory  action,  which  had  been  g<"Ug  on  lu  its  neiylibor- 
hood.  It  la  of  so  frequent  occurence,  that  it  might  be  well  in 
every  ease,  as  recommendeil  by  Dr.  J.  C  Warren,  to  pass  a 
chisel  beliind  the  bone,  and  loosen  it  hy  two  or  three  blows  ef 
the  mallet. 

She  had  a  very  good  recovery,  and  returned  home  about  three 

11 


82 


THE  FACE. 


weeks  after  the  £>|icrution  in  i^ocd.  health  anJ  spirita-  8hc  con- 
tinued well  tor  0,  time,  but  La6,  1  believe,  aincc  had  a  return  q£ 
the  didcitaop 

Case  XL VIII,  - — Mafignnni  Discosg  of  the  Upper  Jaw, 
Hcn/ovaL  —  In  April,  1S5£!,  Mrs.  N.  M.  applicJ  to  me  for  a 
tumor  wUicli  hnd  csi^tctl  uboitt  five  months.  It  coninicnced 
a  few  wet'kfl  before  the  hirth  of  a  diiM.  The  tumor  occupied 
nearly  the  whole  of  the  upper  masiUarv,  prcsaing  tlown  the 
pnlatc,  cxtciifhng  from  the  root  of  the  cnninc  Imek  to  (Lc  lost 
molar.  Extcrnolij,  the  swelling  otcnflcJ  quite  back  to  the 
car.  The  whole  bony  margin  of  the  erbit  waa  lo^t,  ami  its  plaee 
supplied  by  an  irrc^Iur  BwcUing.  The  pupil  was  turned  up- 
wards. No  tumor  couhl  be  perceived  in  the  nostril.  The  skin 
(jver  the  tumor  was  movable,  but  tcnae  and  gloiS^y*  Tkcro 
\xang  DO  doubt  in  re^'ard  to  the  D]aUp:iant  nature  of  tlia  disease, 
an  operation  waa  decidod  upon. 

Tiie  incisions  were  maclc  &  little  differently  from  thoi^c  I  Imvo 
ueuuUy  pi-actiscdf  on  aeeoimt  of  tlic  e:^tcnsion  of  the  disease  so 
far  bjtekwarda.  The  first  iticiaion  coninKiOced  midway  be- 
tween the  orbit  and  auditory  paaaagc,  nnd  cstcndcd  in  a  Keuii- 
circular  form  lo  tlic  angle  of  the  mouthy  with  fi  \cry  bri>a<l, 
backward  awcep  \  iont^yid  of  commencing'  juet  back  of  the  oriji- 
tar  pro<7fes  i»f  tlic  superior  nmsilhuy.  In  dei>rc9fliiig  the  bone^ 
aitar  the  u^ual  divisions,  the  hngcrs  were  useJ,  as  it  was  so 
dGgoaaratcd  by  tlio  disease  as  not  to  nllow  a  firm  hold  with  for- 
cope-  After  removol>  it  was  found  that  tbe  concer  had  pene- 
trated into  the  pterygoid  fossa.  Tlua  waa  scooped  out  Willi  the 
fingers^  end  a  hot  iron  applied. 

The  eye  regained  its  nutural  position,  and  the  wound  healed 
without  unpleasant  symptorasp  In  a  fortnight  she  left  the  Hos- 
pital, and  returned  homo, 

Case  XLIX.  —  Ilemovtd  of  half  of  Lower  Ja^e  for  Cflrt- 
cer.— Ja.mes  W,,  50  years  of  age,  apph'cd  to  me  in  the  early 
part  of  September,  lSo9,  for  a  tumor  about  tlio  size  of  a  hen^a 
eg*r»  oecupying  the  angle  and  horizontnl  [tait  of  the  right  j?idG 
of^  the  lower  jaw.     The  disease  had  commeneed  twelve  years 


c-ucrcRors  ttmoe*.  >o 

[tvriooslT,  with  %  umahoes^  in  the  jaw*  fi>11oweil  hj  sirellm^. 
Three  vcftn  brioK,  the  pAm  in  Lt  became  oxce7^ivi\  when  an 
upenmg  irmc  made  viih  a  lanoet.  and  a  di^^han;e  ot'  duid  ii>ok 
place,  anendcd  with  relief. 

H  hen  1  saw  him,  the  outlines  of  i)ie  jaw  had  dUuppeared : 
and  the  place  wa*  occnpied  bv  a  $niiX>th.  n^und,  slicU-liko  luiuvir- 
whkh  extended  from  the  canine  toc-th  backwards.  Hfini;  a  Utile 
upon  the  ramus  of  the  jaw.  The  tumor  projooccil  inwanl?:.  prv^s- 
in^  upon  the  tongue,  lUiing  up  ihe  palate,  nud  iib^inioiiriL:  aUhie 
ooe-dilrd  of  the  apertare  of  the  tauee?.  Hi*  health  w;i^  ptvttv 
good-  He  auflbreil  princi[tallv  from  the  ob^iruotion  to  do^lti^ 
tition,  and  the  affection  of  the  \oice.  The  di^'a^e  thu^  far  did 
not  KCm  to  hare  invaded  the  ^^1^  parti. 

There  appearetif  thcrefure.  to  bo  no  quc^tii^n  a^  to  the  prik- 
prie^  of  its  removal:  the  onlv  di.»iiht  wa^,  whethL*r  to  rvmi»vc 
the  jaw  at  the  articulalion.  or  .*aw  off  the  b^^ne  just  WIow.  The 
prine-ipal  objection  to  di^nrlii^ulatiim,  where  the  tumor  is  lar^e. 
b  the  division  of  more  or  ]e^^  of  the  lihiun^it^i  of  the  fai-iol 
nerve.  The  objections  to  sawing  off  tlie  Kmc  in  ii:^  a^oendinj; 
ramiu,  given  bv  some  surgeim;?,  is,  that  the  rouiaiiiin^  fra^iu-iit 
is  dnkwn  forward  bv  the  pten'*j'i*id  muscles,  and  aftovwanls  pni- 
duces  irritation.  This  I  have  not  found  to  lii>ld  gitM  in  praciii'e. 
In  this  case  it  was  decided  to  disarticulate,  the  opcnitiitn  boin^r 
performed  as  in  previous  eases-  While  continuing  the  dissceiiim, 
however,  after  the  facinl  arterv  had  been  cut  ancl  ti*-*!.  it  wa*  cut 
a  second  time,  although  the  inei->iiuis  were  not  canieil  any  fur- 
ther below  than  before.  The  tutnor  luul  lifteil  it  out  of  place. 
1  ruention  this  fact  to  show  Imw  the  best  concerteil  phui  may 
be  frustrated  by  the  anatuuiieal  di?iphieenient  of  the  [kuIs,  in- 
duced by  the  growth  of  tumors  in  tlicir  ni"ijrhboHn»od.  The 
flow  of  blood  wa^  arrcste<l  at  unee :  tlie  patient  lieenmc  quite 
faint,  and  was  obliged  to  Ijo  phireil  in  the  horixoutal  position  tor 
a  few  moments.  This  is  worth  mentioning,  as  it  so  ran'Iy 
oocurs  in  tlic  course  of  r-urgical  O|)0rations  whci-o  the  patient 
iff  kept  up  by  the  stimulus  of  the  ether;  ami,  preWous  to  the 
introduction  of  that  agcjit,  it  pnibahly  occiiriXHl  Jis  otieu  fnmi 
the  exhaustion  of  the  system  by  jmiu,  as  from  the  loss  ot  bloinL 
Tlic  [*cparatiou  and  di^arlieulation  of  the  diseased  portion  waa 
completed  as  usual. 


84 


THH  FACE- 


He  hnr^  w^arcely  a  htid  Bjmpttun  ;  ami  tin?  wound  vtis  nlmost 
entirclj^  ii«iled  ut  tlie  eiiJ  of  two  wunkrt,  wln^n  he  kft  Uiwti. 

On  makiuir  a  gectlon  of  the  tumor,  with  tlie  saw,  the  jnw 
wjis  fotJTHi  expanded  into  a  shell,  the  Ciontent^  Iwlng  a  soft  gray 
ni*».iter- 

It  mny  lie  worth  mentioning,  that,  in  dejir&saing  the  jhw  for 
difiarticulation*  fllthcu^h  dune  with  great  care,  the  ramus  jijutly 
gave  way  in  the  timior;  at^ainst  whit^h  oixurrence  a  mution  ]& 
given  in  rtome  works  on  siirgerj.  TJie  faciiil  nervu,  und,  m* 
fiir  IIS  could  he  siAt^ertsined,  the  pjinitid  duct,  eeeinetl  ti>  have 
e?iea[)t^d  thi^  Iririrtions;  llic  drssectlor  for  thtr  di?i3utM^ulHtii>n  of 
the  Inmc  b^ing^  itiadu  aa  fur  ji^  pos.^ihJi:  i'mm  the  iaaidt,  uJler  the 
tnmor  wtu  sufHelcritlj  freed  frum  the  aoR:  p&rta. 

FiBRODS  TcMOttS.  —  Fihroas  toiiiora  on  the  jaw  are  rare, 
thoLigh  they  occur  here  more  frequently  t}ian  on  other  honen. 
As  dcBcnbed  by  Paget,  tliey  are  round  orovul,  lohidateil,  dcnae, 
ami  heavy.  Tliey  are  almost  uniformly  while,  and  oecaaionidly 
contain  minute  spiculre  of  bone. 

Cask  Jj. —~  Hemoml  ixf  iht*.  Upper  Maxilhtrij  liitint  /tir 
J^tliious  Turi/'fi\  —  In  the  eujruoer  uf  I8o7,  1  wiia  re<[ue«lt'd 
by  Dr.  Edward  Reynolds  to  visit  with  him,  in  consfultation,  & 
patient  '^ho  w;La  Budevin^'  fmni  an  afTeetion  of  tlie  left  upper 
jawbom;.  Some  months  befure,  the  disease  liad  commenced  by 
an  irritation  in  the  ueighborhood  of  the  left  laehryuiji]  pitft^age, 
which  priKluceil  an  oljstruction  ami  an  overflow  of  tears.  Tfiia 
VfKs  fuDowtfd  hy  au  mcreaae  in  size  of  the  upjier  maKillary  bone  : 
doaUy,  an  apeiture  ap^ieared  in  the  alveolar  proeesH  of  one  of 
the  molar  teeth,  through  whii^h  there  waa  r  discharge  of  blood. 

In  the  lefV  noaCiil.  there  wil^  a  polyploid  luuujr ;  cuid  fliere  had 
been  one  or  two  bleedings  from  this  puiuL  A  probe  vMm  passed 
into  the  opening  In  the  mouth,  whioh  penetrated  deep  into  the 
niaxllUry  sinua,  and  waa  followed  by  a  free  diachurge  iff  blood, 
The  patient  being  rather  low  in  health,  imd  propuain^  to  make 
a  visit  to  her  trieudf^  in  Muiue*  I  provided  her  with  iuBtnictioue  ; 
and  ahe  agreed  to  sec  uc  u^iu  Li  ttic  courae  ui'  tlm^  or  four 
wcek&. 


FlBROUe  TUMOIiS. 


85 


At  tho  oxpirnlion  of  the  time  n|>p3iTit*?d,  she  returned  to  Hos- 
lOD,  improved  in  hcilth.  The  tuinor  in  tbo  noslril,  however, 
had  increusod,  aa  well  as  ihe  diateutlon  of  tliD  maxilliirj  ebufe ; 
sutd  Hte  haul  Budbjvd  From  one  or  two  aeverG  hcmoiThagea> 
thiriog  lliG  following  week,  a  bleeding  of  ho  Hcvere  a  nnlura 
took  place,  aa  to  render  it  necessary  to  bavc  some  iictive  sur- 
gical procedure  nt  onee  ndopted. 

Befurc  Tiiiiking  my  decidon,  1  pnssf^rl  a  finger  into  the  nostril, 
whi(?h  dist'losed  ii  Isir^ro  opening  into  the  nuisilliiry  sjnns,  from 
which  the  tumnr  in  tbo  nose  fiecmwl  to  have  projctled.  Tlie 
Jaw,  in  tho  neighbf>rhood  of  tho  upnTturc  in  tlie  mouih,  hiid, 
avice  the  laj*t  esnnuuation,  three  weeks  befurc,  been  more  or 
Itaa  forced  downwards  into  a  rounded  elnattc  tumor.  These  cir- 
cumstances  left  little  doubt  tliJil  the  maxilUiry  sinus  was  occu- 
pied by  a  tumor  which  wag  gradua-Uy  forcing  Uself  out  from  the 
bonv  cnvity  in  which  it  had  originated.  1  advised,  tlierefore, 
fm  immediute  o[>crfttion. 

The  operative  procedure  was  ns  ti^unl,  and  occupieil  nbont  ten 
Tninutes,  The  hemorrhage  wus  not  exceeaive,  and  the  veaaela 
were  easily  secured.  The  edges  of  the  wound  were  aj  ore«  ap- 
proxiniAted  by  sutures;  and  a  bit  of  lint,  moistened  with  cold 
water,  hiiil  over  the  surfaee- 

No  linl,  bits  of  epongc,  Dr  other  substances^  as  recommended 
by  some  of  the  French  surgeon*,  for  filling  up  the  cavity  made 
by  the  rernovrd  of  ihe  jaw,  were  used  in  this,  or  the  other  ca*ea 
in  which  1  have  done  the  o]>eratiou.  Wlieuever  I  have  seen 
tbcm  u*«I,  they  have  been  the  source  of  much  urrtntion,  have 
been  with  difficulty  removed,  and  liavD  enused  a  mo&t  otfenalvG 
odor,  from  the  retention  of  fold  secretions  in  the  mouth. 

She  recovered  fully  and  entirely  ^  and  now,  at  tbe  end  E)F 
nearly  nine  ycars^  T  have  hcaifl  of  her  In  tJ»e  enjoyment  of  goml 
be^ilth-      The  eye  siLffcred  no  injury  from  the  operaliun- 

The  tumor  was  of  a  fibrona  character,  and  wiw  completely 
bounded  by  its  c^ip.*ule.  In  its  expansion,  it  had  at  first  nearly 
oljlilcratral  the  lachrymal  passage  ;  next,  it  had  proilurtid  an. 
abnorptLon  of  the  hone,  in  thi^  vicinity  of  the  noittril,  iorcijkg  ita 
way  thningh  into  timt  cavity;  and,  (inally,  it  was  making 
Ita  way  dowawank  through  the  bone  into  the  back  jiart  o\*  the 


inou 


di. 


86 


THE   FACE. 


The  oj'ienition  was  aa  effectual  anil  auLiafaiitt^ry  ia  its  result  iia 
g.uy  one  of  this  dcacriplioiJ  that  I  have  ever  dune  or  witnesaud, 

Apparent  TrMons  of  tfie  Lower  Jaw^  recottdart   to 

THE  ItESrOVAL  OF  Ca^'CER  OF  THE  LlT. — It  ifl  aumetiiiiCH 
neceasar/  to  remove  a  part  of  iJie  jaw  for  oilier  Jiseases  tliau 
ttLDiora  oF  the  bone.  Tumprs  which  take  tlieir  origin  in  tlie 
Yicinity  of  the  bone  Homctiines  gi'ow  around  and  envelop  it  so 
as  lo  necefi^jt;ite  kd  rcuioviJ. 

AlWr  Laving  exaiuiaed  a  firm  and  a[ip^irt^nllj  ojsseous  tumor. 
of  the  lower  jaw,  anJ  after  Laving  fiillj  decided  on  an  opcvatiim 
foi  its  removal,  I  linvc  often  htcn  surprised  to  Icam  thiit  tlie 
pjiiicut  hud,  A  year  or  two  before,  heen  operated  on  for  cancer 
of  the  lip.  On  rritically  queatioiiiug  luLUf  I  have  discovered 
time  tlie  tuiuur  had  origiuat<;d,  not  hi  tJie  jaw  lleclf  but  under 
lU  in  the  position  of  the  aubniaxillarj  gland,  and  increased, 
tmlil  Hnidly,  embracing  the  bone  Jind  becoming  adherent,  it 
coLtld  not  be  d let! ngiue lied  from  the  bone  iLscir. 

Caag  LL  —  Ti^mor  ^imiltting  Canccroue  Diseaee  of  the 

Pttrviid,  itccomjMtiiitil  imfh  Famfi/^is.  —  1  hiivc  ^jcen  lately 
conaulted  by  a  ■j;enl]cijian  wlio  had  a  liatd  tumor  growing  ju^t 
helilud  hia  ear,  of  a  year's  atanding.  It  citenJeJ  under  the 
jiiw ;  was  very  firm,  almost  like  bone;  aud  appeared  to  bo 
tlic  parotid  in  a  Atate  of  Qiali;^'nant  didciiae.  The  eide  of  hie 
foc'e  was  paralysed;  and  aUo,  curioLis  to  relate,  there  waa  a 
Blight  |i:indyais  of  tlie  left  arm,  the  tumor  being  on  tlic  right 
side  of  the  body.  1  found,  on  investigation,  that  a  few  months 
belore  tlie  commencement  of  the  preeeut  tumor,  a  cancer  of  the 
lip,  of  some  yeurfl'  duration,  had  been  removed  from  the  left 
fiide- 

Case  LH.  —  T^pwr,  involving  iht  Jaw,  oacurritrj  njltr 
Htnwval  of  Ca/tcer  of  the  hip. — ^A  gentleman  it8  years  of 
age  was  politely  referred  to  nic  for  odricc,  by  Dr.  Gilinnn, 
of  Portland,  for  a  tuuior  abL>ut  as  large  as  a  email  orange,  grow- 
ing from  the  lower  and  outer  cdi^e  of  the  jjiw,  on  the  left  aide, 
concealing  Ujc  auglc^  and  extending  backwards  so  au  to  pres;^ 


TUHOES   SECOXDART  TO  CASCER  OF  LIP.  SI 

Upon  the  gnat  \es^h  of  the  neck,  and  partially  lo  inteHorc  with 
the  tiacheft.  The  inner  aspect  of  the  jaw  wa.<  qiiiic  nonnal,  lliuI 
rhc  teeth  were  eviJcTnIv  not  involvcJ.  It  feh  like  an  cxost^^^-ij?. 
and  had  the  regidor  form  characrori^tio  of  a  cystic  tumor  of 
the  bone :  it  was,  however,  pertoctly  tirm,  ami  had  nono  i^i'  tho 
ela^ticitv  of  the  latter  kind  of  ^ruwih.  I  had  ^oillotL  in  my 
own  mind,  that  ii  was  of  a  bt^uy  natiiro.  whun  tlio  |>;uiciu  ti^d 
me  that  it  had  be^un,  about  a  year  l>efoi'e,  tis  a  small.  iu<n-ul»]c 
tumor  in  the  situation  of  tlio  ^ubm:L\iltary  gland  \  and  that  it 
hxul  not  become  fixed  until  after  cighi  months*  and  had  then 
taken  on  a  rapid  growth.  He  also  ^idil,  that,  four  yeari^ 
before,  he  had  submitted  to  a  jiniluEiLred  operation,  by  meatus  <»f 
eancer  jdasters  applied  dally  for  i^evend  weeks,  fur  a  ^-Jiru-er 
of  the  lip,  of  whieh  a  scar  5till  rcmainM  rather  to  the  riirlit  of 
the  median  line.  On  a^eertainiu^  this  faet,  the  Inmur  was  a^ain 
examined;  and  it  was  found,  that.  \iy  exerting  niueh  foive.  a 
flight  movement  upon  the  jaw  coiihl  bo  prinhieeib  The  patient 
Tvas  therefore  informed,  in  iw  ilclieate  a  manner  as  iHi>filile,  i>f 
the  nature  of  the  disease,  and  that  an  operation  miirht  K*  per- 
formed for  the  removal  of  the  tuinor,  either  alone,  or  w:lh  a 
portion  of  the  jaw,  whieh  would  Ik?  a  nmeh  less  ditfirnlt  ami 
bloody  affair :  the  danger  of  reciiri'enee  would  of  course  n-maiu. 
lie  widely  coneludcii,  however,  on  aeeonnt  of  his  a^^e  and  Ins 
entire  immunity  from  jiain,  as  well  as  troni  the  danger  of  recur- 
rence, not  to  have  It   Jntertcred  ivhh. 

Case  LITI. — An  old  gentleman,  7*>  years  of  a<fc.  wa*i 
brought  to  the  Mu^saohu^eIts  General  Ihispital,  with  a  tumor 
of  the  right  side  of  the  horizontal  part  of  tlie  lower  jaw,  oi' 
about  the  size  of  a  pigci>n'g  e^^^'.  It  was  6rm]y  attached,  atul 
Gccmed  to  fonn  a  part  of  the  iHiiie,  and  so  far  painful  as  to  iu^ 
duce  him  to  rccpjest  its  removal.  It  had  eonnneneed  at  ifie 
lower  and  inner  edge.  Upon  inf[uiry,  1  touncl  that  he  had  bi.'eii 
operated  on  for  cancer  of  the  li[)  a  few  months  befoi-e  the 
growth  had  appeai'cd.  I  informed  him  of  tho  probable  nnluru 
of  the  disease,  and  of  the  Jan^^er  of  recurrence  after  n'moval. 
He  decided  to  have  an  operation  pcrfornicib  Aeeoriliji^irly, 
the  portion  of  jaw  involved  in  the  tumor  wud  removed.     The 


ss 


THE   FACE. 


diflcaae,  on  examinatiou,  vras  Found  to  be  cancerous,  and  firmij 
embraced  the  bone,  although  by  c^rctul  diaact-tiun  it  tould  be 
cntin^lj  aoparatix]  Erom  it,  inclLiding,  howcror,  the  pcrioatoum* 
The  Icrminolion  of  this  case  was  intcrcstrng.  After  the  |>a- 
tient  hw\  ivcovereU  ft'om  tbc  ether,  he  got  up  and  insisted  on 
walking  downtitairaf  which  he  did  with  the  aid.  at'  two  persona, 
one  on  c^icb  ttidc  of  him*  Just  ne  he  arrived  at  hia  hedside*  he 
beeamc  suddenly  tiuntn  Tho  nttcndnnts  come  running  upiatairai 
and  inforujed  me  that  the  patient  waa  in  a  dying  state;  and,  on 
going  instantly  to  him,  I  t\mnd  tUal  respiration  had  ceased,  and 
that  tbc  pulaatiuna  of  the  heart  were  scarcely  pcrecptihJc.  The 
mouth  wue  imnicdJatcly  opened,  and  the  finder  parsed  down  the 
throat,  in  order  to  allow  tbc  entrance  of  air  into  the  larynx: 
it  was  then  found  that  the  tongue  had  heeomc  retrovcrted  from 
the  xiarlial  dL-tjiehrnont  ol"  tioiiie  of  itd  muselcti,  and  bad  retracted 
down  the  throat*  It  was  at  once  seized  with  forceps,  and  dra^vn 
out  of  the  mouth,  and  means  taken  to  produce  arlifieial  reapi- 
ration,  as  in  ca^ea  of  drowning  ;  an<i  cventuJilly  respiration  and 
the  circidiition  were  restored.  The  patient  did  well  for  a  time  } 
but,  at  the  end  of  about  a  week,  he  was  seized  with  thoracic 
ayniptoiDS  of  wliich  he  died. 

NECiioaia  of  tub  Jaw.  —  Necrowa  of  the  jaw-hone  is 
eomctinies  caused  by  arBcnious  acid,  uaed  to  destroy  the  ncrro 
of  a  tooth i  at  others,  hy  phosphorus;  bIho  by  the  depre^eing 
effects  of  cold;  and  now  and  then  we  bcc  it  occur  without  any 
«peciHc   euusc. 

The  use  of  oi'scnic,  introdueed  into  the  cuvity  of  a,  carioua 
tooth,  Jiaa  hccn  very  estcueivcly  Allowed,  for  the  purpose  of 
prodiiein;^  a  aluu^'h  of  tlie  pulp,  and  thua  admitting  of  tlic 
flubaequcut  preatrvation  of  die  tooth  hy  filling.  Unlesa  care- 
flilJy  protceted  by  uii:tture  witli  uiorpliia,  to  dull  scudibility, 
tbc  pain  is  otlcn  of  the  ujodt  excrueiatLjig  eliuructcr ;  but,  with 
the  btuuiuhin;^  cflect  of  tliia  agent,  tlic  cselinnjtic  action  g'Ji^ 
on,  in  many  easca*  uaheLded.  in  one  or  two  instances  in 
whieh  this  agent  boa  been  lucd,  and  allowed  to  remtun 
for  too  great  a  length  of  time,  or  el^e  from  eouic  peculiarity 
of   eonalitutioii,  principally   in  persons   of   scrofulous   diathesis 


NBCROdlS  or  THE  JAW. 


89 


imd  of  JowTitolity,  1  have  acen  very  ocverc  effects  prodnccd; 
iho  cauterizing  action  not  only  destroying  tlic  vitality  of  tho 
tooth,  but  going  liirtLcr,  pofgiUy  by  ub^urptioiiT  Qi^^  produQing 
catteneivo  necrosis  of  Ujo  alveolar  procceBcs,  ulraoat  oa  great  in 
llie  upper  jnw  as  we  ace  in  the  lower  from  tlie  effects  of 
iJiospliorutJ.  In  one  ease,  a  Jciicato  young  \adjj  whom  I  enw 
in  conedEAtion  with  Dr.  N.  C>  Koop,  of  Boeton,  to  whom  she 
|»pJic<l  for  Julvicc.  li/uJ  eufierc<l  extensive  Jestraction  of  the 
processes  of  one  side  of  tlie  upper  jaw,  cnu^edf  fta  was 
(Htppoacdr  by  arsenic  applied  by  a  donti^t  and  left  too  long  in  tho 
cavity-  The  foUovrin;;  case  I  aaw  la  consultation  with  Dr.  £. 
T-  Wilson,  Jnn.  3,  ia65. 


Case  LIV.  —  JVecroAis  of  Upper  JitttJ  arisinf/  from  the 
ZTfC  <'J^  Arsrnioifs  Acid*^A  young  married  lody^  of  scrofuloua 
habit,  lind  arsenic  introduced  Into  the  right  bieti^pid  tooth  of 
the  upper  jaw,  whore  it  wad  left  over  niglit,  cnusing  great  auf- 
fcnnx-  Tho  tooth  had  been  aRcrwoi'dt^  hJedi  but  was  olwaja 
the  touree  of  more  or  leati  imtroginoae*  Aloul  three  years  after, 
elie  hftil  a  long  and  debilitating  illness,  at  the  end  of  which  fihe 
fotmO  ihot  tJjie  toothy  together  with  one  or  two  of  Its  noigh- 
bora,  waa<|uttc  loose,  —  ao  loose,  in  fact,  that  she  removed  them 
with  her  fingers.  On  applying  to  Dr.  Wilson,  ho  foutul  that 
the  alveolar  proocesee  were  in  a  stato  of  ticerosis,  and  re<|ucstGd 
loy  advice  witli  regard  to  an  operatioa.  The  guxos  had  receded 
quite  exteuaively,  leaving  a  largo  piece  of  jaw  dead,  and  in  a 
svo^t  oflbneive  condition.  On  seizing  the  bone,  I  found  it  so 
iinnly  fixed  tliat  1  a^Iviacd  againet  any  immediate  o]>eration. 
Dr.  W,  agreed  to  give  her  a  detergent  wash  of  tnnuin  ond 
veofloie,  aad  tct  await  tho  farther  loosening  of  the  bone-  I 
aftcrwarib  loaiiicd  that  it  eoparated  piccofncol. 

Dr.  Wilson  itiforms  me,  that,  whenever  bo  usee  the  oraenie,  he 
alwaye  applies  it  in  the  niorniog,  so  as  to  watch  ita  action,  and 
removoii  it  before  night;  most  of  the  aecidenta  having  been 
mu^ed  by  npplviiig  it  one  day,  and  allowing  it  to  remain  until 
the  next  before  removal. 

In  another  case,  a  young  Imly  liiid  a  bicuspid  tooth  filled  by 
a  dentist,  the  nervo  having  been  first  destroyed  by  arsenic  left 

12 


90 


THE   FACE. 


in  over  night.  Six  tnonths  after,  Iicr  face  swelled,  iind  nii  ab- 
Hcess  formed  at  the  root  of  the  tooth  which  was  estraeteil, 
the  alveolar  proceas  ooming  out  witli  it  in  a  state  of  necrosis. 
Aftcrwanis  othex  pieces  oF  bone  came  away  from  the  jaw  in 
the  vi[?imty. 

Her  face  looked  puffy ;  and  she  had  conaiitutional  symptoms, 
such  BJi  HWelling  of  the  alxloraen,  and  great  losa  of  strength. 
Many  of  the  teeth  in  the  npppr  jaw  hccajne  bo  loose  that  tbey 
might  have  beeo  extracted  with  the  fingers.  She  was  a  very 
handsome  person,  of  fine  physieal  development,  and  had  ft 
licjuitilal  set  of  teeth  ^  and,  before  the  use  of  the  araenle,  bad 
alwuyK  hjid  good  health- 

1  have  Heen  other  similar  easea;  but  those  given  above  will 
eerve  to  ifhistrate  the  alfcctioQ. 


Cahe  LV.  —  ^^ecrnsis  of  half  of  Tjower  Jav^  from  Phospho- 
TUft.  —  A  young  woman,  19  yeara  old,  entered  the  Hotipital  on 
the  91)th  Februaty,  1800,  for  necrosis  of  the  jaw  of  five  mooths' 
Btflinling.  She  ha^l  lieen  an  operative  in  a  matr,'h  facUiry  fijr  two 
yeaJs,  and  her  employment  waa  to  pack  the  matches  in  paper. 
Five  months  before,  an  abscess  formed  under  the  posterior  part 
yt?  the  jaw,  bebind  the  angle  ;  and,  from  this  spot,  there  wns  Jt 
discharge  of  offensive  pus.  Denuded  bone  was  detected  in  this 
situation-  On  the  7ih  of  Mnrch,  she  was  etheri^ied  \  and  a  hit 
of  bone  an  inch  long,  and  two  amnller  pieces,  were  removed- 
On  tlie  25th  of  April,  she  was  ii^ain  eiheiizeJ,  and  the  cheek 
kid  freely  opeo,  exposing  most  of  the  jaw,  which  was  found 
("ornplclely  dead  but  finn.  (^n  the  I'ifltli  of  Afay,  a  finid  opera- 
tion was  pertbriue*!.  The  bone  wjia  finuly  seized  by  a  pjwerful 
pair  of  forceps,  worked  gently,  for  some  time,  to  and  fro ;  and, 
finally,  a  portion  of  the  body  and  the  whole  of  the  ramus  were 
removed.  On  the  I'lh  of  June,  the  wound  was  closing  rapid- 
ly; and  new  buiic  was  foniKl  to  bo  forming  in  the  phice  of  that 
which  had  Ijcen  lost,  tlii^  processes  being  well  maikeih  This 
pjitient  remained  some  time  aftemArdA  in  the  Ilospit:d,  acting 
VLA  nurse.  The  woun*!  graibially  healed,  aurl  she  waa  left  with 
(jLite  a  well-formed  jaw,  serviceahlc  for  all  purposes.  T  «ab- 
Beijuently  saw  her,  Bonie  years  ailerwards,  m  the  lull  enjoyment 
of  health. 


NECEOSIS   OF  THE  JAW, 


91 


C-SSE  LVI.  —  Necrosis  of  the  Loii^r  Jan\  from  tJiP^  EffscU  of 
Cold.  —  A  joung  lady  25  years  of  nge,  in  moderjitoly  good 
lii^aldi,  nbout  tlic  middle  of  September,  1859,  waltod  over 
SomJi-Bo^ton  Bridge  with  her  fnce  eicpused  to  a  very  bipfh  wind- 
Almost  imraeclintoly,  she  began  to  feel  an  uneaeinosa  in  the 
right  tide  of  the  lower  jaw.  This  increased,  accompsnied  with 
fiwelling  of  the  ja;uin.  After  some  weeks,  the  aecond  mi>]iu- 
tooth  was  removed,  being  completely  lr>03eaed  and  detnched 
from  lis  fiock(>t.  The  disease  extended  fnrward.  At  the  same 
lime,  the  leil  knee  hcgan  to  swell,  and  r  ooplona  ofi^aion  of 
seriiTik   took  place  into  the  joint. 

At  the  lime  of  my  visit,  I  found  her  confined  to  the  soft  hy 
the  trouble  in  the  knee,  and  in  a  very  nervouB  and  highly  ap- 
j>rehensive  condition.  On  oiamination  of  the  jaw,  the  canine 
tooth  and  those  behind  it»  with  The  e^treption  of  the  hwt  molar, 
were  looi^e.  Passing  a  proh^i  into  one  of  the  numonjiia  openings 
whit'h  exirttEi.1  in  front,  the  alveolar  portion  uf  the  jnw  was 
found  denuded  ;  and  the  prohe,  at  one  point,  passtHl  ijuite 
tliruiigh   it-      A   alight   swelling   appeared   below  the  jnw. 

As  she  was  auffering  no  pain,  and  the  bone  wad  atill  rjinte 
firm,  T  did  mit  advise  any  immcnliate  o[M:Tatioii.  She  wjia  n^L-om- 
m<"ii[lwl  to  take  wine,  and  as  mnoh  nonrishniont  aA  the  Htnniiii'h 
could  well  bear,  consistently  with  her  confinement,  and  to  have 
All  attempt  mailc  to  remove  tfie  (lead  bone  as  soon  ha  it  seemed 
luuKcned  from  its  attachments. 

Thia  Wits  al^rwardd  done  hy  her  physiciaji,  and  she  completely 
re<y)vered,  • 


Case  L\TI»  —  Necmslt  of  Lovrcr  Jaw,  fnmh  Ejjyosmx  to 
Cold,  while,  under  great  Menial  Dcifrcssion.  —  A  man  49  yeai^ 
of  age  entered  the  lloapitid,  March  10,  I3^fi,  with  a  necroais 
of  tlie  rigljt  eide  of  lower  jaw,  extending  from  beyond  the 
symphjBifl  to  the  aoglc- 

Inflummation  and  awellin^  had  commenced  in  the  jaw,  after 
cxpofinre  at  a  fimeraJ,  while  autlcrmg  from  want  of  foed,  and 
under  great  mental  depression.  Moat  of  the  teeth  hail  dropped 
ouU  tliL^re  was  a  very  otfeneive  dUchargc,  and  lua  health  waa 
much  aJlccted. 


92 


Tilt    FACE. 


I  removefl  the  whtUe  of  the  jnw  in  n  necrosod  NUite,  Iravmg 
the  pprkiBteum  at  tliis  fliUea,  Biul  a  thin  riui  oi'  iiew-tViniiwi  hime 
on  tte  lijwer  eJg^. 

The  iucisor  tecLh  rcmaiitcf]  Ioopc  in  tliR  ;^ima,  tKelr  nwte  pro- 
jecting inti*  tlie  cavity  left  l»y  ihc  reinuvel  bone- 

I  saw  Uiid  iBflu  t»n  the  last  of  May,  eiitii-ely  recovered.  Kcw 
bone  was  deposited  in  iLc  place  of  tlie  olil,  whidi  lie  (.-ould  Lee 
in  tlic  mELstiealion  of  mtxlerately  hard  J^ubt^tanees.  TLu  iuciaor 
teeth  huJ  bei^ome  pretty  firmly  CxL-d  lu  tJieir  pliicoa. 

TRE   TONQUH. 

Ca^e  LVIII. —  En^ijsttd  Ttimor  under  the  Towgur.,  re- 
Ecmhiiiitf  Itmiula.  — Tlip  tumor  iirdcr  the  tongue  CidW  rnitii- 
la,  whether  it  be  a  dilatation  of  the  salivary  duct  or  a  distinct 
tumor,  Is  alw&ya  troublec^ome  in  treatment.  I  tried,  ibr  a 
number  of  jeare,  DupuyLreu'fl  method  of  a  pcrmiineut  button, 
wLich,  though  eflect*jal,  has  the  iIismtI vantage  af  requiring  to 
be  pcruianent.  Pt^riiitps  exeieion  of  a  |)ortion  of  the  ^ae,  and 
the  free  a]i]i]iciLt]on  of  the  tincture  of  io^line  to  the  interior, 
if  this  be  found  neoei^ary,  is  aa  good  as  any  prsA^tiee.  Tlio 
fbJlovfing  ca^  of  lumor  urder  the  ton<rue  U  interesting,  as 
resembling  this  difiea^i  whicli  I  huve  fri^qucnUy  seen  of  great 
size,  and  fonuinj^  a  tuuior  on  tlie  side  of  the  reek.  It  ivas,  how- 
ever, in  thia  ci^cc,  [ilai;i;d  in  the  ujediau  Une,  and,  a.s  suun  as  tlin 
operation  was  commenced,  was  found  to  be  a  dilTerenL  afftelion. 

When  I  first  mlw  this  patient, *od  opening  bin  moulli,  it 
**emcii  tu  Le  entirely  iilltd  with  a.  greatly  enlarged  lougue, 
Ou  iarllier  inspection,  the  ttjugiie  was  found  cro;vdtd  Into  tlie 
back  ^mrt  of  tlic  faucee.  An  daatic  tumor  occupied  the  mouth, 
and  eileiided  beneatii  the  jaw,  njipeai^ing  in  the  neek.  The 
patient  was  25  years  of  age,  a  [jaiiitei'  by  trude  ;  and  tlie  tumor 
hud  been  of  eeven  yeara^  growth. 

Tliie  large  sac  was  completely  dissected  out,  with  alight 
hemorrhage.  Its  contents  were  aeid,  while  colored,  and  of  ihn 
^onsifitenee  of  cream.  An  Indannnatory  action  followed,  pro^ 
dueing  hoarseness  and  difficult  deglutition;  tlud  lasted  a  week 
Qt  too  daysi  and  he  viiXA  entirety  ^vcll  at  the  end  of  a  fortnight. 


J 


Tira  TONOUB- 


03 


Cape  LtX, —  Cancer  of  TontfUG,  MemGVftl.  Bccurrence. 
JJctUhw  —  A  ^'Cntlcman,  30  years  of  n*je,  cnllcd  on  mo  about 
the  year  1850,  on  tn^count  of  a  Avhito  film  under  ihc  Iwick  part 
of  hifl  toD^e,  on  the  n^ht  eide.  It  Imd  tbt^  rippcaronce  of 
mucous  membrane  wfiich  liad  been  touclicii  by  nitrato  of  eilver, 
ujv}  turned  wliitc;  but  the  ed^ce  wcro  moro  perfectly  dc6no<l. 
He  was  nervous  nbout  it  and  wi^liM  its  removal,  feiirin^  that  it 
mi^bt  become  cancei-oua,  I  disflectc*!  it  Harmfully  off  from  the 
loDgUQ ;  and  ho  IniJ  no  trouble  for  q  nunxbor  of  yciira*  In  L8i>5, 
on  my  return  &om  abroad,  I  found  a  smoJl  ulcer  at  the  spot 
from  whicli  the  dLfioaee  had  been  removed.  He  did  not  acnil  for 
m«  till  about  eix  mcnthg  aflerwiLrds,  when  the  ton^c  was  ^oLdly 
tixcdt  and  pervaded  by  a  cancerous  inftltruljon.  Ho  wos  in  a 
tnoet  deplorable  condition  :  the  saliva  was  eonstaatly  running 
out  of  bia  mouth,  duglutitlon  ^va»  ditticultf  and  the  pcun  at  times 
jfory  severe.  The  disease  gradually  extended  down  \\i&  throrit, 
finally  opened  a  large-sized  vessel,  when  n  jiroftiae  hemor- 
iOOOurrt?d,  which  was  checked  by  a  gflffile  of  a  strong  solu- 
perchloride  of  iron.  He  was  pfradually  exhausted  by 
lose  of  blood,  and  finally  died  in  an  anaamic  condition. 

Tins  ca^e  is  curious  from  the  manner  in  whicli  it  commenced, 
nithcut  ulceration  and  as  a  riimjilo  wliite  deposit.  I  have  lately 
4&ccn  another  ca^g  with  white  dcpoait  on  one  eide  of  the  moutli, 
and  extensive  cancer  of  the  gums  on  the  other,  brou^^ht  on  hj 
cxccssjTG  use  of  tobacco.  In  regard  to  operations  Rir  cancer 
of  the  ton^e,  I  can  simply  say,  they  are  genernlly  unsiicccpe- 
fiil.  As  to  the  method  of  operating,  I  formerly  need  hgatui-cfi, 
rarely  the  knife  ;  but  of  late  years  the  iScraseur. 


Case  LX.  —  Solid  Encysted  Tumor  of  the  Tonrjite^  He- 
fnttvnl.  —  Oct.  12,  18-17,  a  pliysician  of  Worccater  brought 
to  my  house  a  patient  ^\'ith  a  tumor  on  the  end  of  hia  tongue* 
It  was  about  as  largo  as  a  filbert ;  on  the  tip  was  an  ulcer  the 
eize  of  a  poa.  The  timior  wa*  first  noticed  seven  wooke  before, 
ttnd  die  ulceration  two  weeke.  There  was  no  pain  nor  tonJer- 
nesE. 

Passing  a  |iotntod  knife  behind  tlic  tumor,  I  made  an  incision 
around  the  left  side,  whoD  the  pressure  of  the  knife  caused  tho 


u 


TIEE  FACE, 


eecnpc,  through  the  ulcerated  apcrtiu'e.  of  a  solid  red  eubataace, 
like  a  fiiuJI  cherry.  The  ujjcration  wa^  ccmplfteJ  by  an  iu- 
ciaion  on  tho  right  side,  by  winch  a.  cyst  ivaa  removed,  wltli  a 
eicinll  portion  of  the  tongue. 

The  cy^t  resembled  those  ao  frequeatly  met  nith  in  the  sub- 
Btance  of  this  organ .  The  aolid  tumor  appeared  to  be  organized, 
nad  not  nudignant ;  yet  its  connection  with  the  cndoaiug  cyst 
niuet  have  been  very  slight,  cs  a  moderate  preeaurc  cspcllcd  it. 

A  etitch  was  employed,  aail  the  pntjcnt  went  home  the  eume 
day.     He  had  been  in  the  habit  of  chewing  tobacco. 

In  another  instance  of  a  solid  tumor  aitiiiitcil  in  the  centre  of 
the  tongue,  a  ?*implc  incu^ion  wsib  made  over  the  top  of  it,  when 
a  BmolJ,  hard,  iibroua  tuinor  waa  ehot  out,  having,  apparently, 
acnrccly  any  connection  with  ita  envelopes, 

I  haye  alao  eeen  a  tumor,  in  thla  situation,  apparently  of  a 
ffttty  nature. 

SALITART   CALCUTiDS* 


Case  LXI.  —  Ldercntui.^  Cane  of  Salivaty  Cahxiius, — 
An  Euglish  gentleman,  40  yeara  of  age,  applied  to  inc.  in 
Angur*t,  18h")D,  on  account  of  a  very  painful  enliu-gement  and 
jiillaunuation  of  the  lell  submaxillary  gland,  attended  with  on 
ubticesa  behind  it,  wliicli  discliarged  through  the  duct  under  tlie 
tongue;  a  &midl  quantity  of  pna  alao  eacaplng  tliroiigli  tlie 
gInnJ  and  integument.  The  inflammation  of  the  gland  came  on 
two  years  before^  after  eipoaure  to  cold.  Subec<]uently,  and 
alter  much  autfering,  two  email  caJeuh  were  extracted  from  the 
duct  in  tlie  mouth.  This  gave  temporary  relief.  The  pain 
however,  in  the  gland  and  whole  of  the  neck,  continued,  some- 
times  of  the  most  agomaiag  description ;  aflecCing  the  eyatem, 
and  keeping  him  from  hia  employment.  AppUcatLons  of  iodine 
and  other  rcmcdica  had  afforded  no  relief. 

It  wrta  with  great  difficulty,  that  the  aperture  iri  the  mouth, 
through  which  the  pua  wna  discharged,  could  he  brougiit  into 
vicwf  aa  it  lay  far  back,  and  was  obscured  by  the  tongue  ;  but 
by  [ihicing  him  in  a  atrong  light,  holding  the  tongue  to  one 
sidci  and  rcqucaling  him  to  preaa  ihc  glaud  up,  pufi  was  accn  to 


&ALTVAKT  OALODLU! 


95 


le  from  it.  A  probe  waa  lasmuated  into  tliia  opening  ;  but  it 
□nt  of  Hut^cient  siy.G  to  eervc  rs  a.  guide  to  tlje  knlte.  An 
utrUioQ  jL>vvnw^aiila  wns  tbcref'ure  miwle  clone  to  the  jitw,  until 
the  pua  flowed  ixccly.  This  opening  abortl/  closed  np,  and  the 
operation  rcrjuired  to  be  repealed.  In  the  meiin  time,  it  wns 
inijxjs^ible  lo  iiiiikc  the  etliglite^t  examinntiL>n  of  the  gland  exter- 
nally, the  touch  ofthe  probe  gave  such  ejtqalfiite  pain. 

UnHcr  the  influence  of  ether,  a  semilunar  iuciaion  waa  made 
over  itti  surface,  exposing  the  indurated  aud  hlghlj  inflamed 
glnadp  The  blood  gushed  out  at  once  trota  the  wbole  eurfueei 
iring  it,  and  requiring  some  delay  in  the  diesectlon,  A 
I  aperture  svos  l<>und  at  some  distance  from  the  opening  in 
,  which  would  admit  a  line  probe  into  an  almost  callous 
ranftl  bcncnth  iho  gland.  With  much  care  aud  great  difliculty 
the  ehc  of  the  probea  waa  graduidlv  increased,  until  a  director 
could  be  introduced.  Thia  being  a  little  curved,  and  turned 
in  an  upward  direction,  encountered  ft  resistance  which  at  first 
appeared  lo  be  bone,  but  was  fin;dly  aaecrtaiued  to  be  a  cakuJue. 
A  finger  was  introduced  into  the  throat  and  under  tlie  tongue, 
nnil  preaBure  mode  on  the  outside  ;  but  no  hard  eubat4inee  could 
anywhere  be  distinguished »  The  only  means  left,  therefore, 
Bccucd  to  be  by  penetrating  to  It  throoirb  the  hard  deposit.  By 
caretijl  touehcs  of  the  knife,  and  dilatation  with  the  sci^^eors, 
an  aperture  waa  finally  made  hirgc  enough  to  admit  of  the  intro- 
duclion  of  a  email  pair  of  ]>ulyj ma-forceps,  hr  which  the  atone 
was  broken  up,  und  withdrawn  pieeeiucid.  TJie  enlargement  of 
the  aperture  by  the  scieaora,  by  intrudueing  thorn  shut  anil  with- 
drawing llicm  ^>artly  open,  was  followed  by  a  guah  of  blood, 
which  continued  to  flow  for  aome  tijuc,  as  if  from  the  Avouud 
of  a  larjro  vGs^l ;  and,  it  being  impoflsjblc  to  reach  the  deep 
origin  of  the  bleeding,  a  bit  of  sponge  waa  crowded  down  into 
the  cavity,  as  soon  as  the  calculus  wad  removed,  aud  arre^itcd  the 
flow  of  bloodi  This  being  removed,  after  a  few  minutea 
tile  bleeding'  recurretl,  but  suddenly  stopped.  Aa  a  matter  t>f 
precaution,  and  in  order  to  keep  the  wound  open  to  permit  a 
free  discharge,  tbc  d^iungc  was  replnceJ. 

From  tliia  time  ho  ^ulually  recovered  ;  and  now,  at  the  cud 
of  aeven  yoore,  remains  veil. 


CnArTER    UL 

THE   NECK- 

FORElO]ir   BODIES    IN    THE    Aia-PASaADElS. 

De»  Qross,  die  (Jislin^iahml  Profeaaor  of  Surgery  in  tbe 
Univemty  of  PenupjUanlii,  :tu{\  surj^uon  at  tlie  Pennaylvania 
Hu^plLilt  has  dtyijG  nHire  thnn  any  other  pL'raon,  in  hia  work 
with  the  djOYC  title,  La  illuHtrate  tLif^  ^lubject,  as  he  haa  all 
otiier  Bubjecte  in  fiurgery. 

It  18  well  known,  that  operations  on  the  trachea  ar«  always  of 
ti  Btiirtliiig  ch:ir:ir(tr,  iind  re<|uire  gre^t  pkilJ  and  |)]'oiii[Jt  action 
on  llie  part  of  a  surgeon,  to  save  life ;  whether  it  J*  for  the  re- 
moval of  a  forifigu  body,  for  craup,  or  for  the  other  inflam- 
matory al1k.iioas  of  t)ilt4  organ. 

In  tlie  tatter  instances,  the  surgeon  is  ol\en  called  upon, 
without  any  previous  preparation,  jutssiUy  in  the  midille  of 
lite  niglit,  witliout  asslstanee,  and  with  a  bad  iitrht,  to  perform 
one  of  llic  most  critiLiid  O]ierntion8  in  sor^p^ry  ;  tlie  paiienL  gasp- 
ing for  breatli,  and  dependent  on  the  exertion  of  the  utmost 
skill  for  life. 

Froio  the  great  difficulty  in  respiration,  die  nock  is  generally 
crowded  with  \enoua  hlood,  the  free  flow  of  wliich  uheciirea  the 
inciftione  i  and,  on  the  Um^liea  being  opeueil,  it  \a  apt  to  ^n^h 
into  the  ali^pitBt-nges,  and  eurtooate  the  [Kitient,  If  tiie  surgeon 
hesitates,  on  die  other  liand,  &nd  waits  to  secure  the  vessels, 
death  may  oa:ur  before  tl«e  traofiea  is  rcat'lifd.  Fortunately, 
in  must  ini*tjini:efi,  iis  suou  as  tlie  lur  cnlcra  freply  info  tho 
Imi^i^a,  tho  con<;i^Rtion  in  the  veiua  id  rchevtid,  and  tht  bleeding 


Tbe  dingnoHis  of  the  existence  of  a  foreign  body  in  the  traeltea 
or  iu  tlie  Ijronchua,  altbougb  at  iirvt  it  would  seein  not  to  be 


FOItEION   BODIES  IN  THE   AIR-P.4SftAnEB»  ^1 

tttteodcKl  wilh  muoli  difficulty,  ia  often  very  obftyure.  Tliid  is 
particularly  tlie  ca?e  in  youti^  iufjiuta,  and  in  cliildren  of 
four  or  £ve  ycnre  of  a^e.  On  ita  fir^t  introducLion,  there  is 
usually  groat  ohokin^^  and  violent  in'itntion  of  the  air-piLBsoj^. 
After  a  time,  Lowevor,  if  the  aubstance  sink  d'^wn  into  the 
lungs,  these  symptoms  dieiipjiear ;  and  it  tfi  then  necessary 
to  look  tor  niiftlher  cla^s  of  phenomena  upon  wluch  to  burie 
an  opinion.  These  tonaiet,  in  the  first  plricc,  of  didnoss  on 
percuJiiaion  of  the  nifuoced  side;  eecondt  ^f  more  or  lees  dim^ 
inutifm  of  tho  rc^spiralory  murmur,  according;  ns  a  larger  or 
ftmaller  hi-onobiid  tubo  i^  ohetnictod;  thW,  of  more  or  less 
biMDchi^l  and  suhcropiLunt  r^ea  ;  bat  these  niny  be  observed 
equjilly  on  tlie  sound  side  of  the  ehe^t,  bein^  provoked  by  the 
general  irritiUion  of  those  organa.  The  diiignoaia  ■beeoines 
iu<*re  diHieult  uhere  the  palient  has  had  a  prevltins  broucfiial 
didturbiuicc,  or  has  been  exposed  to  the  whooping-cough  c>r 
mcjules,  nil  of  whic^h  compl  lent  ion**  I  biive  hnd  orrasion  to  wit- 
ness. The  importance  of  a  correct  diaguosia  is  verygreiit;  for, 
if  an  0[>erMtion  be  deferreJ,  the  aubaciinee  may  suddenly  be 
atHrt«d  from  its  hidin^f-phtce.  and  di-iven  up  into  ilie  glottw^ 
caualng  death  hefcic  any  help   can  he  ohtninpd. 

Tho  following  page*  contain  the  euh^caiice  of  reraarka  on  this 
subject,  in  a  condeQfied  form,  publfahcd  in  the  *' Host  on  ^loili- 
eal  and  Surgical  Journal"  for  1«47,  and  referred  to  in  I)r. 
Grossed  valuable   work,   with   adJilional  caee^ !  — 

Oa8K  LXTI. — Bf'/iti.  in  the  LeJY  liroiw/mii. — On  Tue.'*- 
day  evening,  Oct.  13,  1347,  I  wiia  called  to  aee  a  little  y^i'l, 
eight  years  old.  The  same  moming^  while  laiighhig,  a  common 
giirdcn  hesm  waa  dra^vn  into  the  trachea.  At  first  she  was 
tuKU'ly  sutlopatetK  Oradnnlly  the  cciigh  and  atrngglcs  l>ei"ame 
less  violent ;  nnd  during  a  ride  of  four  or  five  miles  nlmrmt 
entire  tranJioillity  in  the  respiration  wart  reatorwl.  After  ;in 
hour  or  two  rhe  difliculry  of  breatliing  refnrncil,  nnd  finally 
bei^ame  so  laborious  that  the*  parent.^,  being  ajamicd.  dotor- 
mined  to  brin»^  her  immediately  to   lloaton- 

I  saw  her  nt  7  oVlock,  r.M.  The  countenance  was  pale, 
nilher  livid,  and   expreBaed   great  nnjciely.      On  nny  elnin^e  of 

lb 


98 


TH£   NECK. 


position,  a  eou^b  waa  produced,  attended  vrilh  the  ejection  of  a 
quantity  uf  mut^us.  On  auscultation  ol'  ttiG  bsLck  of  the  cli&Bt, 
tl]G  Pound  of  the  natunil  rcApirfttion  waa  much  obscured  by  a 
\in\t\  niu<?oiifl  role  :  in  front,  the  rile  wiia  very  bud  on  the  ri^hi 
fiile;  l)Ul,  an  tho  Ic^,  the  sounds  of  respiration  and  the  riles 
were,  in  a  ^TOiit  measure,  wauling.  On  percuasion,  the  left  siilo 
wiie  a  tittle  Matter  than  the  ri^ht.  There  wus  no  aound,  either 
in  the  lungs  or  tnit^hea,  to  indicate  the  movement  of  a  foKigti 
body.      The  voice  waa  hiiaky,  as  in  croup. 

Ill  view  of  the  above  symptoms,  I  haJ  no  doubt  that  tlie 
foreijjTi  body  was  lodged  in  the  loft  bronclms,  and  advised 
the  following  eoiirae:  First,  in  order  to  ascertain  if  the  Bub- 
etanoo  was  movablOf  aud  likely  to  ascend  towiirds  the  larynx, 
that  tbe'cluld  should  be  suspended  with  the  head  down^A-ards^ 
the  throat  irritated,  and  [lercussion  laitde  on  tlie  chest.  Second, 
if  the  Bubstiuicc  could  he  made  to  fall  into  the  trathea  by  these 
nicaiiB,  to  perform  the  opemtion  of  triidieotomy. 

The  first  proposal  was  carried  into  ertect.  Tho  ehikl  was 
taken  by  the  legs,  and  held  with  the  head  downwards;  then, 
pajiBing  my  finger  into  the  throat,  I  carried  it  quite  below  and 
behind  the  epiglottis,  so  as  to  induce  etrong  effort?*  to  vomit. 
Percussion  of  the  chest  waa  abo  practised. 

The  proceaa  above  described  was  twice  repeated  without  avidl. 
A  (Treat  cjuaniity  of  mncus  was  brought  up  by  cougliing;  but 
no  siraiimdation  was  induced,  nor  other  symptom  to  indicate  it 
change  of  position  in  the  foreign  body-  Quiet  was  now  en* 
joincdj  and  an  opiate  in  ca*e  of  gre:LC  irritation. 

The  following  night  wn5  passed  quietly,  nnd  only  disturbed 
by  one  fit  of  coughing.  These  attacks  were  produced  hy  the 
slightest  men tfJ  or  physical  e^ccitement.  The  rules  were  sliglitly 
increjised. 

In  consultation,  it  waa  concluded  as  folhiws  :  — 

1st,  That  the  great  want  of  success  attending  the  oporatton 
of  opening  the  inr-pa9sages,  and  sean'hiiig  tor  foreign  hfnlicJ*» 
iirising  from  the  ii'ritubllity  of  llie  parlti,  aud  the  consequent 
diHiculty  of  manceuvring  instruments,  did  not  render  an  imiue- 
diale  op(*rat]ou  desirahlcf  particularly  as  the  patient  was  com- 
piu-ativcly  ea&y,  and  the  danger  not  pressing. 


FOTteiGH    BODIES    IN    THE    ATR-FA8SAOES> 


99 


» 


2<K   Tlint  the  spnnliLDeoua  expult^urn  of  these  bodies  was  nut 
3<1,   ll'  sTmptomg  of  etran^jlation  came  nn,  to  npcTaXt;  imme- 

It  \Ta&  tlelermmcil  tu  give  llie  diikl  nn  emedc  [>f  iikh-Im!.,  as 
roRsiderahle  febrile  aolion  wsw  present,  and  tlie  effitrt  of  vomit- 
ing might  possihij  move  the  forei^  hady.  This  was  done  with 
much  relief  to  the  breathir<r,  hut  without  causing  mty  change  in 
the  ^iluatiort  of  the  niihsNinL-e. 

On  the  morning  of  the  15tb,  I  found  her  quite  as  cotnforlrtlilc 
80  on  the  dnv  previoiiii. 

Abinil  4  u'cliurk  in  the  afternoon.  T  waacnlletl  in  hjistc.  In  u 
p«rti:iysm  of  mental  excitement,  proflnced  by  the  mothi^r's  inking 
Imve  uf  her,  tlie  bean  was  huddenly  iljj-enga i^kI  ,  ixntl  brought 
on  etrad^ilalirm.  When  I  nrrived,  she  waa  almost  pshmistcd  ; 
iJie  fai^e  waa  hvid,  and  she  wa-S  writhing  in  di^IrL-aa,  like  a  j>eraou 
h&Ying  a  cord  tied  tightJy  around  the  nei!k> 

I  IniineilmteTy  prcx^eeded  to  open  the  Irncliea.  The  skin  anil 
m|)erliciaJ  fificiit  being  divided,  nnfl  the  tliyrctid  plexna  <jf  veins 
avoids  or  lied,  b^  I  waa  Beparating  the  sierno-hyijid  and  Bterno- 
tlijriiid  iiiiiscles,  il  Huddon  cniek  vmin^  heard,  Jia  if  m\nc  [lortion 
of  the  lung  hml  given  way,  Thia  wan  imniedi:ilely  f^jllowtnl  by 
an  ^nphyHema  of  the  cellular  tnembntne  in  the  neigbborh(»od  of 
tJie  wound;  and  a  smiLlI  tnmor,  filled  with  air,  waa  foreed  up 
ont  of  die  chest,  on  the  left  aide  and  in  front  of  the  tmcheu,  at 
each  movement  of  inspinition,  A  niitif^^ation  of  the  dialrcrw  in 
breathing  Mbiwwl  tliifl  occurrence.  The  tumor  waa  now  bold 
bark  with  a  spatLiIa,  a^^d  a  fihar[*-pcinted  bisttinry  plunged 
into  ihe  tniehea.  Tlie  bran  vvjih  neen  greatly  swidleii,  uioviiig 
ugi  and  dowii  in  the  tmciieid  pass^age,  ami  eomplelely  lilling 
its  ealihre*  The  edges  of  the  tnn'bea  being  m-paniied^  the 
be-jin  wan  seized  with  some  dldirultyT  uu  account  of  ile  soft- 
Dees,  and  withdrawn.  Sha  iinmediatelyf  od  die  concrlusicm  of 
die  oprraiion,  fell  iiito  a  inoM  profound  sleep, 

Tlic  hean  bati  swollen  to  more  than  duuble  Its  original  tizc. 
On  ineitsurcinent,  it  was  aiiicertamed  to  he  twu-tliird:i  of  au  iuub 
in  length  :itKl  half  an  inch  in  hrejukh. 

The  patient  reca\ercd  without  any  biul  couaequcncea. 


lf»0 


THE    NECK. 


lieiiifirlcs.  —  Tbe  rupture  in  tlic  idr-pn^sriffeB  did  not  preserit 
any  aiilis4?f|uont  aymptomd  which  cotild  bo  referred  to  ihcsQ  or- 
gtuiB,  and  therefbre  there  must  bo  aome  hosiintion  in  deciding 
u[Km  the  eefll  uf  thi^  accident.  In  fJl  probnbility,  it  look  placo 
at  the  root  of  the  Jun^;  hi  one  of  llie  Urger  hroucliiid  tubes, 
and  the  nir  made  its  way  out  of  the  clicst  without  impliealio;^ 
the  jilcunil  citvity.  A  Hiinllar  rupture  I  once  before  observed 
in  croup,  —  the  neck  and  whole  ?^ide  of  the  chest  becoming 
eiupbjscmatous,  willi  on  inimediute  relief  to  the  breathings 
aa  iQ   the   preeeat  cs.bc. 

Sulwequenlly,  having  procured  some  garden  boans  of  a  simi- 
lar kind  lo  the  one  removed,  I  immersed  them  in  wiiter  of  the 
tcmper'Ature  of  the  body  and  found  tbat  in  forty-eight  hours 
thoy  were  inrrcnsod  in  bulk  to  more  thnu  double^  and  aorue  to 
treble,  the  nnliirnl  ni/e.  This  flbowa  that  wlien  suhstanees  whieh 
may  Ijeeunie  enhirgwl  by  the  heat  and  mniHture  of  the  body  are 
Inlnrtlut^ed  into  llie  air-paBBBgea,  no  hope  can  be  enterULined  t^f 
their  spontaneouB  eiipnlsion.  In  euch  cases,  operadcin  should 
not  he  delayed. 

I  aaw  ihis  patient  fifieen  years  afterwanle,  grown  to  a  lar^, 
fine-looking  womjm.  8ho  hrul  never  exjkerieneed  any  ineoa- 
venieoee  from  the  ctfecta  of  the  jux-ideal  or  the  operutioo- 

Case  LXIU.  — IhrsG-sUoc  J^ail  in  tht  Jironc/ius.  Spon- 
taneous J^jspulsion. — On  May  10,  1816,  n  little  boy,  be- 
tween two  and  tln'cc  yours  old,  was  brought  to  me  with  a  nail 
In  its  luQgs.      Tlie  aceouiit  girea  was  oa  follows  :  — 

Three  weeka  before,  the  child  came  into  the  hou^o  from  a 
bhickamith'a  ehop  in  tlio  neighborhood,  from  which  ho  had  lately 
ix)en  forbidden  by  hie  mother.  In  order  to  punleh  him  for  his 
didol)C[Ucncc,  alio  took  biin  in  hei'  ^.i-nip,  and  eet  him  down  iu  a 
chair  with  some  violence.  ilc  wua  immediately  tici^^cJ  wirh 
ehohin^^  unil  with  u  violent  cou^h.  Aa  i^oon  as  he  could  an^wer^ 
he  ^^aid  that  it  wa^^  cfiueed  by  %  nail  in  big  mouth. 

The  eou^h  for  a  time  sulpaided,  but  shortly  returned  with  some 
attendant  iiiHamroatory  sympt^tma  of  the  luiigs,  which  luj^tcil  a 
week.  At  the  end  of  thut  period,  Eks  the  child  waa  lyin^*  over 
ft  chur,  with  its  hum]  hiLngini^  downwardSf  a  sudden  ducking 


70BEIGN    BODIE8    IK    TIIS    AlTl-PAfiH AGES .  101 

noiM  wu  heard,  ae  if  a  Bubatanco  Imd  been  thrown  up  into  t}ic 
windpipe^  and  was  at  once  followed  hy  a  praroxyt^m  of  euffoca- 
tion  which  nearly  destroyed  bim-  He  wua  placed  in  a  sittiog 
posture,  and  the  obstruction  was  shortly  rentoved. 

He  had  twice  had  similar  attacks,  always  couiiTi^r  on  when  the 
head  wm  in  a  dependent  position.  In  the  intervals,  he  Imd  a 
hoftree  congh,  and  also  had  night-sweats,  loss  of  appetite,  and 
emaciation. 

In  this  Btat«  I  saw  him.  ilo  was  rapidly  failing  from  the 
irritation  of  the  lungs- 
Hie  signs,  on  auscultation,  were  as  follows  ;  The  whole  chest 
was  flatter  than  natural  on  percussion.  On  both  eidos  a  loud 
mucus  rale  was  heard,  ratlier  moro  marked  on  the  \ch  than  on 
the  right  side,  but  not  sufiicient  to  determine  with  prcei^iion  in 
what  part  of  the  lungs  the  substance  was  imbedded. 

In  the  course  of  six  days,  he  had  four  nttiicks  of  snflbcjition 
from  the  dislodgement  of  the  foreign  body,  which  ro»^c  into  tlio 
trachea.  The  lost  attack  came  on  wliilc  he  was  at  dinner, 
and  so  suddenly  that  he  fell  back  as  if  he  had  been  shot,  and 
waa  with  great  difficulty  recovered. 

Being  now  fully  satisfied  of  the  presence  of  a  forcij^n  sub- 
stance in  the  air-passnges,  I  detcrnuned  to  perform  the  ojicnUion 
of  tracheotomy,  and  directed  his  falhor  to  be  sent  for.  Tfiid 
was  on  Friday ;  and  the  time  appoiiitefl  for  the  operation  was 
tha  ensuing  Monday,  as  the  earliest  date  at  whicli  the  father 
could  reach  the  city. 

The  following  course  had  been  marked  out :  — 
The  child  being  firmly  bound  to  a  board,  to  make  an  opening 
Into  the  trachea,  just  above  tltc  sternum,  with  the  hope  that,  iji 
consequence  of  the  irritation  thiia  produced,  the  foreign  sub^ 
stance  would  be  forced  up,  and  present  itself  at  the  orifice  of  the 
wound.  If  this  did  not  h^ipjicni  to  invert  the  boily,  which,  in  all 
probability,  would  cause  its  dislodgcnicnt,  and  tliuu  it  might 
pass  through  tlic  epiglottis,  the  ^'iolence  of  tlie  spasm  of  that 
organ  having  subsided ;  or,  at  any  rate,  it  might  be  extracted 
through  the  wound. 

The  preparations  having  been  mode,  on  the  d.ay  appointed  for 
the  operation,  ten  drops  of  laudanum  were  given  in  divided 


102 


THE    NECK. 


1T08W,  m  (ir<Ier  to  produce  aa  mrirh  quiet  an  po^silile  iluring 
the  tliseettion  of  the  neck  nnd  opi'ning  of  tlie  win(I[i[[K?-  Pro- 
vioufl  tu  its  performnnctit  T  pn^eeded  to  mnke  n  liisC  cxaminatLon 
of  the  (^hest,  sinil,  inui^h  to  niy  surprise,  found  tliiit  llie  TUUi'iUJ* 
riilc  HjuI  alitiost  entirely  disnppojired.  TTih  mother  snid,  :djii>, 
thjLt  the  congli  hnil  hoen  miirh  Jefi^  for  the  Ijist  two  dity^,  iind 
there  had  bcM?n  no  reeiirronee  of  suffocation  since  tlie  violent  at- 
Ijick  of  Fridny-  Under  thf?a«  cln.'UinsI.ini'eH,  it  waa  det'ldcfl  lo 
invert  the  hotW  before  opening  the  windpipe.  Tliis  waa  mo*t 
thoroughly  trieJ,  and  the  faucea  repeatedly  irritated  liy  jiaHsiny; 
A  qiirll  down  the  thncit^  Imt  withiiut  E-ffiM't-  The  opemtiori,  of 
course,  was  not  peraihled  iu  ;  and,  in  fijct,  from  tliitt  lime  he  be- 
gan to  improve  in  health ,  mul  fully  recovered. 

I  henrd  from  liim  some  months  Jiftenvards.  He  was  in  good 
health, 

JiejtJtirhjt.  — 'The  Apparent  mystery  connected  with  this  case 
BeemH  to  be  explained  in  the  following  luiinner  :  ■ — 

To  quefltiniis  M  to  ci  re um stances  attendant  on  the  hist  p:ir- 
oxyflm  of  suffoenlior,  the  mother  Hsiid^  that,  while  he  hiy  on  the 
fiooT*,  aa  t^he  thought  iJead,  she  seized  witli  her  lingers  the  tough 
flud  stringy  miieu-j  protruding  fmni  his  mouth,  aud^  when  pull- 
ing on  it,  it  t^eeuied  to  unwiud  from  a  body  in  the  throat; 
—  that  oti  Saturday  and  Sunday,  the  two  following  days,  the 
child  suffered  from  severe  paina  in  the  bowels,  which  were  rc- 
lieve<l  nt  night  by  a  powerful  fiee:d  discharge,  forty-eigbt  houra 
after  the  nCtal^k  of  RulToeation.  It  m  highly  probahle,  therefore, 
that  the  nail,  rolled  up  in  the  tough,  adhesive  niucua,  was 
thrown  up  into  the  lar}Tis,  completely  obstimctiug  its  paswigo ; 
and  that  the  mother,  by  pulling  on  the  muena,  jKirrially  detaebed 
k  from  the  nail,  and  finally  dragged  the  latter  into  iho  throat, 
whence  it  wna  Bwnllowed,  and  ultimately  disehiirged  iti  the 
evAcuationa. 

Case  LXTV.  —  A  Bit  of  Birch  BarJc  in  Lf/f  Bronchna. 
Olfli  tt^ed   Ei(/ht    Years.     BarifntjoioTnif  on   the   'SiXfeenih 
i>fit/-      Vaiti  Alfempts  at  Extraction.      Death  at  the  End  of 
a   ^fotitfi    and  a  Half  after  the  jiiccideut.       Injlnmntation 
of  (he  Lef  Liing  and  Bleiira.  —  Nov,  2C,  1850,  a  girl  eight 


VOKKm^    IIODIKS    IN    THE    AIIt-PASPAGES- 


lort 


^ears  old,  wliile  diewin^  n  liit  nl^  birch  bark,  let  U  *I[p  into  tlie 
win^Ipipp-     Th(!  nc-f^ident  wa*  iii^^tiiLtly  followed  hy  a  paroAj*ni 

uf  fiin^hlni;  and  siilT5natii>n,  wUii-li  n.ntimunl  tti  rcnir  at  'mter' 
\ak  for  iieiu'ly  a  week.  A  eiiddeii  thiin^^y  in  ilin  [loiLkm  t>C  ilic 
eiibstiint^e>  rnj  Hie  1  e^t  of  TJe'Ct-mbcr,  was  eucceedt^i]  by  il  relurii  of 
siicli  vIolcnL  coiigliiikg  and  fitianvidutiou  us  in  cxcitt?  fvars  in  ni- 
{^anl  til  ibi^  biiuiediattt  result.  At  tin;  end  of  the  [luruxvsjiK  tbc 
Imi'lt  -'iiaiKrd  duwi]  intu  oner  of  llie  bnmfbial  lul^'a,  viilli  n  miti- 
gation of  lIip  severe  syniptoms.  I  saw  tlie  i:bild  Dec;.  Dth,  whoii 
llie  brealiiin^  vias  iniiidi  oppn.'rised,  and  elic  Ijiid  a  rLiiistaiit  dry 
C4/ugli.  fSliL'  ]ui>ked  ikag*;nrJ,  aud  ibc  cuuQtt^iiiince  li^id  a  IJvId 
tue;  llic  *lun  was  bi>t  and  dry  ;  iJie  pul*e  one  Inindred,  and  tic 
Ap[>etite  1o8C.  The  Jcfl  aide  of  thf  olicdt  was  dulW,  on  j»riT.iis- 
citjn,  ibim  thf.'  riglit ;  ued  scarcely  a  re;?i[ii]~ntory  iiiuruiur  eoidd  be 
ilclecicd  iu  the  (jijtlerior  jitiit  of  tlit  corret^pundin^^  lung ;  llierc 
were  niueoua  ralea  on  a  level  with  llie  bj(\ii'catiu«  of  ilie  ti-acbea. 
In  fiunt,  esjwcially  above,  the  breathing  was  etJIl  |ierf<frajtd, 
tbooj^h  vt-ry  iet^bly.  On  tliu  ri^dit  side,  the  rospiriLtitin  wiis 
puerile.  All  dic^e  circumstances  dencled  timt  llie  aub?^tanee  was 
lufl^eil  Lii  the  left  broiK'bi.d  tubo. 

Tfic  foJIo^vmrr  [ligbi,  she  bud  anodier  p.jrosyaiu  of  couching, 

iduHDg  ^ddcb  the  bark  waa   agaui  dialodgcd,   and   pa^acd  up 

into  tlic  larynx.      The  u[.tai;k  wne  ultoiided  with  sligbt  ejji-;(a\iF4, 

Ldryii^otomy  wlis  performed  Dec.  I'Jtli,  llie  pationt  beiii^'  fully 
etiieri/t'd.  A  pair  of  forceps,  sU  inches  in  teiigth^  and  so  con^ 
fltruetwl  as  to  open  only  an  inch  at  the  end,  waa  then  tarried 
cIovTTi  Into  tbc  left  bronchial  tube,  but  without  graspjng  iho 
uflcndin*^  unbalance.  The  operation  was  tbricc  repeated;  tlie 
Iiidtrun^ciit  being;  retjdncd  each  time  about  one  minute,  wiibout, 
aji]>nreiitly,  the  slightest  mconvenienee.  She  wa-s  next  fiu&pendeil 
by  the  beds,  und  the  tliroat  irritated  to  provoke  free  vomiting, 
but  without  avad.  Finally,  the  abdomen  waa  compressed,  fuhI 
tlic  air  in  the  lungs  euddenly  iind  violently  expelled  by  the  liands 
apfdZed  Lu  the  rliest.  The  clnld^  coo^iderably  exIiausLed,  was 
|mt  to  beil,  and  tlic  openin^r  protected  by  a  bit  of  gimze.  She 
fijul  a  quiet  night,  with  less  ooiigh  ;  and  tliQ  wound  mouifesled  a 
(lisposiition  to  clu^c. 

After  ocvercd  wccka,  she  waa  taken  hoiiiCi    The  coui^oetlon  of 


104 


THE    NEHK. 


fli*)  limjTs  inrmist^l ;    and  the   <isj)irod  Jnn,  9,   I Sfil,  nearly  n 
tiHintli  nftcr  tito  ojH.'nil!oii,  Jiiid  [lenrly  il  luuntli  imd  a  liulf  after 

TliG  riglil.  limi!^  wns  m  n  lipaltliy  siale.  TIip  lff\.  lung  wiu* 
dark-colored,  pilteil  on  prt'Sdurc^  wuh  finniy  aLLiiclied  to  the  ilia- 
phriLgm,  nnd  exc^t^sively  lomZeil  witli  hUu^d  Hiid  eerum.  The 
bnmdilid  tiibefl  were  filled  wilh  iiiuco-[ninilcnt  miiHer,  and 
those  on  the  left  siik  were  in  a  state  of  high  inlhtinmation. 
The  (iftending  body^  three-*|Uarter3  of  an  Inch  lonij  ami  one 
qnarter  of  an  iudi  wide,  willi  tlie  ap|JcarH,^c^e  of  liein^  much 
BwollenT  wjw  fuiind  lying  loose  i!i  lh(?  irjtchea.  It  fiail  ovirlenily 
hcen  ui"i.^iiIentaUy  jiur^hfid  up^  during  the  exatiiinfiriiNh  frcuu  the 
leA.  hroiicliial  luhet  where  there  were  marks  of  itA  having  becii 


Case  LXV.  — I3U  o/  iVrti  in  Lf/i  Bronckug.  fiirl,  aj/erl 
I'^our  Ytf<trs.  I^irn/uf/ofoii/t/*  ^j^cLion  q//Ac  Sktit  (ind  JittF' 
fiH  (iftt  JV«^,  fuUawi'.d  htf  ti  fiifitrli  TiU  of  tke.  ShfU  tit  fhe  fntl 
of  ti  Jt-iu  WTuethT.  liecovcrt/.^In  Apnl,  If*.')!,  I  was  i^allLil  to 
«cCt  in  conBLdtatioHf  a  chllil  who,  four  day^  bcjore,  had  inhal<^I  a 
bit  oP  nuL.  Slic  waa  ecLzed  with  violent  fOUghiEig,  paroij^iiis  of 
whii^h  had  continued  to  recur  at  interv-al3,  At  the  time  of  njy 
vifiit,  her  CDuntenmice  was  livid,  hreathinv  dif^iculti  and  her 
Stien^h  much  iiujijilrcd.  Aufic^ullatron  le^calt^  n  g^reiit  dimi- 
nution of  tlio  rej^piratury  murmiu'  iii  the  left  luu^,  with  Mimo 
r^es;  while,  on  the  ri^dit  aide,  it  waa  dietiuctty  [aierile* 

A«  the  ayniptimid  wci'e  urgent,  the  cri to-thyroid  im^mhrane 
wfia  immethiUcly  divided,  whik  tlic  child  was  under  tliu  iuHucuce 
of  ether.  A  hougic»  slightly  bent,  being  passed  into  the  left 
brcjicldal  tube,  the  iaubetm^ce  waa  readily  dislodged,  and  the 
pkiu  and  kernel  of  a  nut  were  espullcd  at  lijt  artificial  o[)toiog. 
After  further  search,  under  the  auppopiLiou  that  part  of  tlie 
offending  body  might  fltill  remain,  tic  o|x;nitiou  was  concluded, 
and  the  child  jiut  to  Jjcd. 

Ua  the  tbllowing  dwy,  the  patient  waa  doing  well,  and  ap- 
peared greatly  relieved.  The  woaod  healed  rapidly,  and  she 
waa  soon  aljle  to  go  about.  .Some  cough,  howcTer,  remained, 
uccoiLipatilcd  witii  a  muGoua  rule  in  the  lefl  lung. 


FOREIGN   BODlEa   Df  THK   AIR-PASSAGES. 


105 


At  tlie  eiiil  of  ii  few  week*,  tlic  cliilcl  eudiienly  broiif^lit  ii|i,  ui 
a  ]>arf'Xj5m  of  C(iii;i;tiinrj,  n  eiuall  bit  of  niit-slkcll.  Ail  the 
evmpioms  now  d]dnj)jicaredi  and  abe  rapidly  regained  ber 
lic:i]tb. 


Case  LSVJ,  —  I^n  in  Larynx.  SJ^ciion  Into  Throat 
^tirinf/  Ofteration^  Denth,  llu'rtrf-si'x  hoiirn  nj^encardg,  from 
^t/ioukIioh.  — I  v,-ii»  ri'i|iiost(?d  hy  Dr.  Patc^li,  abnut  tlie  mid- 
dle f'f  ilie  *hy,  to  f^ee  ;i  clilld,  "liii,  lie  sard,  was  in  n  ttjile  of 
sufTocation  from  at  pin  in  tlio  windppp  t  ""^  whom,  it  was  poa- 
i«  wo  should  licit  find  uVivs.  JJc  had  heen  c^llvd  to  it  in 
morning,  ni  nine  o'clock,  when  the  accident  hsid  tirst  oc- 
curreU;  but,  the  sjbstiincG  Inviu^  settled  down  into  the  lunijs, 
and  reliff  beinjr  obtained,  nnd  ihe  doubt  existing  ds  upual  in 
regard  to  the  i'ncis  of  the  eiu^e,  lie  left  it  for  further  obaerviaion. 
The  sym|jlonia  having  recurred,  I  waa  called  iQ-  The  child 
was  ibcn  qnite  bkck  in  tbe  fnoe,  partinll}'  inaenj^ible,  and  Che 
foreijrn  body  flying  up  and  down  in  the  trachea. 

Tracheotomy  wu3  ut  once  pcrforiuod,  the  dissection  being 
muoh  embirratiiscd  from  the  distension  of  the  fat  and  short  neck 
willi  veniiu?  blood,  Aa  soon  as  ibo  tracho.i  was  opened,  the 
apiuin  uf  tlie  Inrj-nx  subsided,  and  the  foreign  body  seemed 
lo  dierippear.  An  instrument  waa  passed  up  into  the  mouth, 
ami  down  to  rhe  bifurcvitiiin  of  the  tmchen ;  but  no  iraee  of 
it  could  he  delected.  When  the  blood  had  ptmscd  into  the 
larvni,  wmsing,  as  h  always  does,  a  severe  paroxysm  of  cough- 
ing, the  pin  had  evidently  been  driven  up  intc  the  mouth,  and 
ewnlliitt-ed. 

The  cliild  now  slowly  revived  from  the  atnte  of  asphyxia;  the 
bTVaiMng  hecaiYkc  free  and  tranquil;  ami,  during  tbc  reniain- 
fler  £jf  rhe  dny,  nnd  the  fnlloxving  day,  tliere  vra/i  no  return 
of  ctiu*rh.  He  confimLnd,  however,  pule,  ^nd  withnni  good  re- 
action; dying  on  lliG  ni^ht  of  the  second  day,  apparently  from 
the  shock  rereived  by  the  aCL-ident*  as  we  occasionally  see  in 
|}ivtifnt4  recovered  from  drowning, 

Case  LXVII.  — vl  Oiinn  of  fTom  In  the  Tradim. 
OpcrriH'in.     EjittftctiQii   iif  the.   SuhsCance.     Hccov^iry. — -In 


ICG 


THE  NECR. 


tlie  Bpnng  of  18C2,  a  clilld  of  about  five  yenrs  of  age  was 
broiiglit  into  the  Hospital  by  jia  nn>Ll»er,  wlio  smIjI  llial,  two  dava 
before,  it  had  got  a  ^^raip  of  corn  Into  iLe  wiiidpi[>ei  TKe  strug- 
gle for  life  was,  for  a  time,  violent.  Resort  was  liad  to  the  U{*ual 
meona  cf  relief;  and  respiration  finally  became  ([uiet,  lejiving 
liiin  much  e^ihausted.  Since  tben,  be  had  bt-en  LoEtrac  and 
stuffed,  but  without  any  return  of  atmuguktlon-  A  subcrepi- 
tant  rflJc  woa  heard  over  the  whale  tJurfjLce  of  the  lungs,  on  both 
aidea;  but  rather  grenter  over  the  1e(\  thim  the  rii^^bt  Jung, 
There  was  aUo  greater  abdeoce  of  resptratory  sound  on  tlie  left 
aide. 

On  account  of  the  danger  of  waiting,  it  wob  determined  to 
try  the  following  es peri t oca t ;  — 

The  child*  being  ethen;ted,  waty  su^pcndtrd  with  llic  liead  down- 
words,  as  in  a  former  case,  nnd  ahaiply  struck  on  tlic  back,  the 
faucea  being  at  the  *ame  time  irriiated;  but  these  efforts  were 
without  cdcct  ia  dialodgtng  the  foreign  Hubatnnce*  The  M\d 
waa  therefore  retained  in  the  house,  and  narrowly  watched. 

On  the  next  day.  the  respiration  waa  eaaier;  and  he  appeared 
gentrally  in  a  better  condition,  altitougb  it  was  very  difficult  to 
make  an  Lu vest i^i^al ion,  on  account  of  his  eiccsflive  timidity, 
which,  in  children,  is  often  a  moat  st-noua  ob^staclc  to  diagnoeiSi 
On  the  ne;tt  day,  the  house-pupil  reported  that  the  night  had  been 
<iuiet;  buti  on  vi;?iiing  him  later,  the  molber  infotnicd  lue  tliitt 
he  had  aiiice  iiatl  an  almost  fatal  attack  of  suffocation.  In  the 
course  of  this  attack,  the  child  had  brought  up  a  good  deal  of 
thick  mucus,  which  she  had  dragged  out  from  ita  mouth  with 
her  fiagers.     I  dccx<le<l  at  once  to  operate. 

The  child  was  etherized,  and  the  traehca  opened.  On  the 
entrance  of  air  and  blood,  the  usual  convulsive  action  resulted, 
followed  by  the  appearance  of  the  kernel  of  corn  at  the  aper- 
ture, and  its  almost  immediate  expulsion.  All  the  symptoms 
were  nt  once  relieved;  aud  the  child  went  home  well*  ten  days 
after  the  opcriilion* 

If  the  opcrntiun  had  been  delaycdi  the  result  would,  in  all 
probability^  hire  been  fatal. 

Gondii etoiis,  —  The  following  coaclusiona  may  be  deduced 
from  a  review  of  these  and  similar  reooi"ded  cases;  — 


totrart  to  Ike  A— at  «f 
^aj  mtoaumoe  waxa  m  ma/am  *» 
of  b^k  fa»  tbebnl  nd  ■iiTifii    «r  tW 


^ 


I 


2d«  liGbAciJNCHM,«rtk»cMit«nbraadviderd»pv*- 

nedin^  bead,  vltca  cB^agcd  in  dkc  hf^Bx  or  Kod^vd  m  tibfr 

Img^B,  maij  W  trvsud  vith  more  trnpunitr.     If  Sal.  llicj  «aCl^ 

nitf  prg-Mttl  aa  cd^c  to  Uie  Kobe,  so  a«  to  penail  tkft  ptiW^gi 

of  air  oo  dtbo-  mIc     When  lo^cd  in  the  Wo«ich«,  nidi  m 

■■betABOc  beooiiic«,  after  a  liine,  c&Tdopvd  m  iiNNrw,  m>  ■»  to 

«lMtr«cc  tke  fm  act  of  rcspintion  :  il  \b  theQ  farxxd  nptrvd?, 

«id,   in   tf>e  etra^glc  whicb  ttisaa,  the   idim:u»  U  diACOgai^td^ 

Tbc  bodj  then  frnDs  back*  aod  mnains  quRvomt  ontil  it  ii£^ 

becovKS  om«fed  wiit  cuira»,  wheo  tlie  proce«a  of  dblodgcanM 

U  i«pcaUed.    Someliaies,  m  tlie  liolcnt  cou^h  wbidi  oeom  wi  iIm 

dMngv  of  pUcc,  it  15  forced  out  into  tlie  moulh,  auiil  QwaJJowtd 

or  ejected;    ai  otbere,  bj  comirg  up  stiddenlj,  when  tlir  p*- 

lieal'd  uttenlioii  ia  diftr^cted,  it  tnkea  tbe  Urvnx  by  gurpnfic,  ad 

it  were,  »dJ  easily  e7ca|re^. 

Au  iDlere^Ing  case  of  ihb  Utter  cJa.^  occurred  in  a  little 
^^irl*  a  |iatieat  of  Dr.  ILde,  on  irhoui  tmrheotumy  -KtiJf  \vf* 
formn],  by  Dr,  J,  C,  WarreD.  fur  tlie  removul  of  llie  wixxlvn 
Btup[>crof  an  inbatanil,  nhicli  IukI  been  sucked  into  the  imcfaea. 
Am  eooa  aa  thb  pa^^a-re  was  opened.  M  irrilaliou  suttfiOinl ; 
the  forci^  eub^tancc  settled  down  !nU>  die  bn^nchu.^;  nniJ  al- 
lliou<^  [lie  wound  wa«  kept  open  a  >veek»  achl  nttcuijUA  mmle  Eo 
dlsJod^  it,  they  were  wllbout  avnJI.  Some  ukonlhif  afterwanls, 
319  the  pftHcnl  was  lookijig  out  of  ik  wiuJcw,  very  intcnUj' 
watching  Lhe  phasing  of  n  milltnry  company,  the  ML>p|rer  catiio 
up.  without  elFnrt.  IdIu  tlie  Miotilh,  nnd  un^  lit  ouce  cji|>vUci]. 

3d,  if  the  substance  is  fiitecl  iu  the  bronchus,  imJ  the  jmlicnt 
TOting,  tile  pri>spcct  of  seizing  it  by  in^trunieuts  iiitrvKlticotl 
through  the  wound,  and  carried  down  in  the  direction  of  tho 
lungs,  is  cxircmeU-  emidl-  In  Fact,  I  do  not  know  of  u  sin^dc 
iucceasful  cnse  upon  reconl,  with  the  exception  of  one  in  which 
Mr.  Liston  opened  the  tmchea  of  an  adnlt,  nnd,  introdui^ing  the 
forcepa  with  r:ome  difficulty,  seized  a  bone,  whldi  had  booornc 
engaged  in  the  right  bronchus. 


108 


THE    NECK. 


4lli,  SoTOP  flmibts  will  nrisp,  liowever,  us  to  flip  propriety  of 
Ii^fiving,  ill  !iny  cnsc,  a  fciroi^rn  substance,  fur  n  period  of  time,  in 
llie  hinn;s^  wirliout  an  pfTitrl  to  remove  it.  For  nltliough  it  mRj 
finjilly  become  detaelied  und  he  ejeetod,  as  ii  freqiienilv  is,  nftct 
rpmnining  ninny  niontlis  or  ye^irs  imbedded  iu  ihe  lun^rg,  or 
Btowal  riway  in  [he  lirom-hinl  tiibp?,  jet  f:itJil  orpinic  lesions  are 
not  iirn'oniiniinly  llie  re!*ulc.  Tlie  aurgciin  muse  therefore  be 
guided  li_v  llie  ijnrtiouljir  [■ircu]nsI:ini'eB  of  eni'h  cnse. 

It  is  reuiapLihle  in  how  grejiT  n  nnmliei"  of  these  casea^  whic*h 
we  lind  ref](»rded  a»  hfivjn^  ot^urred  in  children^  tlie  substance 
introduced  was  a  eominon   giirdeii   betui. 

CROUP. 

Tnirheotomy  is  also  requirnd  in  m.iny  cjisea  of  croup.  About 
twenly  yenrs  ngo,  I  openLTed  several  times  in  aueh  eases,  Ini- 
inetliutP  relief  from  muffooalion  wiis  obtjiined,  iirul,  liir  n  few 
il'AVSf  the  result  seemed  iiiiikost  ndminiloiid  ;  but  the  lun^ri  hsid 
become  allectuil,  und  the  powers  of  life  so  weakened  tliiit  the 
iSnal  result  was  futnl.  An  curlier  performunee  of  the  operation 
waa  neoetksm'y  ;  but,  nt  rh:Lt  time,  the  public,  ami  even  the  pro- 
fession, VkViX'  riot  I'linviiiced  tbut  (hi^re  wn^  liltle  or  no  dntigcr 
unending  it.  J  have  never  se^n  a  ease  where  denth  eould  be 
;i3*.TilH'<l  to  it,  Tracbeoiomv  in  croup  wu,*-  it'vived  in  BiinTou  by 
Dr,  Geor^rc  H.  Gay;  and  llie  praciice  has  bet^'n  liilhnvi^d  *uc- 
cefcsfuliy  by  Urs.  Surmtd  Cubut,  Ht^niy  G.  Clark,  ojid  oiany 
other  fiULgeon^  in   Boston  »nd  elsewhere. 

After  tlie  ii|ier!iliou,  ihc-  air  tA'  llie  njoio  should  he  kept  warm 
and  moiht.  A  double  cube  sbuidd  l»e  omiI,  and  eouipek'nt  per- 
sons  euiphiycd  to  wuteh  tbe  patient,  aui3  remove  the  inner  tube 
in  cjise  of  nbfllriictioru  1  )»ne  no  doubt  ihat  many  lives  luive 
been  lo&t  for  AvmU  iif  lliis  prcTautluu.  The  tube  ^uddeuly  bc- 
Cuinuig  obstructed  by  thick,  adhesive  mucus,  tbe  patient  is 
teiiwd  with  ^iolcut  Hvm|itiFins,  and  tbc  alaruied  parctJt:^  isKud  for 
uiedJcid  aid  ;  but  the  pliyrtieian  arrlvcfi  uuly  iu  time  to  see  ibe 
ease  terininiite,  Mony  of  the  deutlia  which  formerly  took  pLice 
after  tbe  earlier  opeialions  fur  eroup  undoubtedly  aro&c  from 
the  wunt  of  die  inner  tube. 


J 


CltOCP.  —  TLAOiraOTOMT. 


109 


The  following  casee  nre  illustnitive  of  trndioutotuj'T  as  re- 
quires] in  eonic  other  aftisttions  ;  — 

Case  LXVTir.  — I^crryngitis.  Tntcheolomif.  — A  womain 
jiln>ut  30  jpnrs  of  a^c  cnmc  into  ihc  llcis|utfll,  in  April,  1^^9, 
UTMjor  tlie  cnrc  of  Or.  J.  B.  .S»  Jiick^^n.  Slio  had  been  eiif- 
fcring  for  enrac  tinya  o|>inireiitly  with  n  eevere  co]d  on  ihe  lim^, 
and  nuidi  Konreencsp ;  but  no  alarmin^j  pymptoma  apjieiireU  till 
ab<?ut  tlie  time  of  Dr  *Jac^k5on>  mortiiu'!:  visit.  He  hrul  just  left 
the  builtfidc  and  croseeU  the  warj,  when  the  nurgc  called  to  him 
lUat  the  pnlient  wns  aiLffijf^ittin^r.  U|Min  Glopfiiii;^  biick.  he 
foimd  licr  witli  her  face  purple,  preut  dilficultv  of  breathing, 
^Tilirc  loss  of  voice,  puldo  (juick  and  fluctuating,  the  body 
bnlbcd  with  cold  sweat. 

S^ntj  the  (Ifln^cr  imminent,  Im  imin&lintch'  Pent  for  me, 
mnkin*f  prepariitiuos  himself  to  Jo  the  operation  in  cioe  I  was 
Dot  to  be  found.  I  received  the  mcsenf;;e  as  J  wns  enterinu^ 
the  Hoppital,  and  proeceded  nt  once  to  ita  jierformnnec,  Wlicn 
the  firflt  fneii^ions  were  mfide,  the  bhmd  rusliwl  out  of  the  vessels, 
txith  Arteries  nnJ  vcina,  of  a  color  nonrly  ob  black  ob  ink-  As 
Boon  as  the  tmchen  wna  opened  Hnd  the  tube  intr<.>Ji]eed.  nfter 
the  firet  violent  clFort.-'  vljii^'b  ii^unlly  accompany  ihie  proceeding 
ht\*l  eubsicJed,  ehc  bcgnn  to  bi"cntiie  re^nlnrly  anU  freely,  It  wrva 
five  or  ten  inlnutefl,  however,  nfter  the  fi'ee  entniTjeo  of  ivir, 
before  tbe   blood  iiHstimed  it«  natural  vennilion  eulur. 

She  wna  very  enrefully  watehed ;  nnU  the  inlcrnal  tnbe  rc- 
inuvod  nnd  cleansed  wlicnover  the  mucua  became  drjj  and  ob- 
etrueteil  its  eannl. 

She  did  reinarknhly  well ;  and,  at  ihe  end  of  a  week,  ihc 
tube  was  removed.  She  recovered  her  voice,  and  wns  im^ 
proving  very  nipldlv,  when  phe  arose  in  tbe  ni^ht,  and  walked 
into  a  cold  n»oiu  willi  bnre  feel,  whieh  produc-ed  a  slight  return 
of  her  trraibic,  from  which  «ho  Itad  a  slow  convaleeeence.  As 
Dr-  Jaek.^on  remarked,  in  ihi^  enKc  the  patient  seemed  to  bo 
Ulerully  enarebed  from  tbe  jnwj#  of  deadi. 


Case    LXIX.  —  Tracheotomy.      A    Case   in   whiah    ihe 
Operation  was  repeated  three  times  in  itn  Adult.  —  Uec.  17, 


110 


TIIE  NECK. 


1864.  Jolin  McK-,  50  years  of  ope,  fislicrmnn.  The  follow- 
ing is  the  suL>at!\nce  of  a  letter,  oirrjUln^  ibe  case^  from  Dr,  H- 
E,  Davidson,  of  Gluucesler,  MaasflcbuaettB  :  — 

Three  years  r^o,  <Tontnieted  ft  severe  cold,  ncpompaioied  by 
a  ciUarrlml  jiffeclion,  wilh  much  obulructJon  of  the  noetrila, 
This  wii3  fullowed  by  neorosis  of  the  bones  of  the  polate,  from 
wlitch  exfoliulion  afterwnrds  took  place.  The  following  winter, 
hortrflpnoss  and  imjiiurnient  of  voice  cnme  on,  which  continued 
to  increfise  uolil  June,  when  obstruction  of  breathirg  occurred, 
requiring  the  performance  of  tmebGotomy,  which  was  done 
July  22,  I8{i3.  This  ntfonled  eutire  relief.  For  three  weeks 
after  the  operation,  frequent  apphcations  of  atrong  ifolutjou 
of  nitrate  of  silver  were  made  to  the  lurj'iii ;  after  which  the 
cnniiia  waa  retuovetl,  as  tKe  breathing  had  become  quite  free 
through  the  niitund   jjassage. 

On  the  r^eeoiid  day  of  October  foliowing,  the  patient  was 
seized  with  violent  dyspiioin,  threaieniii^r  apeedy  suffocfttion. 
Traeheotomy  wob  again  performed,  affording  instantaneous  re- 
lief. 

The  nitrate  of  silver  was  again  used  as  before;  nnd,  in 
November,  18fi3,  he  was  taken  to  the  IMasaachuaetts  Geiienvl 
Hospital,  where  he  was  submitted  to  laryn^otcopic  e^famination, 
but  without  detecting  any  other  diffieully  than  inHammation  of 
the  epiglottis.  The  continued  use  of  tlio  nitrate  of  silver  wng 
adv'ij-ed,  together  wiih  the  internal  administration  of  the  ioilide 
of  mercury,  in  small  do^^es,  Jan.  I,  lS(i4,  the  bvc.idiing  had 
become  so  free  That  the  tube  waa  again  removed. 

In  Au^st,  \6iji,  while  engaged  m  filling  off  the  coast  of 
M;ilne,  tlie  obstniction  i*eturned  ;  rendering  it  neccs&arv  for  him 
to  hafiten  home  for  relief  by  a  third  operation,  which  was  per- 
formed Ai.ig.  10,  18fi4.  Since  that  date,  he  bos  not  been  able 
to  do  wnthout  the  tube, 

Thie  patient  was  a  large,  powerRd  rono,  and,  with  the  eioep- 
tion  of  the  pre*(ent  difltfulry,  perfeeily  heahhy.  In  speaking, 
Le  generjilly  inserted  a  small  cork  in  the  orJiScc  of  the  canula, 
■which  enabled  him  to  articulate  in  a  low,  hoarse  voiee.  Any 
attempt  nt  labor,  however,  produced  great  rlifficuhy  of  breath- 
ing ;  and  It  was  for  thie  reason  that  he  applied  to  me  tor  advice- 


CROUP. 


TRJlCHEOTOWT. 


Ill 


The  qttesifon  was,  why  clio  pnssnge  of  nh  tliron;rli  ihe  Uiyai 
was  not  na  free  a«  it  h:td.  boon  nfter  farmer  operjiiong.  The 
tube,  he  sftiJ,  did  not  cauee  him  the  slightest  unrfLsicess- 

Thn  iniin  waa  plappil  in  a  stronLj  siiiilin;Nt,  nnd  llic  tube 
removed,  when  it  was  Ibiind  thnt  gr^nulationa  had  shot  irilo  the 
fenestmin,  in  The  upper  side  of  the  ramxla,  and  had  pnitially 
obstnicted  it ;  the  nperture  heJnp,  pviilf?ntly,  too  nenr  tlie  outer 
end  of  the  tul}e.  The  wholo  tube  wns  now  withdmwn,  when  b 
fit  of  cougliing  ensued,  foHuwed  by  the  pnijection  inro  the  nper- 
tore  of  two  or  three  polypoid  bodies,  wliich  were  hanging  down 
into  the  traf^hpjt  from  tlie  lower  edge  of  the  wound.  These  wore 
Bwi'cej'sively  >ieized,  a.^  they  wei-c  foreed  out  during  piiroxysms  of 
CMiughing,  and  retnoved.  Another  lube  was  now  iutroduoed^  hav- 
ing the  fencstrnni  on  its  upper  Ride,  at  n  ^rent:>r  distance  from  the 
shield;  tio  thnt  the  aperture  wna  wholly  ineluded  in  the  laryo^. 
Re  At  oni'C  breathed  more  freely,  and  spoke  wilh  a  tlcnrer  voice. 
A  few  days  after,  this  liiht;  wati  replaced  by  another,  nijwie  with- 
out the  fenestnmi,  when  he  breathed  equnlly  well,  the  air  pars- 
ing on  the  outside  of  it.  It  seemed  probable  that  the  wound 
h^  been  irritated  by  contttet  with  the  sharp  eilgea  of  tlie 
opening  in  the  tidie,  not  only  eausin*^  a  crop  of  granulatiima 
t»  shoot  inlti  it,  but  prmludng  also  a  ihii'keiiing  of  the  parities 
of  the  trachea,  from  the  polypoid  growths  already  referred  to. 

The  shape  of  the  present  traehcnfomy  tirfjes  is  generally  de- 
fective, the  lube  beting  set  too  oblii|uely  oii  the  bhield  ;  the  fjiet 
being  forgotten,  that  it  has  to  enter  fir^t  nearly  In  irizontally,  und 
then  vertically.  As  originally  made,  they  were  thus  angular  in 
form -J  the  present  curved  figjre  biiving  been  adopted  later, 
in  order  tu  adnut  of  the  iDtroductiiui  of  the  inner  emiuhk.  Of 
the  importance  of  this  iimer  movnhle  tube,  iD  may  be  ir^tnured, 
ihftt,  in  the  present  case,  it  had  to  be  removed  three  limes  a  dayi 
ilk  order  tu  cle^jiL  iiwuy  the  dried  JtccLiiriulatiouci  which  obstruoL 
its  canal, 

Dr,  IL  K-  Oliver,  at  my  request,  made  an  investigjition  of 
the  state  of  dte  lar)'n:c,  with  the  laryugiiseope,  with  the  ful- 
loiring  rejiidt :  In  a  gocul  light,  the  whole  interior  of  die  larynx 
ruuld  be  moHt  diHtinetly  seen.  The  vocal  cords  were  both  niueU 
lliirkcned,  and  partiidly  dianblcd  in  action,  the  cord  on  one  t^ide 


113 


THE   NECK. 


overlnpping  its  fellow.  Tli(^  jirylpmilil  carlilii^jea  were  nlso  ili.i- 
ti)rtei]i  aiiii  muoli  liLi|iedt^  la  llidr  mutioiid'  The  limzL  gluttiilia 
waa  estremely  iinrrow. 


FORErON   BODrcS  IN   TITE   CESOPnAflUS. 

Case  LXX. — A  Ceiti  arrtstvd  m  th<^  (Empharius.  Ex- 
tractwif^ — A  chilli  two  and  w  half  \e^ira  (ild  ivns  bron^IU  to 
nae  *m  Feb,  IC,  H35D,  wlia,  R>ur  Jjijs  befure*  h;*(3  awallmvcd 
one  of  tlie  large  olJ-la^lkioried  centa;  ond  had  not  eince  been 
able  tij  tnlic  ni\y  ^olid  fuixl,  aod,  In  fiKt,  nimost  i-cKiided  lo 
Bwnllow  any  ibiiiij.  The  child  waa  finiily  held  in  a  elt(Jn^ 
po^dirci  ltd  held  ciiiried  back  by  an  nasl^iitint,  and  a  piece 
of  wood  pliiced  brlwecn  the  teeth-  The  fin^'er  of  tlie  right 
band  WAS  novr  carried  duwn  llie  thr";it,  and  nii  attempt  made 
to  dUcovcr  the  aituntion  of  the  foreign  body.  The  epaam 
about  the  throat  »nd  Lrh^lti:^  wji3  very  grcnt,  the  etni^'glcs  of  the 
child  were  violent,  and  the  respiration  ulmust  slopptd  by  the 
explur^tiun.  After  aevcral  attempts,  during  whieh  the  first 
joint  of  ray  forefinger  was  severely  bitten,  a  trace  of  a  nietnllio 
aubstanre  was  di^oovcrcd,  wliioh  mi^'ht,  hortcrcr,  have  bccti  ono 
of  the  e;trtila^ca  of  tlie  iaryns-  I  deelded  to  make  no  further 
allenipta  that  day;  but  to  reaunie  them  on  the  next^  under  the 
influence  of  eliier, 

On  tlie  fullosvitig  day,  being  provided  with  eufiieicnt  nsfliftt- 
nnoe,  nnd  the  patient  being  well  eilierizcd,  the  forefinger  of 
the  left  hand  waa  parsed  down  the  throaty  while  the  teeth  were 
eeparated  by  n  bit  of  cork;  and^  aUer  one  or  two  efforta,  by 
preaein^  the  larynx  forward,  the  foreign  Bulifitnnee  could  be  juet 
toirch&l  by  tiie  end  of  the  nail.  Thie  eifort  it  was  very  soon 
neoof^aary  to  diacontiniic,  oe  it  itn|*aUd  the  respiration.  A  long 
curved  fwlypus  forcepa,  very  Hat  and  emooth,  was  now  selected  i 
the  furelin<ror  of  the  left  hand  waa  earricd  down  ils  before  ;  and 
tlie  hirAiix  being  protected,  lio  that  the  iti^trunicnt  thoulJ  not 
pai^d  into  it,  the  toree|>8  was  intrudueed  hiteriillv,  and,  nftcr  one 
or  two  attcmpiG,  the  very  edge  of  the  aoin  seized,  and  at  onee 
Gxlrjieted. 

The  diffii:uity  Jn  this  eaae  arose  from   the  depth  at  wliiob 


FOREIGN    ISODIKS    IN    THK    ffflOPHAfiT'S. 


\u 


the  foretjm  body  hnJ  Icxlj^d.  mJitiPig;  it  Jilmost  imjyissiblc  to 
A^izc  il  vvidiuut  injitrv  to  tUa  impurlaut  neii^kburing  p^rl»,  Juring 
ilie  viclent  periurbiiiion  ouuscd  by  tlie  iniroduciion  of  the  fin- 
ger nnd  instruint'nt  into  the  viLnnity  of  tho  Ifiryiix,  To  a  person 
wlio  ia  going  ti>  atteiiipl  lliia  operntjun,  I  would  ndrisc  n  shield 
prepared  of  gur(:i  pcrcha,  tiUcd  over  ihe  fii*^t  joint  of  the  for^ 
finger,  to  protect  it  from  the  teeth  of  ihe  pntient:  fla  I  hiiTe 
often  suffered  fj>r  mimy  djiva  sifler  from  eonciHioiifl  received 
during  timiW  operations,  notviiUisIiiMding^  ll»e  ordinary  gugs, 
&nd  otlier  menna  to  prevent   the  (^losing  of  the   teeth. 

It  U  alwflj's  very  im[>orfniii,  wlien  n  fjreigu  body  U  lodged 
in  tlie  neigUhorliood  of  the  irtryn^c,  tlinl  tlie  fL>refinger  of  the 
lufi  hand  should  8er\'e  as  t\  ginde  to  the  inatrunient,  to  prevent 
h  from  doing  injury  to  the  veiy  important  or^im*  in  clo.je  prox- 
imity. Olherwise  the  cp]<^lollis,  llic  edge  of  the  Lirvni,  or  the 
neiphboring  «iift  |n\rt>'j  uiiiy  be  seized  mid  Jneeraied,  AVhen 
the  foreign  biidy  U  bulged  f;irther  du^n  tl>e  (p^ophngii^,  thia  ia 
unneeessary,  ns  llie  pntbaiiT'  or  hook  of  Dcipiiylren,  hanug 
once  puaeed  by  llie  lurynx,  niiiy  be  manoeuvred  kiw  down  in  the 
ce.soplingris  without  mueh  Janirpr.  It  is,  however,  proj>er  to 
say,  tliat  foreign  bodies  very  eoldom  lodge  in  tht^  lucniiun  ;  for, 
if  they  once  become  difiQng;tged  from  behind  tlie  bos  of  the 
Juryns,  they  generally  pass  easily  into  the  stomach,  and  do  no 
firrher  injury. 

r  have  genei-fllly  observed,  that,  where  eenta  hnvo  been  swid- 
lovved,  tbey  hive  made  tJieir  nppesimnce  about  the  third  ihy 
ttftcrwards.  In  one  ease,  one  wns  retained  about  three  weelcs^  and 
then  [inssed  without  injurv  to  the  patient,  1  tueniion  this  fact, 
na  [MU'eiilh  nre,  in  general,  execedinj^ly  nniioua  when  a  copper 
coin  reraaina  ii»  the  intestine*  of  a  child. 


Case  LXXI,  —  A  Cent  iit-  fhi?  (Efcphfigna.  H^^frrtcfton. 
—  A  eliild  fix-e  years  of  nge  was  brought  to  nie,  July  2^,  184E>, 
who  liful  hern  partinlly  chnk^nl  bv  n  rent,  whit'h  h:ul  hjdj^^ed  in 
iliff  <L'sriphagiia_  Aliempta  liad  been  made  lu  disengagu  it, 
which  only  served  To  force  it  fiirther  down. 

In  <trder  In  reach  it.  I  foix.'e*!  the  forefinger  of  the  left  hand 
down  the  throiit ;   and,  widi  mueh  effort,  waa  able  to   loueh  It 

15 


114 


THE   NECK, 


with  the  uml  oi'  llie  nnU,  ns  it  byjusl  below  the  larj'n:^.  After 
giic  or  two  Altcmjfls,  ji  jiair  of  l^^rceps,  oj^enuig  nnterjorly  und 
posteriorly,  and  curved  on  the  flat  side,  were  alipped  over  it, 
guided  by  the  finger,  and  tlie  ce:it  seized  *;nd  extracted. 

These  Cii^efi  will  serve  to  show  the  iiotfhioii  of  luetallic  eub- 
Btances  in  tlie  cteophagns,  which  Boniclimca  reraiun  there  for 
Q  long  time  without  causing  f;i[al  con8Cf|uences,  I  removed  n 
quarter  of  o.  dollar  from  u  child  five  or  six  yenr^  of  age,  which 
liad  re[]]ained  for  one  or  two  weeks  behind  tl;e  liirynx,  without 
preventiug  thepiissage  of  flolid  food.  Bouca,  for  the  moat  part, 
are  lodged  higher  up,  nnd  require  a  diEfcrcnt  mnimgciucnt. 
The  finger,  however,  should  ftlwaya  be  used  aa  n  ^idc, 
Withiu  a  week  of  writing  this,  1  removed,  from  the  throat  of  a 
gentleuiiin,  a  large  fisli-bone  firmly  wedged  across  the  opeoing 
of  the  larynx. 

STRICTURE   OF  TlIE   tESOPnAGUa. 

Strictures  of  the  ceaophagua  rc^iuire  a  very  delicate  treatment. 
On  the  one  iiaud,  if  ariaing  from  traumatic  causes,  and  of  a 
fibrous  character,  they  are  susceptible  of  great  rdicf ;  and  the 
patient  suficriug  trora  starvation  may  be  restored  lo  a  state  of 
nhiiDSt  pcHcct  health  by  a  persevering  and  Judicious  ap]illcation 
of  dilating  instruments.  On  the  other  hand,  if  the  affection  is 
nmlignant,  the  use  of  instruments  is  aometiines  extremely  per- 
nicious. 

There  Is  reason  to  believe,  thjit  a  stricture  of  a  noii'malignant 
charaeter,  ailcr  a  duration  of  many  years,  may,  from  the  de- 
terioration of  health,  or  from  other  reasons,  take  on  a  malignant 
course.  It  is  difficult  to  decide  whether  the  aflection  la  can- 
ceruus.  TJic  complexion  of  patients  suiiering  under  stricture 
often  assumes  a  pale  yellow  appearance,  which  would,  at  fii'st, 
lead  to  the  supposition  that  there  was  conetitutional  disease. 
By  judicious  treatment,  particularly  by  the  use  of  malt  li<|uorft» 
where  sohd  food  cannot  be  swallowed,  a  change  for  the  better  is 
very  soon  manifest.  Where  the  disease  ia  cancerous,  the  use  of 
instruments  increases  the  soreness,  and  they  arc  otlen  witlidrann 
eovercd  with  blood.    For  diktatiou,  the  beat  instrument  is  a  rod 


BTBaCTTRE  OF  THE   CESOFOAGUS. 


115 


<*f  wlialebone,  with  a  ptec€  of  ivory  on  its  end,  of  a  coniwil  nither 
than  of  fl  globuJnr  shnpe-  l^Tiere  the  atriclure  la  quite  situiU. 
and  pouched  at  it*  side,  I  Ijstc  had  most  stiocesa  by  using  a 
conica!  wax  boagie,  with  the  tip  bent  forward;  and  rliU  will 
ofWn  succeed  in  pacing  the  etricturef  when  the  Etrai^lil  one 
would  be  caught  in  the  sac.  I  know  of  a  Dumber  of  patients 
now  living  and  In  hcaltb,  for  whom  I  dilated  strictures  mnny 
yenrs  ago,  who  previouslv  had  not  swallowed  solid  food  for 
tnonlhs,  and  In   some  ca^£  for  years. 

The  foUowiDg  cases,  seJeotcd  from  a  great  number,  are  given 
to  illustrate  the  trealUkeut :  — 


Cask  LXXII.  —  Stnctttre  of  (E»ophagu»  from  Crrustic 
^mmonta.  —  Id  September,  1SC3,  a  you n^  woman,  1.9  ycara 
of  age,  TOamedf  and  nursing  a  child^  came  lo  me  in  a  «t»te  of 
almoEt  complete  glarvation,  at  that  time  liaviTig  swalloned 
notliing  for  the  previous  twelve  hours.  She  said  tJiat,  alktut 
two  Tears  before,  when  ill,  she  swallowed,  bv  neeident,  a  l<*a- 
Spoonful  of  oaUBlic  nmmonin.  in^lead  of  her  proper  medicine. 
A  violent  indammatir>n  of  the  cpsophogu*  ensued,  and  *he  hjid 
not  been  able  to  swnllow  solid  foad  since.  She  had  lived  prin- 
cipally ou  milk,  aud  animal  broths;  hat,  the  system  bein^'  dc- 
preseed  from  cursing,  irritation  liad  come  on  at  the  Btrictured 
part,  so  thiit  she  could  swallow  nothing.  I  made  an  ntienipt 
to  pass  the  smaller l-sizc*I  j^rubaug  of  whalebone,  the  ball  on  iis 
end  being  about  the  size  of  a  jjea ;  but  it  was  arre^^red  about 
hall-way  down  llie  tL-eophagusT  and  would  not  go  farther.  I  ad- 
vised her  to  wean  the  child,  and  live  for  a  few  davs  on  nutritive 
enemas.  This  she  did,  and  whs  then  again  able  to  swallow 
liqiiftlfl.  On  the  Ild»  of  October,  she  was  etheriied.  Afler  n 
numlwr  of  eff>vts,  I  finally  succeeded  in  pa-i^ing  tfirough  the 
fttrioiurc,  into  the  stomach,  a  small  guin-clasti'*  cniheter,  with 
A  itylet  in  it,  bent  to  give  it  a  curve  forwards.  This  opcratiou 
wns  iiftrrwards  repeated  frimi  lime  to  time,  wilhouL  the  use  of 
€lhcr  ;  mid  1  saw  her  last  in  I8li3,  in  good  heiiltli,  enahled  to 
swallow  semi-sulid  food,  but  siWl  occasionally  requiring  the  use 
of  an  instrument. 


lift 


THE  NECK. 


Case  riXXTTT.  —  Strichire  nf  the  fEfinphafpiti  omirrx^t^ 
rifter  Ofiokinr/.  —  A  l:nly,  ^^i  ji?avs  of  Jtgp,  (/uii.'jultcd  me  in 
DeL-ember,  lt*61,  for  n  stritture  of  tJie  CTSophfigus  of  tiiirtepn 
years'  sinmWn'f,  jirmlnct'il,  (is  slie  wiipinx^^eiU  froni  ^'ettiiifr  fli<ik*'d 
wliile  avvnlliiwing  n  jiie(v  of  beefstPJtk,  ivliicli  prixJiu'cd  a  «(ri'ere 
spnsm,  nml  \va.s  fitmlly  L^t'Cled  witli  sdmc;  blood.  Three  yenra 
before  thii^,  n  luzeni^c  huJ  ^liiok  In  her  tliroiiti  nn<I  remained 
thi're  uiiiil  it  Iiiid  dissolved.  Sitk'c  Clic  In^t  nmdi^ni.  <<\\o  had 
with  ilifti^nilcy  £w?Llluw(?d  iiny  i^olid  food.  In  fart,  die  hiid  \\een 
gt•m]l^:l\\y  nidtK^ed  Eo  the  necessity  of  u^iiig  only  liijuid  noiirijth- 
ment. 

On  the  3d  of  Dtnmilior,  I  piiwsed  u  probing  biivinir  n  bulb 
tbe  size  cif  w  pen.  It  went  tikmugli  a.  i-itriuliire,  n.  littlt-  bi-low  ihe 
Ini'vnXj  with  snmc  diltii'idrv,  bi'infring  \i  little  Mood  ^\ilh  it.  She 
was  ordered  ii  iiutnlioua  diet,  wilh  ^lortor.  Ilia  iispect,  nt  llifa 
tinie,  wna  ih»t  t\(  a  ]torMon  with  n  niiUI^iiiint  Jir^cnse.  A  litile 
aoreoi-*/*,  ivhidi  liiwteil  l\vn  duvs,  fulhuvcil  (he  oiK^ralhin,  On  tlie 
third  duy,  llie  s\unG  iTistnnneni  wmj*  Hgriiii  piissed,  with  simiiar 
effect.  The  size  of  llic  inslniim^tit  wnrt  j-nidiiully  iiiiToa^ed, 
and  she  wiLfi  soon  uble  to  luke  ^olld  nutriment.  The  use  of  the 
instmifient  wus  cinirrmu'd,  !(t  longer  lijlervjils,  fur  t\  ypiir,  ihe 
power  ill'  hiKiiiy  sdliil  I'uiid  iiiL-reii^in-r.  She  now  (ISIiti)  no 
longer  requires  ti-entmenl,  and  enjoys  a  moderate  degree  of 
hwilrh. 


TtrMOES   Tiff  <ESOPnAGua. 

Case  LXXLV.  —  Poh//tns  of  Phanpt:/' of  Lfnye  812^  rtt^ 
iachf^i  to  the  oufftiile  of  EjittjioltU.  Opfratiou.  Cure. — 
Thl^  case  in  inlereNtin^  ns  being  ulciio^t  unique,  on  OLVount  of 
the  size  nnrl   sitmillon  of  the   tumor. 

The  pnfient  wns  a  ^reTitleninn,  54  years  of  Age,  who  began, 
in  1800,  Co  bave  a  sorencHS  of  the  iliniiit  in  svallowiii"^.  About 
ten  wpf'VH  ufTi'rwjinlj*,  by  a  voluntary  pfTort,  a  tuninr  enuld  he 
furLtd  up  into  the  mouth,  fniUT  ihc  Lesa[»lmi^u«.  ThiA  did  not 
give  him  much  InconrenleTice  till  al^out  three  weelca  s\vca,  when 
it  begun  tti  inere:ise  rapidly,  iMuaing  uiunh  Iroulile  iu  deglu- 
dtioD. 


M 


TDMORS   IN  (EftOPBLiOUS. 


117 


He  applit-^I  In  mc  ATjiy 
1,  \iMi\y ;  »]id  I  could 
Itonlly  credit  the  state- 
mem  he  iriaile  willi  re- 
gard ii>  ihu  tii/e  of  [he 
tiiiiiur.  By  mjiking,  hoW' 
ever,  n  rt'giirgiliiliiig  ef- 
fort«  he  at  fjitce  con- 
vinced mc  of  the  fact. 
A  hu'ge.  Avhittr-likoking 
tumor,  oF  the  ahiijic  and 
Bizc  ol'  a  Binfill  fiaufliige, 
was  thrown  up  into  tlie 
inuuih.  While  in  lliia 
poailior,  it  caused  <:oii- 
alunt  ciforta  to  vomlli 
(liTee  woodcitt.) 

Seizing  it  with  forceps,  I  passtd  my  finder  down  llic  tliroat, 
Alkd  found  tliat  the  tumor  ori^Luattrd  in  tlit  nL-i;;iiUnhoud  of  tlie 
epiglottis.  By  a  slight  eHort  of  tlii;  pLilient,  it  resumed  ita 
eituntron  in   the  orauph^gus* 

Being  exjuuinixi  by  Dr.  II.  K>  Oliver,  witli  the  laryngoacope, 
ib9  urJ^^LU  WKtJ  found  to  be  by  a  broail  bnec,  conimenciug  \^w 
down  on  the  left  and  outsiile  of  the  epi^dottia,  wln^'li  it  driigged 
down  and  over  to  ilie  aanie  side  :  thence  a  rihbiiu-like  peiliclo 
extended  into  the  (esophiLgua.  On  tJie  2d  of  Muy,  it  was  rcmoTcd 


In  the  latloAvin^  nmnncr  : 


Bciug  brought  up  into  the  mouth,  it  wm  transfixed  by  means 
of  a  curveil  needle  jirmed  with  n  long  tin'eail  so  as  fo  control 
it.  It  seemed  quite  vnscnlnr,  and  bled  freely.  IiiateaJ,  there- 
fore, of  exeisin;_y  it,  [  paaeed  a  strong  li^-^nture  down  the  tlirout, 
and  lied  it  as  utut  the  base  ns  po^oible.  The  Cuuior  vvaa  then 
cut  o6r  in  front,  witli  HSimpaon's  long  curved  scissurs. 

The  pi>riion  removed  was  about  three  inches  long  nnd  two 
indies  in  circujiiference,  and  of  a  fibrous  riiamctcri 

Consideiing  tlie  position  of  the  ligature,  in  the  neigborhood 
of  tlic  larynx*  the  flvnipioins  which  followed  were  of  a  mild 
chiu^iictcr.      There  waa    no  condtilntional  di^turLnucCt   and   ihe 


THE  NECK. 

patient  ewal  lowed  liquids 
without  much  diSicully. 
On  the  iJiird  daj,  a  la- 
ryngoacopic  examinnlion 
showed  the  ary-cpi-^dotti- 
denn  ligament,  on  the  Jefl 
aide,  in  an  a'demiltoua  stale. 
The  linfHiiirca,  tlic  loop  of 
whioh  was  eeiured  on  the 
outride  around  the  enr,  were 
cofioeiJed  by  this  fiwclling. 
After  being  gently  dniwn 
on  for  two  or  lliree  dnye, 
ihcy  came  away  aponinne- 
ously,  SLiy  6fh,  bringing 
wiih  llioni  the  pedicle  of 
the  tumor.  The  patient  ex- 
|]ro9Ped  himself  greatly  re- 
lievfd,  aa  was  natural,  from 
die  openiiirm,  nnd  Iiad  no  farther  synqjtomB. 

A  imiior  o!"  Hft  hii^^i?  a  ti^e,  in  thi.-i  situation,  must  be  uncom- 
monly rare  ;  and  the  only  cu^e  which  1  have  been  able  try  find 
a|>pro;Lfhin^f  it,  thoufjh  of  a  different  anatomical  structure, 
13  to  ha  found  in  Mr-  Gibba's  valuable  woi'k  on  the  "Throat 
nnd  Windjiipe,"  whifh  1  lake  the  liberty  to  transeribe,  its  at- 
tachintnta  being  ne;irly  the  same  as  in  the  present  one. 


"  Que  of  (he  nn»wt  reninrkablo  on  record  is  preanrvi'd  hi  the  luu- 
Bouin  of  tlie  WeaLaiioMer  Uo&plUil,  oC  a  pcuduioaA,  tatty  ttioior  of 
the  phnryux  nud  liirynx,  oociirrla^  id  n  robust  aad  nclivu  man,  *pf. 
fiO,  vklio  hnd  throai-3ympioEua  for  twelve  ycurST  Hud  four  yi-arfl  be- 
Sitva  dejklli,  during  tlie  act  of  vomidag,  a  lurga  uiasH  protruded,  nlilch 
ht  wiip  obliged  i*>  rctiiro  an  speedily  aa  possible,  to  prtvcut  iinnicdiiitc 
sufTothlion-  Ho  died  Hufldealy,  wIliIo  smoking  liis  pJpC'  A  largu, 
pendulous,  fntty  tamor  was  found  Ailing  rLe  pharynx,  aod  exlendiog 
dowowiirJi^  iuto  (he  a'aophagun  to  Ihe  exli^ut  of  uluu  ircLes.  It  nas 
atEa^heil  hy  aa  envelope  of  niucoua  aiembraoc  and  fibroiis  ti°9uc  lo 
tho  It^ft  Bide  oi'  tbo  opiglotlia,  draugmg  \i  downwurda  and  to  tho  left 
fliJtf,  BO  as  iiLHirnly  lo  preveai  perfect  closure  of  tha  laryas :   ii  waa 


BEMOVAI.    OF   TOVSILS. 


119 


■Im  coBBedcd  with  the  i^o-  put  of  the  phurtii :  but,  wiib  %hmt 
Gxccptiooi,  il  haag  pcrfeaJj  loose  id  iIms  pharpa  mid  a^aoplugos^ 

"Tlw  t^mor  *-**  exhibited  before  the  PAtbolo^f&l  Sndtij.bj  my 
coUcAgne^  Ur.  Hoti ;   ft&d  ii  fipired  in  tlie  fifth  rolame  4»f  tb^ 

Hw  woodcuU  itccooapflDTin^  tl^  present  case  were  cimwn  t^ 
Dr.  Oliver,  %wl  represent,  Ivt,  the  lunior  a£  seen  in  the  DMaih ; 
imd,  2J,  tbe  sa[^>o»ed  position  of  the  lumor.  A,  in  ih^  a>$;(k|ilat- 
pi^.  Tbe  b*M  of  the  tongue,  the  epi^totti^,  the  lairnx,  uid 
trachea  ftTC  represented  in  iheir  inte^tv,  while  the  remn-imng 
paru  arc  in  eeocion.  Tbe  eplgloui^*  B,  is  dmwn  down,  aDd  to 
tbe  left,  by  the  tiimor,  C  &un<U  upon  the  greater  corau  of  die 
left  tbvroitl  eartiJa^,  broken  down  tc  expu^  ihe  porta  beaeath. 


BEMOVAL  OF  TOHSILS. 

T  know  no  minor  operation  in  anrgenr  that  affi^nla  greater 
relief  and  more  satisfiictory  results  than  this  one.  I  have  per* 
formed  it  from  fiie  hundred  to  one  ihoii^ard  tim^^.  and  have 
never  lost  a  single  patient,  nor  had  a  sinn^le  case  of  dangeroiu 
haemorrhage ;  and  in  btit  two  ease^  have  I  seen  nny  such  aoei- 
dent :  boiJi  did  trell.  The  ea;^^  were  not  taken  indi^riminaiely  ; 
nor  wag  the  operation  performed  eave  where  the  fymptoiiis 
■were  more  or  less  iirrreai,  and  other  remedies  had  failed  in  af- 
fowlhig  relief,  Many  of  these  patients  were  brought  from  a 
flititnnee,  on  aceotint  of  the  importance  and  severity  of  the 
dj-t^ease. 

In  nJmost  every  inslanoe,  the  svmptoraa  were  ftl  onee  relieved  : 
the  patient  was  able  to  tate  his  food  wifli  comfort ;  lo  sleep 
betrer;  and  eiehange^J  a  palhd  and  depressed  a«pect  for  a 
healthy  and  aTiimace<I  appearance,  gaining  rapidly  in  flesli  as 
ftoon  as  a  proper  amount  of  oxygen  was  allowed  to  peactratc  to 
the  hmgB. 

In  four  or  five  instaneea  onlv  have  I  been  obliged  to  repeat 
the  operation,  Tiie  whole  of  ihe  tonsil  never  U,  nor  ought  lo 
be,  removed-  When  the  enlargement  is  very  great  and  irregu- 
lar, it  sometimes  extends  down  the  tUroat,  with  a  brood  base, 
Mul  it  ia  not  possible  to  embrace  at  once  in  the  instrument  ju 


120 


THi:  M:f7K. 


Tnneh  of  the  ^lanJ  as  it  would  bo  desirable  tn  rpmnve,  and 
the  sipei  only  h  cKrisp<I,  The  consequence  ia,  ibsit  the  lower 
pnrtiuTi  ofterwunU  risra  up,  nnd  comes  into  view,  causing  ob- 
fitrut'tion,  und  requiring  nnorher  operation.  Theae  cases  were, 
however,  very  eiicf'piiona]. 

Once  r  saw  denlli  oepiir  from  enlargeiaent  of  tbc  tonsils.  An 
Dccount  of  the  cnse  is  ^iven  below. 

In  tlie  '*Pliikde]i>hi!i  Maiirnl  Exummer,"  ISifi,  J  jmbllsheil 
an  account  of  certain  defonutlies  of  the  dieat,  nltendpd  witii  an 
ealnrjtement  of  the  tonsils. 

The  gubstanco  of  tlie  paper  is  contained  iu  tbe  following 
lemsrkii  i  — 

In  1827,  M,  Dupuytren  publiehed  a  paper  on  the  Inteml  de- 
preggjon  of  the  parictes  of  the  clieet,  eonaistin^  of  a  depression 
more  or  less  ^freut  of  the  riba  on  eiich  side,  and  a  proporliunate 
protrusion  of  the  Jilernuni  in  front,  ace om ponied  by  some 
nnlero-posterior  onrvature  of  the  vcrtobr-al  column. 

In  1h27,  fltionly  after  ibe  publication  of  this  pjipcr,  Mr. 
Coalaon,  of  London,  [uiblislied  «onie  cnses  in  confiniiiktiun  of 
tho£«  given  by  Dupuvtron  ;  ad<.lin«;,  nUo,  ihree  caeea  of  \\u  own, 
of  n  deJVirmity  of  the  chest,  dilferent  from  that  before  described, 
the  Mermiin  being  concave  anteriorly,  the  sides  of  the  ohoel 
%'ery  prominent,  and  the  epinnl  column  but  BJijrhtly,  if  in  any 
de^^ec^  nltercd  from  its  natural  shape. 

In  the  three  case«  Appended  to  the  paper  of  Mr-  Coalson, 
and  three  of  the  four  eases  of  M,  Dupuytren,  enlar^emeui  of 
the  tonsils  existed;  but  in  none  of  them  does  it  appear  that 
removal  of  tfiese  (>rgtina  was  praetiawit  so  that  we  enn  not 
jud^^e  wbiit  tUe  effect  would  have  been  on  the  symptoms  referred 
to  the  chest,  Lad  this  operation  been  done. 

So  far  aa  my  own  ex]>erieuce  ^oea,  tliis  condition  of  the  chest 
is  partly  loechitnicnl,  partly  constitutional ;  beiTip",  in  a  great 
measure,  caused,  in  delicate  subjects,  by  the  difficidty  of  res- 
piriition,  from  the  obstruction  iu  the  throat,  improving  imme- 
diately when  this  is  removed. 

The  operation,  ns  perfometi  by  the  present  improved  instru- 
ment, U  instnntnncoua,  not  ntrcnded  with  much  pain;  in  no 
case  is  there  any  considerable  hemorrhage ;    usually,  nothing 


A 


REMOVAL  OP  TONarLS. 


121 


TTiore  thnr  a  few  moutbftila  of  bl(>t>d  are  tUachsii^Fod.  Tho 
patients  are  able  to  return  home,  jusd  resume  tbeir  ordiaary 
ootupationa,  as  if  nothinp;  uncommon  hod  iKMurred;  only  a 
slight  sorpneas  beiii^j;  experieiico^l  for  n  few  dflyn. 

The  tbllowin^  Ciwee  illuatrato  the  Bymjilome  of  thie  disease :  — - 


Case  LXXV, —  Enlfirge'>ueni  of  Tomils  in  a  Child  of 
Five  Yenrif-,  u-itk  Otorrkcfa.  Exciifion^  teiih  lieli^f.  —  W., 
of  Newton,  Mnee.,  five  yeara  of  a*ro,  Xovember,  1833.  For 
two  j'carBi  thlfi  child  sutlered  fmni  nti  enlargement  of  the 
tonsils,  first  manifested  by  u  swellinpr  whioh  upijenred  on  the  out- 
side of  the  throat,  and  supposed  to  he  mutnp^.  As  the  disease 
mcreaaed,  he  gradually  bat  fleah  and  Btren;^h,  and  was  subject 
to  frequent  aore  throat,  attended  hy  febrile  iittacke,  occurring  ad 
often  as  once  a  fcirtni;^ht,  and  laatinn;  two  or  three  days.  He 
breathed  At  night  with  great  dilficulfy,  nnd  occasionally  started 
up,  ns  if  from  choking,  when  the  sleep  became  profound.  One 
ear  was  inflamed,  and  there  was  a  purulent  discharge  from  it : 
be  wiia  very  sensitive  tu  any  hmd  niusicid  sound.  He  was 
small  of  his  age,  thin,  and  of  an  irritable  disposition.  The 
cheat  was  found  lo  he  much  dcformwl,  presenting  tluit  appear- 
ance eulled  excavated  atemum  :  ii  being  very  mvruh  depressed 
in  ltd  centre;  and  the  ribs,  at  the  union  of  the  cartiluges,  ele- 
vated, so  as  to  form  with  th^-in  an  neute  angle. 

The  lontiiJs  were  so  much  enbirged  as  to  touch  each  other, 
and  entirely  obstruct  the  po^rerinr  part  of  the  fauces.  One  of 
the  lonaila  whs  removed,  and  aftbrded  imme<Hate  relief  to  all  the 
syraploms.  In  the  month  of  April  following,  some  difficultv 
being  experienceil  in  breathings  the  cdierwa-a  t\Uo  excised.  1 
saw  him  Aug.  Ji,  1W37,  nearly  a  year  after  the  first  operation. 
From  being  a  mi^erHb!*.'  child,  whom,  ns  his  mother  slateil, 
ahe  had  not  the  least  idea  of  raising,  he  had  become  a  fine, 
healthy  boy ;  had  been  perfeclly  free  (rotn  difticnky  of  respira- 
tion, and  hfiil  had  no  frhrjli;'  attack  sinre  tlit*  rpcrarion.  The 
flensiliveuess  of  the  ear  had  diminished,  mid  tha  det<jrinity  of 
the  chest  was  much  lews  obvious. 

10 


ISB 


THK  KECK. 


Case  LXXVT.  —  Enlargtmtnt  of  Tomih  in  a  Boy  of 
MighUci^  17'ar*i  tvith  IJeafncse-  Excision^  with  lie/^tora- 
tion  of  Hearing*  —  B»,  aged  18,  No\craber,  1336-  For  two 
or  three  fcnre,  hn.d  been  subject  to  frequent  nttucks  of  aore 
throat;  for  tbrcc  months,  had  bud  (L  piinilent  di^chnrgc  from 
tlic  right  car;  was  quite  deaf  in  both  cars.  He  npplicd  for 
advlec  oti   fltrcoiint  c>f  the  dcnfncs3i 

On  cKumination  of  tbe  card  by  the  apecnlnm,  the  tynopanuin, 
of  each  side,  wae  found  to  bo  in  s,  perfectly  sound  state.  On 
tlio  side  Irom  which  the  diselmrgc  appcrtrcd.  tlic  linin:;  nieni- 
branc  of  the  ear  waa  rcdilencd,  and  ci>vcred  with  n  ptimlent 
deposit-  The  toneila  vrcr-e  found  to  be  very  Qiueh  cidar-jc-*!, 
find  there  was  considerable  rodncas  of  the    back  port  of  tbe 

fuUCCf^. 

Astringent  remedies  being  tried  for  a  fortaiglit,  witliout  ef- 
fect, both  toneiis  were  removed-  On  tfie  fuJlovring  day,  ho 
be^an  to  hcor  bettor;  on  the  second  day,  hiti  hearing  wuh  per- 
fectly restored,  and  younda  even  became  so  acute  aa  to  be 
painful. 

In  a  day  or  two,  the  dcnfre^s  rcturnwl,  and  Instcd  a  week  i 
he  then  recovered  hie  hearing,  nwd  hat*  rcmiiincd  pcrlcctiy  well 
eincc.  I  enw  liim  more  than  two  ycar@  niter,  and  he  hud  cx^c- 
ricEiCcd  no  return  of  his  diflieulty. 

To  thc^e  en^a  mi^ht  be  nddcvl  one  or  two  in  which  thoeo 
orj^'ans  were  removed  while  tlie  patient  waa  hdinring  under  an 
attiick  of  severe  tyneilhtis.  In  one  cose,  t\\e  aymplome  were 
ioimcdintely  rcruosed  by  llic  opcrnlinii  ;  in  another,  inHommnti"n 
had  extended  to  the  adjacent  pai-t^,  and  an  abpc?t«^tf  formed,  as  is 
often  seen  in  thia  dificaae-  The  aHeciion,  however,  was  mudi 
ehortened  in  ditration,  Instin^  four  daya  ine^tead  of  fourteen,  as 
hud  been  iieunl  with  tliL»  patient,  who  was  liable  to  attuokrf 
every  winter^  Tlie  iipcintiijn  was  repeated  ;  and  tlte  otiicr  tun- 
B\\  was  removed,  on  a  suhaefjuent  attack,  with  the  eame  result 

The  iti^tnmicnt  UJfed  in  ibeeie  openLtiong  bo^  nstiully  Ijecn  tiic 
guillotine  instrument  us  dL-acrihed  Ijy  Ur>  J.  C.  Warren  in  liis 
vork  on  tumors.  It  is  without  any  steel  movable  nceedle,  used  to 
fix  the  IoumI  and  prevent  it  t'rum  fidlin;;  intij  thf  lliroat,,  winch 
appears  to  be  umclcfk;,  ua  the  blade  of  the  instrument  driven  the 


EEiTOVAL  OF  TOXSILS, 


12a 


lining  raembmne  of  the  tonsil  into  its  ^ix)V€,  and  thus  Beuures 
it ;  itn<l,  even  if  thie  were  noi  the  case,  tlie  mucus,  which  cuvcra 
the  fauccsi  cnu^ea  tlie  cxt^ieutl  part  to  udhcrc  to  the  btai](j|  90 
thfit  there  ifl  no  dcn^^Gr  of  its  e&cajjiEig  into   ihe  lliroat. 

From  a  review  i>f  a  large  number  of"  ciwea,  I  find  that  many 
of  the  children  were  of  a  scnjfulous  constitution  ;  that  thp  en- 
loi-gemeni  of  the  lon^ib  cnu^od  i^reM  loea]  Iroubk*  atk^uded 
with  conddenible  con^litittioiml  disturbauoe ;  thiit  the  palient 
was  much  inoro  liable  to  LEidnmrnatory  attacks  of  the  thi:<.)at, 
Elmn  in  enget^  where  thia  ci>nditi^i]  does  not  exii^t :  and  thai 
tbej-  wore  le^s  liu-ble,  ufter  the  operation,  to  thcee  attacks- 

In  about  half  c.f  all  the  cases,  and  in  about  twc-thirda  of 
these  of  chilJrou-  detormity  of  the  ehcst  existed.  ^Vheiher 
thid  de[>ended  im  the  ^neral  c^on^titiitional  habit  of  tlio  patient, 
or  was  induced  by  the  obstructi^tu  lu  the  throat  to  the  free 
pas4iL<^e  of  air,  the  accounts  rectiived  he  to  the  cxoet  tune  when 
either  aflbt'tion  was  fii'ijt  observed,  were  not  eurtieiently  acourtile 
to  juHlifv  a  decieioa.  It  is  eertaiu,  howtver.  ihjU  tliiJ*  <letoraiity 
does  not  increajw,  but  ralhordirmmfr:hi7{«,  after  tbc  removal  uf  the 
obstnictiou  in  tlic  throuf.  Tlie  ojUL'tjUioii  h  a  siinjile  one,  nt- 
teufled  with  no  danger,  and  almost  al>vays  atloitU  iuinjcdiatc 
relief  lu  the  syni}>tonia. 

Case  LXXVtl.  —  Slrtriiftith/tion  ftom  £nhiiyt*d  T'mvils. 
— -A  man  was  br'iu*,dil  into  the  Hospital,  f^triig^ding  tor  breutlj, 
and  almost  pui^clese,  ttuppoj^ed  to  he  luboriTi<j;  iLmkr  an  lUttLek 
of  Ifttyngllifl.      The  dun-^er  of  auffoealion  was  so  iinmincni  tlint 


124 


THE   VEOK. 


no  time  coiilj  be  spnrcJ  to  iur|iiire  into  the  history  of  tKc  c^ac- 
I  oL'Jercil  Iiici  to  be  pluceJ  on  \ils  huck,  iiDti  procecJcd  to  ojjcn 
the  lurynx,  —  a  umttor  of  aomc  difficulty,  owing  to  hia  vioicnt 
offortB  fur  bi'ciith-  As  soon  t\B  t}ic  iiir  ponctmteJ  Jrcely  into  the 
Inrynx,  be  bognn  to  revive;  tbf.  (mlec  beciimc  more  eleudy, 
tlic  rcapirution  rc^lor.  StiiniilnntB  were  given  botb  by  the 
mouth  and  jicr  nmim  ;  but  tlio  eyt^tom  hml  rcccivixl  too  fifvcrc  a 
ehock  to  rccoverf  tuul  ho  ^^nuluaUy  ^unlct  miU  o?cpir(^  quietly 
in  on  hour  or  two  af^r  the  o|xTiuiou.  Ou  rcraoviDg  the 
Inrynx,  iro  miirkfl  of  intlunimction  could  Lc  dotocteJ*  On 
looking  further,  however,  the  cauflo  uf  dtnth  was  di^tiuvered, 
Tbt  lonsiU,  ;:;reiitly  enlur^ied,  nnJ  in  ii  etiite  of  violeut  JJifliini- 
niutioD,  Hileil  up  tlie  fxretorlor  fauoee.  TJio  epi^flottla  hiid  he&a 
graduuUy  eufruiielied  u])un,  so  that  fimJIy  It  wiis  pressed 
down,  iiud  ulnio^t  corojiletely  prevented  tlie  entnuice  of  jut 
into  the  ]uu<;ti.  The  lii^tory  of  tlie  oaHe,  n^  learned  after- 
wardt*  froiu  bia  father,  wws  tfiia.  He  had  been  employed^  four 
diiys  bof<-»i"c,  in  unloadiiijL'  a  ehip  ;  the  wcniher  bein^j;  very  cold 
and  rainy.  The  fulluwing  dny,  he  was  taken  with  sore  throat, 
for  whieh  £onic  eiiuple  rejiiedios  hiul  been  np[)lied  oq  board  the 
\edttel  where  he  sltpt.  He  ^vaa  fir^t  seen  Ly  a  pliytiiciau  on 
the  day  he  wnjs  broitj^ht  to  the  flcepltol. 

CANCEft  OF  Tonsils.  —  Om^'er  of  the  tooaila.  soft  pftltile, 
nnd  uviilu,  U  excetdiugly  rnre,  Di\  \Val:^lie,  in  hln  work  on 
the  "Nature  and  Treatment  of  Cancer,"  snya  tliot  coneer  of  the 
tonitila  Ib  very  tare,  whether  of  the  ^eirrhoua  or  encephnloid 
vuriety.  He  has  not  t^ijen  ii  eo^c  of  primary  cancer  of  the  eot^ 
palate  and  uvula,  nor  found  any  recorded.  '^In  eert;un  casea,^ 
]ie  udda»  *'  where  the  pharynx  Jiud  &oFt  psdate  are  implieated,  it  is 
perfectly  po^dihlc  thnl  the  alicction  amy  have  originulf^d  in  the 
pdntc,  or  that  thid  purt  niny,  at  loimt,  have  bt^en  the  «eut  of 
Bepttrate  formation  j  but  I  know  of  no  cvidenee  of  the  faet/^ 
Tlte  following  ease,  which  I  attonded  with  Dr.  J,  C.  Warren, 
U  one  of  tlie  very  few  whjcli  I  liiive  eeen.  This  one  U  selected 
on  account  of  the  remarkable  trflU3|>08ition  of  the  organe,  which 
wns  not  discovered  uutii  alter  dentli :  — 


REMOVAL   OF  T0N8ILS- 


12S 


Case  LXXVni,  —  Cfufcei'  ui  the  Tkront^  Opemlion 
and  JRecorer}/,  l)Gaf/t,  at  a  Snii^fe^nevt  Penod,  Jrow  Pe- 
ritoneal Infiammation,  HfmarJi^able  TmnspoaUtoti  of  all 
the  Or^ftiu.  —  Mrs.  A.,  nge<l  'i5,  aoiuewhiit  liysjicptic,  oh- 
Hen'ed,  mi  January,  1835,  a  swelling  on  the  left  lousiJ,  which 
gritduiilly  incroiiHed  in  size ;  hccsiuip  more  firm  in  ncnsistence ; 
and,  finally,  extended  to  the  soft  polate,  ami  attached  itself  to 
the  loiver  jaw  bo  ap  niateriullv  to  impede  lie  molions.  She  wq8 
not  niuoh  redufred  in  strenglli  hy  the  dir^eiiee,  not  itiLt'h  emad- 
Ated  :  -her  countenance  was  pale,  and  her  di^e^^LJon  good.  The 
following  was  the  stale  of  the  diseased  parts  just  before  the 
opemiion :  — 

On  the  left  aide  of  the  thront,  snd  occupying  all  tlie  back 
pan  of  the  fauces,  was  a  firm,  iodnnired  tumor,  extending  back- 
wanls  nnd  upwards  into  the  posterior  nnrcs,  and  forwnrtlfl  to 
the  lower  jaw,  to  whirh  it  was  firniK'  Httiinhed.  The  tonsils  of 
thai  tiide  nnd  ar»(t  jiidnte  were  a]j4*>  impliuateih  There  waa  no 
doitht  of  the  L-anceriaifl  nature  of  the  difieif^e.  The  tumor 
was  renioved  in  June-  It  wili  of  a  finn,  cartilaginous  nature, 
almost  of  11  bony  hardness,  suraewh^t  ulcerated  in  the  centre. 

She  recovered,  tliough,  from  her  Jijje  and  tlie  severity  of  tlie 
ojieration,  it  was  some  mouths  before  «be  was  able  to  g-o  about. 
In  the  inonrJi  of  January,  1836,  having  eirposed  herself  to  cold, 
she  wns  seiveil  with  violent  pericimoal  inflamiuation,  and  died 
alter  na  illness  of  four  da^s.  Tlie  examination  o^  the  body 
was  made  hy  Dr.  George  Q.  SiiattUL'k  and  myself,  the  day 
after  her  death- 

On  opening  the  abdomen,  the  onlinary  appearances  preaento*! 
by  a  severe  peritoneal  inflammation  were  fouad.  The  moj:l 
remarkable  thing,  however*  wu.*  ft  lumnr  in  the  lefl  iliac  region, 
at  first  supposed  to  he  an  invagination  of  the  inte>^tifie,  but 
which,  on  fmlher  eiamiaaiiiia,  [tr<ived  lu  be  the  crecitni^'  and,  in 
tracing  up  the  intes^line  to  the  slumacb,  this  organ  vfVi  found 
in  the  right  bypochoudriac  region,  tho  left  being  otcupied  hy  the 
liver. 

Tbe  lieart  lay  to  the  right  of  tJie  Hpiunl  culuiun,  occupying  a 
place  with  the  right  Inng.  whicJi  consisldd  of  Lnt  two  lobes, 
there  being  three  of  the  left  lun^  :  tho  cavitiea  were  all,  in  like 


1S6 


TEE   NECK. 


maiiuert  tr;mept:med>  From  tlie  ngbl  ituriolc  jiroceiMloiI  the 
fi*iir  juilujoijury  veins:  tlic  r^it  vejjti-iclc  \md  the  tl>nu  and 
thickness  uaually  poascsacd  by  the  left,  ami  contained  tUe  roi- 
tral  valves-  Tlie  Itft  ivuncle  received  the  vena  t:ava*  tlic  left 
veuU'icle  touLulueil  llie  tvieuspid  \filvoa.  From  the  riylit  veu- 
trlcle.  the  aorta  h^d  its  origin  ;  tJiia,  iiller  runniug  up  a  little  to 
the  lefts  curved  over  tt>  the  right,  and  waa  placed  on  the  riglit 
Bide  of  the  spinal  coKimn,  hzuing  the  vena  cava  on  itfi  left. 

From  the  arch  uf  the  aorta,  only  twu  arteries,  instead  of 
three»  were  given  off,  tbruiiiig  another  ijeculiariiy  in  this  re- 
markable case*  The  first  artery  to  the  left  >vae  the  Ini'ge^t  in 
size  ;  an  inch  ft-oni  ita  origin,  divSJetl  iati*  what  would  cor- 
respond to  the  ianotninata  and  right  carotid.  The  iunominatft 
gave  off  tlie  left  carotid  and  fliibclavi:m  ;  thtj  other  artery  given 
off  fi^jm  tlie  arch  was  the  right  subclavhin.  The  Kpecimen  is 
now  in  my  poeaeBiion, 

The  subject  i>r  thifl  rcnmrkahlc  iinatoniical  structure  was  the 
mother  of  fifteen  children.  Nothing'  wiitf  obr-encd  duiiiig  life 
to  lead  one  to  suppu^  tliat  such  a  dispoeltion  of  organs  oxislcdi 


FIfiSFRE   OF  SOFT   AND   ItAllD   PALATE, 

The  operation  nf  Ht:tpliyZoruphy  is  of  eouiparatively  modern 
invention.  It  was  first  attCEiipted  iii  Europe  hy  Graefe  (1617 ). 
and  was  firol  performed  with  aueceas  by  Roui  (181^),  who 
Beeme  not  to  have  knoim  of  the  unauccej4»ful  attempt  of  the 
Oenmin  profci^sor.  Slufrtly  aller,  it  wae  aguiu  jjcrfDrnicd  by  Dr. 
John  C.  Warreu,  of  Button,  rtho,  not  beuig  aware  of  wlicit  bad 
hean  dune  in  Europe,  himself  invented  new  instruriiento  fi>r  it. 
The  operation  waa  tit  first  deemed  applicable  only  to  fiasurcu  of 
the  Nrll  palate,  which,  of  eourf^e,  arc  ahnost  llic  txceptioaal 
casca  ;  as*  out  of  from  eighty  l-j  one  humlrtd  opciatious  i'or 
fiasureof  the  palate  which  have  fallen  under  my  own  observation, 
in  nut  more  than  a  tenth,  pi-ohably,  of  the  whole  nunil)cr,  was 
the  fissure  limited  to  the  soft  parLa.  Nearly  all  c^isca  uf  fissure 
exteudiii<i  Into  tlie  haixl  palate  were  rejected  as  unfit  for  opera- 
tion, idthough  Roux  liad  enggeatcd  tlie  idea  of  relaxing  the  soft 
palate  hy  cutting  it  completely  away  froio  its  attachments  at 


FISSmtE    OF   liOlTT    ANTl    HAUIl    PALATR. 


137 


the  posterior  ci\^c  of  the  pjiliite  bones.  This  opernlir>n  \s  very 
likely  to  prorc  aborthcT  from  the  'liviaioii  ot"  the  vi*a3(?lfl  whii?!! 
supply  the  flaps  with  noiirishiiient ;  and,  eveo  if  it  Biicceeda,  it 
1enve«  an  itDneiressarily  krge  npi^rnire  ifi  ihc  lionon,  still  to  be 
covered  by  artificinl  fneans.  Being  impressed  by  the  very  grrnt 
proporfiim  of  the  vqscr  of  v\eft  palsile  whieh  were  deemed  in- 
curable, I  WHS  ]&\  10  pei-form  an  operfition  for  the  esjicrciiil 
relief  of  the  more  extensive  fi-^snTe*!.  whieh  ineUiile  imtii  ilie 
»o\\  ftn<l  hard  pjiUte ;  nnd.  in  April,  184,^,  J  piifilished,  in  the 
"New-KngJHnd  Quiirttrly  Joiirnjil  of  Medicine  nnil  8nr<rery," 
:Ln  in"eoiint  ()f  a  new  iiper:jtii>n  liir  )he  cUjsure  of  fi*<suivj<  in  the 
hard  p;date,  to^retlicr  with  r.  very  iinportiiTil  niodifii^uion  of 
the  o]>pnilion  of  slnphylornphy,  iia  pmctised  for  the  relief  of  fis- 
sures of  the  eoiV  piilale.  The  i^peration  upon  the  hnnl  pnljitr 
(f  (jiHJtc  from  llie  descriplion  i*f  my  first  nasi',  im  re|)ortt\l  at 
that  time)  consistetl  in  "diasecting  up,  wilh  n  lon<r,  dnuble- 
cdgeil  knife,  curved  on  its  fliii  side,  tlic  membmne  covering  the 
hard  pnlnte,  pursuing  the  distJet'tlfin  ijtiite  hnelt  to  tlie  root  nf 
the  iilveolnr  prfuvswi^.  By  this  prLU'etlure,  whieh  was  nol  ef- 
fected vrithnnt  conEidcrahle  difficulty »  the  membrane  seemed 
gradmdly  to  unfold  itself,  and  eimld  he  erisily  dra^vn  iieriisa 
the  very  wide  tinsure.  A  narrow  shp  was  now  rcnioveil  fr<im  the 
edg;es  of  t)ie  soft  palnte,  and  with  it  the  two  halves  of  the  uvida. 
liy  this  nirnns,  a  ecmliniion?  flnp  was  ohiiunetl,  hei^nninp  at 
the  ruotfl  of  the  [ineisor]  teelh,  and  extenrfiny  Iwickwnrds  to  the 
eilge  of  the  velum  pnhiti.  Finally^  Hii  autures  were  intn>diieeU, 
on  tyin^  which  the  whole  fissure  waif  oMiierflied.  .  .  .  Thii^ 
patient  retiirnnl  hrmie  into  the  country  at  the  end  of  tliree 
weckfl  ;  n  firm,  tleshy  psdnte  l>ehig  flumeJ  behind,  and  half  ihe 
fissure  in  the  hony  pahtte  obliterated.  In  the  followint^  sprin^;, 
I  ngiun  itjienjled  cm  the  niinairnng  fifsnre  in  the  hard  j>alate,  nnd 
Buereedi^l  iu  I'losin^  liijf  tlie  extent  of  it;  the  lisrtue.''  yiuliliTi^r 
witli  j^oine  diflk'ulty,  owin^  lo  the  induration  enu^eil  by  the 
former  o[a^ration.  The  snudi  aperture  whirh  remained,  I  di- 
rected to  [)e  cl<.weti  hy  n  gnkl  plate/'  I  had.  at  tUls  time,  opera- 
teil  in  thi»  nuinuer  in  ruiirteen  dilferent  cil^jor,  "  whiiTh,  wilfi  one 
esception,  Imd  terminated  sneceflsfidJy,  chher  in  the  elosnre  of 
the  whi>U'  fiiH.Hure  of  lioth  hant  and  so\t  |KL|ate»  or  t*(i  i'tir  th.^t  iJie 


1£8 


TlIE  HECK. 


apcrtiire  which  remained  In  tlie  houcs  coulJ  be  easily  closed  by 
ao  obturHlor  filled  tu  the  ntjjolmng  teeth*" 

The  improvement  to  which  I  have  aUudai,  in  the  o|>eratioa 
upiin  thd  poft  palnte.  cocaisted  m  the  reluiation  of  the  tissiiea 
at'  the  fi^siireJ  relum,  by  meujia  of  iuclsiooe,  unide  with  strong 
ciirveJ  BCiHsora,  ao  aa  to  divide  the  attachinenta  of  tlie  soft 
palate  to  the  toreU  and  to  the  poatenor  pilhir;  or*  in  other 
vrorda.  dividing  tlie  posterior  pillar  uf  the  piUatc  juat  where  it 
bepn*"  to  *tprerid  out  into  the  velum.  The  ctfcct  of  thiH  in- 
cision Th  at  once  seen  in  llie  almost  complete  relaxation  of  the 
|taFtA.  BO  us  to  admit  of  their  ctiey  approximjition  and  union  hy 
suture.  At  ifti^  time,  I  hiLd  met  with  uo  catte  in  which  this 
procedure  failed  to  relax  the  parta,  as  I  tliought,  aafficiently  for 
tlic  rei]uiremciit^  of  the  operation;  and,  in  the  foiirleeu  caeca  of 
opemtioD  i'or  coiiiplJiutcd  cleft  palate  which  1  had  then  per- 
formed. I  hiid  met  with  but  otie  imauccesaful  result-  In  auhae- 
qiicur.  opEi'ationa,  however,  I  found  that  there  existed,  in  some 
ca^es,  ao  additional  obstacle  to  the  a}t|>]'o?(imatioji  of  the  Hapa, 
which  enuld  be  ovei-corae  aa  easily,  mid  in  the  »ame  tnar»ner,  as 
the  former.  This  obstacle  cone iats  of  fi  band  ol  iirm  tia^ue,  ex- 
tending; nhove  and  behind  the  f<oft  palate,  rmd  standin;:  out  in 
bold  relief  when  that  or^an  li  put  on  the  stretch  by  drawing 
upon  it  with  the  forceps*  Thia  resisting  masa,  like  the  other, 
J  have  always  divided  by  an  a^lditionid  atrokc  or  two  with  tiie 
scissors,  whenever  the  incision  of  the  poclenor  pillar  and  ad- 
jifiSnC  mucous  membrane  haa  eeemcd  insuHieient  properly  to 
reins  the  palale.  By  this  division  of  all  the  piu'ls  which  op]n>.^e 
any  active  reeiMnnce  to  the  approxiiiinlion  of  the  t^ides  of  the 
fissure,  the  fipcratiim,  eib  T  have  performed  it,  Avas  finnlly  per- 
fected in  its  essential  features;  and,  since  that  fimc»  1  have 
known  of  no  unportant  impnivcmcnts  in  it.  except  in  n  few 
matters  of  opcnitive  detail.  Ihuin^^  the  pjist  few  years,  how- 
ever, I  have  generally  nhf^tained  from  the  attempt  tij  etteet  the 
entire  closure  of  very  extensive  fissures  in  ihc  hard  p^ilatc, 
owing,  in  part,  to  the  severity  '»f  tlie  operation,  but  chiefly 
to  the  fact,  that  modem  iniproveTucnts  in  mechiuiical  dentistry 
have  furnjdlted  us  with  a  mo^t  ef^eicnt  and  eondortablc  subati- 
tule  fur  lite  nntin-al  hard  piktc,  in  lia^  lorm  of  a  metallic  or 
huid  rubber  plate. 


I 


FlSftClLE    OF    SOFT   AND    ILlItD    PALATE. 


129 


1^/  tlie  intimlur.tinn  of  thrse  imprnvi^mdits  in  tlie  pliin  and 
JiitduKlft  of  a|ieraUng,  tliu  Hiir^'ery  of  vlvh  [mintp  at  imce  ac- 
quired a  new  anil  vastly  enlarged  im^iortance.  Tlie  O(»eralioc 
of  fitiipliyloniplij,  ae  invcnlcd  by  Rniix,  ami  practised  by  ruany 
feurgeoiiti,  hiolli  in  Europe  nnt\  Ameritai,  hud  been  coiiMilered 
npplicalile  nnly  to  simple  fissures  of  tlie  velum,  a  claaa  of  cujieH 
constituting  but  a  very  small  frm'lion  of  ibe  total  nuiuber  of 
cleifl  palatea,  a.nd  tLie  very  ones  in  whifb  the  need  of  eurgical 
aid  in  least  urgent. 

The  biglily  t^uct^essfnl  resHlli*,  hitwever,  whidi  1  vvas  enabled 
Uy  report  m  ibe  treninient  of  nncs  whk'h  biid  previtiMfily  been 
fon^idi^reil  as  beyond  llie  uid  of  siu'ger^',  toother  with  the  en- 
conrnging  success  whicb  bad  been  already  attained  by  Rdu^, 
DictreiiliftcJi,  Olid  many  olber  surgeons*  front  the  operation  in 
the  »ai\  palate,  soon  exeited  the  renewed  interest  of  tlie  pro- 
fession in  this  inoflt  di.strpjaslng  deformity* 

Mr.,  nrj\y  Sir  William,  Fergusflon,  was  led,  in  1844.  by  the 
diHaectlmj  of  ji  Hpc*'iim'n  of  deft  prdfite,  to  Jidopt  a  rnetluiil  veiy 
similiir  to  mine;  dividing  ibe  levntores  jiiibui  mn?(defl»  witb  a 
slender  cnrveil  kmfe,  snmewbtit  higher  thtin  in  my  proreditre 
with  tbe  Kcis^orti,  iiml  dividing  the  phnlt^riur  piUnrs  of  the 
pillule  in  pre<dj«ely  the  ^aine  tnnnner  an  I  hiul  already  dc- 
etTibed. 

The  wnhject  of  deft  palate  has  been  still  further  illiiHtraled  by 
Beveriil  Biiti^h  enrgeon^  of  distirictlnn ;  among  wbom  Messrs. 
Avery  and  Pollock  of  London,  Mr.  Collin  of  Dublin*  and 
Mr.  Field  of  llrigbtun,  nre  espedally  prominent.  All  thefie 
gentlemen  have  (i|)crnted  with  the  nnwt  perfe*  t  tiiecesi*  npnr 
fissures  aa  wdl  of  the  bard  n*  o(  the  soft  puliilc  nnd  they 
have  nil  adopted  the  plan  *)?  rtqmintbi^  the  soft  text.nn*^*  frettly 
fr>Tn  tUf  pahwine  an*h.  Mr.  Pollock  dii'ide^  tbe  pnhite  mufi- 
eles  by  n  [inrtially  r^nbrnucoud  ineifdon,  at  a  point  near  tbe 
bamnhir  proc!eaBes,  where  the  fibres  begin  to  spread  out  into  the 
Tdiim. 

Tbe  following  flcrount  of  tbe  different  ainges  of  tbe  opemtlon, 
as  I  have  latdy  perfoi-nied  it,  very  nearly  re«einble«  that  wbidi 
I  published  in  lS4lif  to  whidi  nlhiAJon  Iieui  Ijecn  imule :  — 

17 


130 


THE    KECK. 


1,  77^6  Sepfirrtfion  of  tht  Ptthrtine  Membranes  fpGni  the 
Sones^  — This  prcMrediire  T  hare  found  necessaiy  in  fully  nine* 
tentfis  *if  tht  cnw?a  upon  whioh  it  hji^  l>een  my  !i>t  to  operate. 
In  most  of  the  firisurea  ivliiuli  apparently  extent!  only  to  iLe  mar- 
gin of  the  bony  vmiiIc»  the  top  of  tlie  fissure  is  of  n  round&l 
railitr  thnn  an  angular  fono,  so  aa  to  render  it  difficult  or  im- 
po-^silile  to  bring  (he  flajw  tocher  at  thia  part  without  first 
Ion*;pning  their  nttaehments-  By  adopting  (his  measure*  how- 
cveT-T  the  upper  aatures  are  applied  as  eiisily  t\s  the  lower  ones  ; 
and  the  danger  of  partiul  failure  at  this  parlioukr  part  of  the 
pdate,  formerly  eo  common,  ia  idmo&t  wholly  obviated-  Li 
eflses  of  more  exiensive  fsfiure  of  ihe  hnnJ  palate,  tliis  eopara- 
tion  is  to  he  cmrieil  funher,  in  some  insinnces  even  to  the  alveo- 
lar proeessea,  T  h;tve  ailvaya  f<impleted  the  operation,  aa  fur 
as  1  hare  thought  il:  prf»|ier  to  atli^mpt  it  at  ull,  at  a  single  sit- 
ting, because  in  this  way  we  are  nlmost  certain  to  obtain  ^od 
union  of  the  velum^  and  a  partial  closure,  par  ffltssetnent^  of 
at  leafit  the  posterior  [xirtion  of  the  fisfiurc  in  tbe  bonee.  When- 
ever,  by  tlie  re-establishment  of  the  velum  and  of  tlie  posterior 
part  of  the  palatine  lault^  we  have  succeeded  in  reducing  the 
tissure  to  a  simple  foramen  in  the  hard  roof  of  the  mouth,  we 
have  praetically  relieved  the  patient  from  bia  disgusting  and 
difltreflsing  deformity  ;  for  he  only  needs  ji  light  mclallic  or  vnl- 
eanite  plate,  sncli  aa  is  now  worn  by  every  one  who  lias  a  set  of 
false  teeth,  to  enable  him  to  artieidate  as  well  aa  If  the  aperture 
were  closed  by  the  natural  hone  and  membranes-  Led  by  the^e 
tongidcraliona,  and  by  the  desire  to  shorten  as  much  aa  possible 
an  operation  which  must  almost  necessaiiJy  be  performed  with- 
out the  aid  of  anwfilhesin,  I  have  ceased,  of  late  years,  to 
operate  for  tlie  cloaure  of  the  nnterior  portion  of  the  cleft  in 
extreme  cnaca  \  and  thi*j  notwithstanding  the  fact,  that,  in  ray 
cjirlicr  years  of  practice,  I  aiieceeded  in  completely  elosing  a 
\ery  large  proportion  of  all  the  fisjsures  upon  which  I  operated, 
including  some  very  extenaivo  ones,  and  tliua  established  the 
operation  as  a  perfectly  practicable  one.  In  commencing  this 
part  of  the  operalioTi,  J  have  alwajs  used  a  knife  eubatantially 
hhfi  that  which  I  first  employed;  viz.,  a  double-edge<i,  apear- 
noint^id  knil'e,  elrongly  curved  on   its  flat  side;   winch  1   have 


I 
I 


»DRE   OF  BOFT  AND  HARD  PMIATB. 


131 


fonnd  to  answer  well  for  aliuoet  all  fissures  of  motleratc  extent, 
although  in  some  extreme  case?,  in  wbich  the  huiics  liavc  de- 
viated widelj"  frora  tlieir  nijrmal  curvature^  very  considerable 
diAi<^[|lty  has  been  expenenced  in  making  the  first  mdatona  at 
the  edges  of  the  Sasurc.  lu  theae  caaes,  iheix^  is  of^en  no  pro- 
per roof  to  the  niuuth,  owing  to  the  extreme  obliquity  ot"  the 
bones,  which  riae.  as  it  were,  jilmost  TCrticallj  from  the  idreotar 
marg^ins  towards  the  noatrila-  To  facilitnte  ihcao  Erst  mciflion* 
in  fiueh  cases.  It  has  beuu  prupo^ed  hy  Dr.  Suiylv  to  coaimence 
the  disflcciion  with  n  eleuder  knife,  shaped  somewhat  like  an 
ordinary  gum-laueet*  and  used  througli  the  nostril,  where  the 
edge  of  the  fissure  may  be  more  readily  reached  llian  frooi 
themouth*  8har[ily  r(!t;urvLi]  kulvca,  worked  from  the  mouth, 
have  alao  been  ueed  for  the  same  class  of  cjisea  ;  and  a  jmrtieu- 
Jatly  ingenious  one  has  been  invcnte*!  by  Mr*  Pollriek,  In  which 
a  abort  chisel-shaped  blade  is  attached  to  a  metallic  stem  by 
means  of  a  hinge,  and  is  fitted  with  r  screw  muvement  by  which 
it  may  be  adjusted  to  any  rcquireil  nii^de,  Buth  these  contri* 
viinccs  hiivo  been  tried  and  ajjproved  by  Mr^  Culfis,  and  are 
doubtless  of  ^eiit  uLilily  in  the  cases  for  which  they  are  de- 
fligued.  This  cunimencemenl  of  the  dbseclion  at  the  edges  of 
the  fissure  la  by  far  the  most  difficult  jiait  of  tin:  opemtiou  ;  for 
it  is  at  tliis  piU'L  of  the  pahite  that  the  membranes  are  ah\aya 
found  most  llriiily  n^dherent  to  the  bonen.  As  we  proceed,  how- 
ever, llie  sepiiration  becomes  very  much  easier,  and  the  mem- 
branes seem  aiioost  to  peel  off  from  the  bnuea-  I  have  therefore, 
at  this  jKiint,  gcner;dly  abandoned  the  knife,  and  have  continued 
the  dissection,  as  far  ds  I  have  thought  necessary  towards  the 
alveolar  pi'ocessee,  by  incaus  of  curved  sciaaors.  In  lliia  way, 
I  have  been  sure  of  preserving  the  greatest  possible  thickness  of 
tisisiies  in  the  Haps,  without  endangering  their  nuLrilioii  by  the 
division  of  the  prdatine  arteries-  In  most  of  tlic  caaes  which  T 
have  seen,  llicre  hiw  been  Jiltle  or  no  deficiemy  of  materials  to 
fill  ihe  gap ;  but  the  fissure  has  been  the  result  rallier  of  the 
iibliipie  direction  of  the  ununited  aides  of  the  paluline  vault. 
The  <r|ieniLiLin  consist:^,  then,  not  ao  much  In  fitretoblug  the  Haps 
tiglitly  across  the  cleft,  »s  hi  bringing  them  into  a  more  nearly 
hurizonud   position.       I   have    not,   iberefore,   eeen  that  much 


132 


TKB  XECK> 


bcm^fit  16  to  be  expcctal  from  lalornl  inddiona  tbrriu^h  tlie  pnla- 
tinc  mciuUmnc^,  ami  linvc  jiTwim  ab^tuuci)  fi-om  Dinkinir  tlicm, 
i'wni  lEic  i'ciiT  of  ctLudtig  nouUWfi  und  troublceomc  Lcmorrlia^, 
acU  lliHa  unnecessarily  proloTi<rii;g  rn  already  too  tcdioue  operEt- 
tion.  At  the  pofitoriur  edges  i>f'  tlic  osm  paluli,  tiic  union 
botwoen  the  soft  parts  ^nd  the  bono  ja  very  intiiDfilCj  owing  to 
the  insertion  tliere  of  the  temlinoua  fibi-ca  of  the  velum,  and 
more  partitukrly  of  tlie  reflected  tendon*  of  the  tensiijrctt  pulati 
miifioIcA.  For  completing  the  Hcpnrntion  at  this  point,  I  use  a 
pair  of  probe-poinled  ecisflora,  ivbich  1  liave  fmind  to  divide  the 
firm  tiesuee  mueli  more  cunveniently  and  expeditiously  than  any 
knife.  In  alJ  tlie  operations  wjiicii  1  liave  performed,  I  bare 
QicC  with  but  n  single  case  of  troublesome  licmorrhagei  At  the 
momcot  of  freeing  the  ilapa  from  tlicir  attacljEiienta  to  the  ^hja- 
tcrior  margins  of  (lie  pidate  bones,  a  few  arterial  twiga  are 
generally  divided;  but  1  have  always  been  able  to  control  the 
blccdinj^  by  the  use  of  iced  water.  Jn  a  single  itif^tancc,  lawv- 
ever,  in  which  the  upper  stiteli  waa  iiiinsujilly  tcnec,  the  blee*licg 
continued  after  the  adjustment  of  the  sutures,  but  immediately 
ecased  when  the  stitch  was  divided  so  as  to  allow  the  membrane 
to  apply  itself  more  closely  to  the  bone. 

2.  The  Jlf-lu. ration  of  fh^  fwn  Halves  of  tht  Vtlum  htf  Me 
Divijfivii  vf  Rt^ieiintf  Band's  of  Muscle  and  Mticiiua  3Ifm- 
hratit, — This  has  been  a  most  iimpurlant  feature  in  all  the 
operations,  and  is  still  performed  in  the  same  manner  as  in 
the  earliest  CHse».  The  instrument  employed  \&  a  pair  of  large 
and  strong  French  sciaaors,  curved  ou  tlie  flat  aide*  One  of  the 
ludves  \i[^  the  *plit  uvnla  is  eci^ed  witli  appropriate  forceps,  and 
drawn  across  tlie  Hasure.  This  brings  out  In  hold  relief  two 
etroDgly  resisting  bands,  one  below  and  une  above  the  palate* 
The  former,  conaiatln;^  of  the  posterior  pillar  of  tlie  palate,  is 
then  divided  by  a  pi»weriul  alrokc  of  the  scissors^  and  the  ia- 
cisioD  extendei]  forwards  and  baekwards,  dividing  iia  mncb  of 
ihe  mueous  mem  Inane  as  may  lie  necessary  to  relieve  all  tension 
aL  this  part-  The  other  hand,  consistirg  chiefly,  as  Sir  William 
Fergtiflson  hiis  ehown,  of  the  levator  palati  muscle,  with  its 
muci^ua  covcrin^jj,  is  next  divided  in  the  same  manner  as  the 
posterior  pillur,  ineluding,  as  before,  in  the  incisions,  u  greater 


FiaSUEE  OP  SOFT  AND   HARD   PALATE, 


133 


or  ksB  extent  of  tlie  luljoccnt  mticoue  menibrnncT  aa  may  eoem 
to  be  rotiuieiCe  to  effect  the  perfect  reluxution  of  the  orf;an. 
The  complelion  of  this  etag^  of  llie  opemtion  is  shown  by 
the  striking  chn,agc  in  the  conditioD  of  tho  hitlf  of  the  velum, 
which,  troiu  A  state  of  violent  ^piiuiiioJic  coaCmctiuii,  burying 
itself,  as  it  were,  in  the  aide  of  the  throat,  bocomea  perfectly 
fluccid  tmd  powerlese.  As  soon  as  this  rceult  id  littainod,  thU 
part  of  the  (^|ierntion  is  to  bo  coiiBiJeretl  as  finltiheJ,  whothor  iho 
iacLdioiiti  Imve  been  more  or  less  extensive.  By  tlijj^  metliod,  no 
part  is  cliviiled  until  it  hoB  been  firj^t  brought  into  a  etiite  of 
tenaioTi,  and  tUue  shown  to  require  it.  For  fueiUty  !\nd  cerlmnly 
of  exceuiioii,  Uivldin;^  no  more  and  no  less  Uian  is  rorpiireJ,  and 
fbr  nbiiuJiitc  fi^ecdum  from  danger,  it  eccme  1o  mo  tlint  this 
method  of  reUxin^^  the  sofl  parts  has  never  been  ^nquij^^eU. 
That  other  plana  may  bo  ut^efid,  J  have  no  donbt;  but  wlLOthiM" 
they  oHor  ."Ldvatitage^  eqmil  to  the  present  c^n  be  settled  only 
by  a  serieB  of  comparative  ti'iala  in  prsietice,  such  a&  have  Eot  yet 
b«cn  made. 

3-  '£he  Paring  of  th&  Edga  of  ihe  Fissure^  — Thia  is  per- 
formed eometimes  with  ecidsora,  nnd  eometimee  with  a  flt-odcr, 
pointetl  knife  ;  nud  I  am  nut  aware  that  tfiere  is  any  decided 
prcfcrcneo  to  bo  given  to  eitlier  method.  The  ed^^e  of  tho  Hap 
iti  mode  tense  by  drawing  upun  the  uvula  with  n  [loir  of  etrong 
but  filtndcr-loothed  furcepiiT  which  I  have  deviiied  for  the  purpoHe, 
and  wliich  is  shown  in  tlie  plnte.  These  forceps^  of  wliich  two 
pnirr*  are  i-cquirod  fur  the  two  eidea,  are  made  with  a  dfiuble 
ourvo,  and  aro  bo  contrived  m  to  seizo  the  extreme  edge  of  the 
(hdatc  without  encrojiclung  more  upon  one  jiurtace  than  the  other. 
The  same  furcops  are  employeti  aleo  in  the  prece<l3n^  stap;o  of 
the  operation  to  put  the  palate  on  the  stretch  ;  nnd,  aa  a  ^enorul 
ride,  after  i^iice  eciiiirij:^  llic  or;;an,  I  do  not  let  it  ^'o  n^aiu  untU 
£  have  pared  \i&  edge.  1  have  not  fountl  it  dcslnibk  to  attempt 
to  profi«rve  the  whole  uvula  j  for  it  generally  hanga  eo  low  in  tho 
throat  05  to  eautfc  irritation,  and  thus  ijitarftre  with  tlie  Kut^cws 
of  tho  opcrafioa.  In  moet  ca^ice,  thoreforc,  1  remove  the  grentcr 
fjortiun  of  Lhc  two  ludves  of  thifi  uppend;ige  at  the  time  of  paring 
the  ed^Oid  of  the  palate. 

4.    The  Applicutioii  and  Ailjusttntut  of  the  S'Uiii\:s^  —  In 


13-1 


THB  NECK. 


tfie  enrly  days  of  &tn|jbTlorai>liy.  tbis  waa  by  far  the  moflt  difli- 
cult  ami  vexjitjous  jjart  of  the  operation,  owing  to  tlic  extreme 
irritability  of  the  parts  ]>rovokiiig  violent  muflcular  retraction 
whenever  the  Hapa  were  priekeU  by  the  nccjlc.  AiVer  juloptin^ 
the  pliiu  described  for  the  rclnxation  of  the  organ,  I  obacrt'ed 
tliat  tbia  etagc  of  the  operation  was  gi'cally  facilitated;  eo 
that,  for  a.  miinber  of  jeara.  I  was  in  the  habit  of  pasalng  the 
Huturce  with  a  &niftl]  curved  nctdJc  held  by  furocpB.  Incrcnacd 
experience  hajj.  however,  denion/^t rated  the  usefulness,  in  many 
cafiea,  of  the  ingerious  croehct-aiguilie  of  Sehwerdt ;  a  &»liarply 
recurred  needle,  mounted  in  a  handle,  and  having  an  cyc  at  its 
point  vhieh  can  be  opened  and  closed  by  a  alight  |)re3anrc  upon 
a  spring.  The  instrument  ia  threaded,  and  po^aed  through  the 
cd-,'e  of  one  itf  the  flnpa  from  behind  foTwarda,  and  one  end  of 
the  tJiread  drawn  through  by  eatching  the  loop  ivith  a  tenaculum 
or  houLc.  The  nceiHc,  etill  tlirc&dcd,  ia  then  withdrawn,  and 
earricd  tlimugh  the  Hup  on  the  opposite  ^idc;  the  eye  la  then 
opened,  and  the  thread  wholly  diecngaged  from  it  by  drawing 
upon  the  loop.  I  have  generally  adJufiCetl  the  middle  &uturc 
first,  by  that  mcanfl  controlling  the  pahife,  an<l  tluia  rendering 
the  insertion  of  the  othera  enaier.  The  lower  one  is  beat  insert- 
ed htaC.  At  the  lower  part  of  the  pjilate,  where  the  parla  are 
rery  movable,  1  have  found  it  diHicult  to  fix  them  with  this 
in^tnimcnt,  and  therefore  prefer  to  uae  a  delicate  curved  needle 
held  ia  a  porte-aignille-  The  ehiei'  objection  to  the  needle  of 
Sehwerdt  is  the  difficulty  of  keeping  It  aliarp,  owing  to  ita  being 
split  at  the  point.  Very  broad  sutures,  made  of  a  number  of 
wsised  tUrcatls  arranged  in  the  form  of  a  dat  baud  or  ta]>c,  have 
been  much  employed  tn  France  ;  and  Diefienbaeh  used  to  insist 
atrongly  upon  the  advantage  of  uaing  wires  of  auft  lead.  I 
have  always  used  a  single  thread  of  common  eurgeon'a  silk, 
thoroughly  wa.\cd,  and  tied  with  the  ordinary  surgeon's  knot. 
I  have  prepared  the  silk,  at  the  suggestion  of  L>r.  C.  G.  Page, 
by  soaking  it,  a  day  or  two  beforeJiand,  in  the  conijiound  linc- 
liii-c  of  benzoin,  by  which  it  acquirer  an  aUlicsivc  property,  and 
ia  lees  apt  to  slip  when  the  knota  are  tied.  U  is  important 
to  hniig  ihe  opposite  ed^ca  of  the  fissure  into  absolute  contact 
with   caeb    other  without  much    tension,   or  the   istitches  will 


FIfiSCRR  OF   SOFT  A>1>  HARD   PALATK, 


ins 


oa  certainly  nit  their  wny  out,  uml  thus  (Ipfea-t  the  enH  for 
which  ihey  :iri!  cmj)h>y&l.  In  an  intereKtin^  nnt^c  of  ojH.*nttitni 
for  the  closure  of  a  very  exttneive  fissiire  of  tlic.'  harJ  paliite, 
perfnnnol  by  Mr.  Collis,  iinJ  rcpcirted  in  tlie  "  Duhlin  (^imr- 
terly  JourmJ  of  Mt!<Jirnl  Science"  lor  February,  ISOS^  the 
flaps,  nltliough  of  ampli?  bieuJth,  teiiilcd  obstinately  to  revert 
to  ttidr  nn^inal  iKi^iliuii  in  c;ontuct,  with  (lie  hone»,  nm]  Uiua 
catised  injuriijiis  tenftion  upon  ihe  btJtdier;).  Thii^  wii:^  oven;ome 
by  tlie  very  hapjiy  utid  lugenioiia  ex|]Gi]ient  of  piisbitig  ths 
3apBi  ns  it  wcrCf  tnwnnlA  the  rnediun  line,  by  nicHna  uf 
wedges  of  springe  intnHhjriHl  hptween  thi^rn  ami  the  bonea: 
these  were  ejuiily  reinovwJ  through  tlie  nustril,  after  forty-eight 
hours,  Qiul  the  result  wa^  a  neni'Iy  complete  and  mo8t  satisfac- 
tmy  uniopi. 

5.  ^Yie  A/tfr-trea/iiietiL — This  was  formerly  the  severest 
and  mo^t  vexatious  pnrt  of  tbe  management  of  the  case,  owing 
to  tho  HM|ij>ij.s(?rl  necci^sily  of  the  intenliction  nf  the  use  of  food  for 
several  days  folhiwhig  the  oih-nition.  In  my  firi-t  va^cn,  T  pur- 
sued iJnH  plan,  mmrifthing  the  jjiitient*!  for  several  liiys  solely  by 
Buematn.  The  ohvionjuly  uiifuvonihle  effect  of  thus  atnrviu^^  a 
person  in  fidl  ln'idth.  and  accufti.omcd  to  a  (,fcaenms  diet.  led  Sir 
PhiJi|j  Oranipton,  of  Dublin,  to  try  the  experiment  of  nllowing 
bis  pittients  an  airtple  i^upply  of  soil  food,  8iicb  as  hoilod  breail 
aiul  milk,  enstJinI,  8onp»  ji^U.Vi  ^^'V*  during  the  whole  period  of 
the  treJttmcat.  The  piil.ilication,  in  January,  1^^43,  of  the  two 
ctiBGs  ID  wliicb  thiH  pl&n  had  been  aucccasfully  tried,  was  im- 
mediiitcly  followed  by  the  abandoiimeiit  of  the  old  and  most 
irk^inne  rcstnction  ;  and  |iuticnt8  lire  now  »llcnved  jub  nmch 
lli|ald  or  tiemi-solid  food  as  they  desire-  ^fiieli  [rouble  \^ 
oflea  experienced,  afler  the  Grst  three  or  four  days,  from 
the  secretion  of  tou^^h  adhesive  luucus  in  and  around  the 
line  of  suture^  nhich  *;ive&  rise  to  an  irritating  cough  of 
such  severity  as  Aoraetimea  to  threaten  the  destruction  of  Uie 
newly  foriiit.'d  adhesions.  In  this:*  condition  of  the  partn,  I 
liuvc  aeeu  inucli  heue£t  from  tlie  ust.;  irf  n'arrn  ov  acid  drinks, 
or  ironi  bruahlng  tbe  pjirta  with  a  weuk  solution  of  nitrate  of 
fliher* 

At  first  I  wiLs  UiaposttI  to  I'einove   the  sutures  ut  the  earliest 


13«j 


THE    NECK- 


popsible  perirtil ;  but  latterh',  from  having  onoe  hrnl  all  tho 
adheaiona  p:ivo  way  Uurirg  the  H.ct  of  withdrawiii^  tlie  threails, 
I  have  lillowed  tliem  to  reiunin  a  very  lim^  tiine.  It  is  rather 
iniportniil  that  the  month  should  not  bo  too  widelv  opered 
during'  the  Oiirly  eta^s  of  tho  adhesive  proepsB.  Onco,  on  the 
fifth  or  sixth  day,  I  have  known  the  entire  wound  to  give  way, 
from  ti»e  patient  opening  the  mouth  too  widely  for  the  purpose 
of  inspection. 

The  number  of  onaea  of  cloft  palate  upon  whioh  I  have  oper- 
ated by  these  methods  h  now  about  a  hundred  :  of  this  number, 
in  less  thun  onc-tentli  wna  ihe  fissure  eonfine<l  wholly  to  the 
Eoft  parts  ;  and,  in  at  least  three-fourths,  tlie  gap  cstentled  into 
or  through  the  maxilhity  portion  of  the  pakiino  vault.  In  not 
more  than  nine  or  ten  cases,  therefore,  have  I  found  it  practi- 
cable to  close  the  fissure,  without  first  dissecting  up  the  mem- 
braues  from  the  poaterior  part  af  the  hard  palate,  and  cutting 
tlirou<rh  the  tendinous  attaehmenta  of  the  v<>lum  to  the  ORsa 
palati,  I  have  in  no  case  been  deterred  from  operating  by  the 
extent  of  the  deformity ;  and,  in  several  cases  of  niotii  formidable 
flspeci,  I  have  eiiceceded  in  improving  the  voice  and  facilitating 
deglutition,  as  completely  na  in  ovon  the  simplest  fissures  of  the 
velum.  In  one  case  of  simple  fissure  of  the  soft  palate,  I  was 
tempted  to  o|>erate  without  first  dividing  the  musclea.  The 
edgea  cf  the  6ssm*e  came  so  easily  together,  tliat  any  farther 
incisions  seemed  unnecessary  ;  and  for  several  days  e\Qry  thing 
hjoked  fair.  About  the  seventh  day,  however,  the  adhesions 
gave  way,  owing,  as  I  believe^  in  part  at  leaal,  to  the  imperfect 
method  adopted.  As  to  the  proper  age  at  which  to  operate, 
in  one  case  of  a  fissure  which  extendei-l  but  little  more  than 
through  the  uvula,  I  operated  on  a  child  of  between  six  and 
and  seven  years  :  but  gonerally  it  i^  necesaary  to  wait  until  the 
patient  is  old  enough  to  fully  appreciate  the  importance  of  the 
operation T  and  to  submit  patiently  to  pain  and  inconvenience: 
fsr  this  is  onp  of  the  very  few  opcrntioas  in  which  the  use  of 
ana^sthetica  is  inadmissible.  Under  very  peculiar  el  re  urns  tan  ees, 
I  suppose,  ether  might  he  administered,  but  not  without  some 
rijik  to  the  patient,  and  much  onibarrasBmeut  to  the  surgeon, 
from  the  constant  flow  of  blood  down  tlie  throat. 


FISSUHE   OF   SOFT   AND  H\KD  PALATE, 


137 


Tho  result  of  tlioao  operations  niny  ho  etafcil  briefly  ne  fol- 
lowe ;  With  tlio  excejiliun  uf  pcrhnpe  hjiif  a  Uosfln  cflpce,  1 
hnvo  nt*ver  failed  t<>  ^'ct  more  or  lees  union  of  tlie  Eoft  pnlnte, 
Stinietinies  one,  or  more  rnrely  two,  of  tlie  sutures  have  f»iven 
wjty  at  tho  upper  pnrt>  wlicre  ilio  tissuca  nrc  put  most  Cully  nn 
the  etrctoii.  IJ'  nny  oC  the  ttiichcs  hol<],  however,  nntl  the 
smnllcet  union  tnkes  plaee,  it  niny  be  nfrcrwnrds  extended  cither 
by  the  renewal  cf  tlic  BUture^,  which  'i&  now  it  compnrntivdy 
tfxsy  matter,  or  by  the  ooeitaional  ripiilieiUicin  of  xUq  eobd  nitrnte 
of  silver  to  the  nngk  of  the  remnining  fieeure.  The  r;reot  point 
id  to  cntiiblLfh  tlic  nich  of  the  soft  pj\htte  ns  oomptelely  its  poe- 
slljle  :  nnd,  vrhca  this  i^  oneo  acoom[>liiihed,  any  aperture  which 
niny  rcmiun  in  the  hnrj  pjilnto  ciin  be  effectually  eloec^I  by 
aimple  nteehimicid  nieitns.  In  (<ti6C«  of  extreme  fi^aure  e^Iemlin^ 
through  the  nlveolnr  iirt'h,  wliero  u  few  ariiiiciid  teeth  are  ahuciet 
ahvayfl  rerpiirL-d  to  fill  the  ^'sip  Cittieed  by  the  lo^t  or  didturled 
incieon,  the  phite  upon  wbiefi  tho  new  teeth  are  luounled  serves 
also  to  clo^  the  remaining;  eleft  In  the  rotjf  of  the  moiith.  Of 
ooui^e,  in  aJl  onsei^*  the  more  completely  the  tii^eure  ean  bo 
closed  by  the  operation,  the  better  it  i^  ;  but  what  I  wieh  particu- 
larly to  enforce  is  the  fact,  that,  even  in  the  e>ttrome  cuBca  of 
very  wide  fif^surc  in  tho  bimcfli  an  operation  can  bo  performed 
whieh  ifi  aa  cfFeelual  in  restoring  tlic  voice,  and  almost  n&  easy 
of  execution,  ns  in  cages  confined  to  the  veljm  or  extreme  back 
part  of  the  pidatine  vaidt. 

The  question  U  ufien  at/iked  of  the  Burp?on  whether  the  voice 
twill  b«  immediately  restored  by  the  operation ;  and,  if  not,  iq 
what  time  the  full  restoration  may  be  expected.  The  anawer 
mu&t*  of  com-jje,  be  very  iiidffinite ;  fofj  in  fact,  the  pntient  Ima 
DOW  to  learn,  for  the  lirut  tiuie,  the  art  of  uain^  the  pnlaCe  in 
articulation.  Almost  cvcrv  patient,  after  the  opening  is  entirely 
clo,-iCiI,  experiences  a  sense  ot  i"elief,  which  u  owinjr  both  to  the 
gi'cater  ca^e  with  whidi  <.k^Hutition  U  peHormed,  and  aUo  to  tho 
protection  afii>rded  hy  the  new  jialate  to  iho  mucona  membrane 
of  the  poetoriur  fauces,  which,  bcfurc  the  operation,  was  dry  and 
parched  Ironi  the  constant  pnssit<^  of  the  air  over  it-  I  have 
Intisly  had  occaeiou  to  see  several  patients  two  or  three  yCnirs  nller 
the  operation.    Two  of  them  are  toLicheie  in  public  institutions; 

la 


138 


TKE    NRCK, 


anil  ilio  oijjv  clcfeut  to  be  perceived  la  n  sliglit  liuskineBs  of  ihe 
Toice,  vihU'li  wouUl  h:»rilly  be  noticL^iI  by  rtnj  une  ignorant  of 
thtir  fiirmer  conditinn,  I  do  not  retneiuher  la  have  seen  a  case 
in  wlitL'h  ibe  pnTient  \va^  not  mnieriallv  benpliteil. 

Tboou  rt'ni;irks  nre  i^ondenseil  firinm|iiil]y  frurn  ti  report  mnde 
to  the  Ainorif.'iin  A^i^oeL^ition  in  liSGi>.  nnd  borne  out  hy  litrtber 
experience.  It  is  lliougbt  unnecessflry  to  introduce  cuaca  in 
iliurttnitlon,  wliicb  Is  done  In  tbac  pnppr,  fiirlber  thsir  one  or  two 
wblrli  lire  reinnj^knble  for  eonke  peculiarity. 


Cawk  LXXTX,  —  Coi)pi?yiitnl  Fis-^nre  nf  th^  Soft  mul 
Iltifd  PaUtU,  ii'ith  iJiHthtt  I[fVf}Jtp.  —  Putient,  20  jenra  of 
age.  By  an  operation  performed  on  tbe  Up,  si:c  yenr^  before, 
tlie  ir](or[ii.tvillnry  bone  bcid  been  nlninst  wboDy  rcmovec]  :  ns  ia 
UHud  afti^r  llij:^  uperiLlionf  tin?  innKillary  boncd  binl  [Hron  dra^n;ed 
into  contHCt  wilb  cucb  otlier  in  front.  Tlie  pnluliiie  pn»:eyBee 
of  tbe  mnxilUry  und  piibitinE^  bonea  aef'iiicd  iilmust  waTitlng,  and 
ihu  wbolti  ttitli  wiifl  very  narrow.  Opevatinn  :  From  ibe  ex- 
treint*  deficienfy  of  tbe  bony  viiult,  the  membvjLnea  could  not  be 
tniide  to  iMjme  together  across  tbe  yp.  Tbe  Telum,  bowever, 
nnitt'd,  Afler  a  Pn-tniirlit^  iindin^  dml  tbe  coverings  of  tbe  hard 
imlur<?  b:iil  bci-oinc  Acry  nnicli  tliicltened,  I  iignii]  dissucled  diem 
np»  Jind  rbiH  time  wae  able  tn  unite  the  tinps  by  auliire.  J?f- 
m^h  :  Piirtiid  :"Io^uri?  of  tbe  gap  left  nfter  the  first  operjilinn, 
wilb  i\  ibir.'keEi^il*  HcFtby  F^tatB  of  it^^  edi^er^,  whidi  ^eemeil  to 
pr<nriisc  a  tiX\\\  furiber  Jiciiijiuiion  !n  ita  iAym,  or  pot^^ibly  e\i-n  i(H 
tntiiT'  oblilerrtlion.  Tlie  reinjiining  bole,  wbicb  was  quite 
Hiiinll,  was  clitsed  bv  two  bits  of  elastic  Tidcanized  India-nibber, 
alifelied  l<ii;L't[iei"  in  fbe  fiinii  (tf  n  shirt-stud.  A  pliisJio  ii[)errt- 
tioti  wnM  ullerwards  perfonned  u^toti  tlte  lip  and  uoj^e,  with  the 
effect  of  very  greatly  improving  tbe  iippciimnce  of  tbe  pittient- 

Case  LXXX.  — /"/ji^ttr?*  of  tfie  Hard  and  Soft  Palritc, 
^r'lth  j\Fediirti  I^inntn-c  of  tht  Alvt^nhir  Arch,  n/rd  Dn'ihle 
Harelip.  —  Tbe  paT lent  was  a  young  mini,  17  yejtrs^  of  iige, 
upon  wboni  a  very  deiten»uj^  and  |nLTfe(.-t  operation  fctr  doubJe 
bareli[>  liad  been  |)erti>niicd  ui  bitiniey*  by  my  friend  Proressur 
WilUrd  Parker,  of  Ncvv  Yuik.     Ai  tluit  lime,  as  Prufep'jior  Par- 


pibbuhe  or  soft  aud  hard  palate. 


139 


:er  line  kindly  informcJ  mc,  he  rcnoorctl,  IVonk  Uic  cxh'cinily  of 
llie  vomer,  n  smiill  os^cuiia  lubtR-lc,  wliirli  jorcicd  a  pnij^jctioa 
similuf  to  ihiit  ofton  oauactl  bj'  the  mtcrmJiKilbiry  boncB  in  cneoe 
of  double  bnrclip  complicnlcd  with  double  tiflsuro  nf  fho  nlveolnr 
arch.  I  hnd  bwrn  coiifiiilte<]»  from  time  to  time,  on  nccaunt  of 
i\ic  elcft  in  Uii^  pulHtc  ;  but  it  woe  not  itnliE  lie  had  nttiiiiied  the 
ape  of  scTcntoon  ycmra  that  ho  finally  camo  to  mo  for  on  o[>era^ 
tifm.  Tiiia  wne  pcrfurmcd  in  tho  manner  nircndy  dcpcribcJ 
at  length,  with  the  result  of  pcrfcf'lly  rc-eetabliehin-^  the  vtlum, 
and  covorin^  tho  posterior  portion  of  the  olcfl  in  the  bonce. 
The  operation  wus  more  difiicult  thnn  ufiUEil,  owing  to  the 
email  size  of  the  month,  resulting  from  the  previous  opota- 
ticn  on  the  lip,  nni]  the  unusual  obliquity  of  the  two  ununited 
bnlvea  of  the  pfdntiuc  vault  \  yet  the  tmprox^otnent  in  nrticiiktion 
waa  more  a[>ccdy  and  more  decided  tliun  I  remember  ever  to 
have  observed  in  nny  other  case.  A  very  few  weeks  after  the 
openilion,  he  was  able  to  wear  a  gold  plute,  which  vrtii  made  for 
him  by  Dr,  Hufus  E.  Dison,  of  this  city ;  and  it  y\iie  at  this 
time  that  my  utlcution  was  purUcularly  ntirnclcti  to  the  dvtulur 
arch  and  the  anterior  portion  af  thf  t]6tiure>  Tht?  upper  Up  vfue 
so  eloHely  ap|»licd  Ui  the  teeth  in  front  as  wholly  to  t^onfcnl  them> 
except  when  lifted  with  the  fingers.  A  glanec  at  this  part  of 
the  mouth  reiealcl  a  renuu-kable  deviation  from  the  ordinary 
condition  of  the  jaw  in  tliid  deformity,  inaanmeh  as  it  showed  tho 
exietcncc  of  a  pcrta.'tly  eyTmnctncal  medran  fi^purc  extending 
oomplotcly  through  tho  alveolar  aroli,  between  the  eontrol  la- 
ciBor  teeth.  Upon  the  right  eide  of  the  eleft  were  eeen  the  firat 
end  second  jionnancnt  ineiaorfi ;  then  the  canine  tooth,  out  of 
line,  and  pIa<Td  ratlier  abuve  and  in  front  of  il^  normal  posllitm  \ 
then  fhe  two  bicuepidd  ;  nnd,  Inetly,  tlie  two  molars.  In  front  of 
and  abcfvc  the  ri:;ht  Literal  inei^or  \va»  the  corrcttponding  niilk- 
tooih,  hanging  quite  looec  in  the  gum,  Prceiaely  the  adnie 
number  of  teeth  existed  on  the  left  aide  of  the  eleft,  even  to  the 
preeem-e  of  the  Intend  incjsor  of  the  temporary  eet.  The  cen- 
tml  milkHncieorri  lind  also  formerly  existed,  one  upon  each  side 
of  the  fifi*U]-e  -,  but  had  been  removed,  a  few  years  before,  on  ac- 
count of  a  tendency  to  croae  ench  other,  and  proBC  against  tho 
lip.     At  my  request,  Dr.  Dixon  removed  the  two  rcraaiuing 


1*0 


THE   KECK, 


.--^' 


iiiilk-tei?tli,  anH  alsn  the 
riglit  cenimi  iiiL'isor  of  llie 
p  c  rm  :j  TIC  n  t  tct^  wlilcli 
f^eftiit'J  i;lI>i»op[xl  lo  take 
nil  a^vk:v!Ln]  poitiaou  im  rc- 
^■itrdt'd  both  (he  lip  au(3 
the  jaw,  A  cnet  of  llje 
moutli  lias  Iccn  (Ji-eservol 
□nd  £giireJ,  8lius\i[ig  (Ije 
[iiiMtldii  uf  the  £pfiure  iind 
(he  UTLiiiigenjent  of  the 
teeth.     See  woodcuts 

Tlic  woodcut  preset]  tfi 
tlie  siuXe  of  the  [n\rls  m 
tijc  case  Df  mccUiin  fissure.  Being  taken  from  u  ciiat  made 
after  ihe  opemtion,  it  shows  the  resloratiun  of  the  posterior 
part  of  the  hiird  pnlate,  together  with  the  reluin :  it  serves 
alsc»  to  g^jve  a  geneml  idea  of  (liu  exti^iit  to  which  It  is  aiiucd 
to  clo£e  cxLeri&Ivc  iia^urud  in  the  hociy  urdi. 

Thlfi  i£,  so  fur  UB  I  am  nwAre,  fhc  onlv  case  ever  ohservod  of 
a  true  mediun  iisfiure  of  the  alvcolitr  urcli,  or.  In  other  woida, 
the  only  oiie  in  Vklilcli  tlie  clelt  lioa  Ijeen  st^eti  Lo  occupy'  ihe 
poftilion  of  llic  line  uf  t'lituro  nhich  sepnmles  the  two  Inter- 
muxilljirj  hoiic^  from  CTieh  ot]Lt;r-  In  all  cni^G^  hilhcrto  nollccil, 
the  r'left  in  Llie  nUculcir  jiidi  hii»  beeo  upon  oni;  or  hotli  tides; 
oorrcapondin^^  In  nii^at  c^cs,  to  tljc  Ihie  which  Lunrko  Lhe  union, 
in  early  ftctol  life,  of  the  juoxlllary  with  the  intermaxillary 
bones. 


I 


QAti^  hXXm.  —  Fissure  of  Jlard  and  Soft  Palaic, 
DouUc  llardip,  operated  oit  11  i/eizra  f/e/ure.  Oprrafioji, 
Cure,  —  The  fuUowing  eaee  is  interesting-,  aa  bhowing  the 
miatoiiucitl  nppcitmneod  preacntcd  hy  the  puktc  in  i\  person  LU 
yearn  of  ngc,  \v]io  Imd  been  operi»t<jd  on  eevcnleen  ycnrs  hefurc 
fordoullc  harelip,  witli  rcmovnt  of  the  iotcrmEVsillnry  bone.  The 
lip  w'lie  short  nnd  contractcil,  and  prescQied  a  large  i-ed  pkcc  in  ita 
centml  pj»rt,  pri^duecd  hy  the  prolnhiiiri,  which  rnn  quite  upi 
through  the  whole  ccntnd  rcgiLin  of  tljc  lip,  to  meet  tlic  middle 


FlSSUTtE    OF    SOFT    AND    IlARU    PALATE. 


141 


portion  of  ftVm  wliirli  (■i>v[*rp[.l  iKc  interiiinsillary  l)onG.  Tina 
had  not  l;eca  vk'ork(!(I  info  llie  lip  aa  1^  ■;;i;iit:rELl]v  Udiie,  but  bini- 
p\y  fonaetl  tlie  ecptuiu  uf  the  nosei  The  ri:ault  derni>Qfitratcd 
tljis  mlvnnla^^e,  tluit  no  snuT  Vfna  left*  aa  usual,  ItJiJiuj^  to  both 
njsirili*;  but  the  cii^Urix  an  tUe  ri^'-ht  Me  was  ronce;ilfJ  nliove 
in  d  plait  of  akiiii  thnt  on  llie  left  sute  beuig  iiltmc  vi:^ible.  This 
re^iult  was  Uepemh^iit  probiiLlj  upmi  the  fat'I,  thnt  the  opE-'rution 
hm]  L>een  perrormcd  ;it  tvvu  nepariile  t!ui&»  upon  llie  (wo  ^ides  t^f 
tliu  lip.  The  cn^e  8U^'j?;pste(l  the:  idea,  Ujat,  if  the  inleniieiliiUe 
pijrtion  ofeltin  were  more  fullj  removed »  niid  only  suffident  left 
to  fiinu  u  ^eplLim  for  the  nose,  the  eear  nflenvarild,  lustead  of 
preaenting  the  unsightly  form  of  ii  letter  Y,  wuuld  have  tlie  him- 
pler  fonn  of  a  single  cicatrix  in  the  noedlan  line.  Tlie  ftppear* 
Jince  of  the  bone;*  wus  ns  follows  :  — 

The  mitxillnry  honea  hiid  not  eome  together,  but  were  acpu.- 
rated  hy  an  interval  of  at  leneit  nn  Ineli.  The  Grst  teeth  upon 
the  ^idcs  vei'e  the  eani[ie»;  itud  there  were,  upon  each  fiide  of 
the  juw,  five  teeili  iihove  iind  ^evcn  below.  Tlie  vomer  was  cen- 
Iru]  over  the  buck  part  of  tlie  fij^stircJ  palate,  which  is  ^en- 
erully  the  case  in  ftimple  cleft  palate  uncontplicated  with  hnrelip; 
bijC  ill  front  it  curled  Eo  (lie  jight  side,  and  aecuied  to  unite  with 
the  jmterior  jmrt  of  the  u|i[»er  j?iw.  It  resembled,  to  a  eertmn 
extent,  a  ti^t^ure  of  the  palate  complicated  with  harelip  on  one 
ftklc  only,  iu  which  chhp  the  vomer  'n  generally  conttminus  with 
the  pjJatine  plate  of  oi^c  aide.  Wliat  the  njLfure  of  ihi^  a|>- 
]>nrent  union  was,  does  not  e:iaet]y  uppcar,  when  it  la  remem- 
hered  that  (he  intermiixillnry  huiie,  whieh  is  nlwny*  nttJiehed 
lc»  the  end  of  the  voiuer,  hiid  been  removed*  It  ia  posAjble, 
that,  from  the  early  age  at  which  the  o|icrjition  had  Im^co  per- 
formed upon  the  lip,  iheae  parts  may  have  been  dra^-n  to- 
jroiher,  and  coulesced, 

I  operated  on  this  yonng  ninn  in  June,  I8f53,  for  the  fiasure 
a?  the  palate;  the  o|jenLtiun  being  perfectly  bucceasful.  An 
artitieial  phite,  widi  incisor  teelh  attoehed,  wna  aflcrwards  intro- 
duced to  111!  [he  ga[i  in  the  jaw,  iind  cover  the  reuiaining  Hsnure 
in  lh<f  hard  ^^date  in  front. 

Tfie  fidldwiu^  ohservatiiinfl  were  mndc  eighteen  months  after 
thia  (jperution,  when  the  patient  consulted   mc  inedicully.      Jia 


148  THE  NECK, 

regards  the  reatoratioti  of  the  voice,  it  was  less  than  in  the 
greater  proportion  of  cases  in  which  I  have  operated  ;  for  what 
reason  I  could  not  exactly  determine,  as  the  sof^  palnte  was 
quite  flexible,  woe  united  as  low  down  in  tlie  throat,  and  protect 
ted  the  fauces  as  well,  as  in  the  natural  state  of  the  organ. 
The  improvement,  as  regarded  comfort  in  breathing  and  de<£]u- 
tition,  was  very  great;  as  previously  he  could  scarcely  take 
liquids  without  a  portion  being  rejected  by  the  nostrils. 


DESCIilPTlON   OF   PLATE. 


INSTRDMESTS  EUPLOTED  IN  OPERATIONS  FOR  CLEFT  PALATE. 

FigB,  t  and  la.  Forceps  for  aeiEing  and  holJing  the  edge  of  the  fissiim! 
Tclum.  They  ar«  in  p&irs,  one  for  wh  sido  or  the  AMure ;  Fig-  1 
being  for  the  lull  aide,  and  Fig.  la  for  the  right. 

Fig.  2.  Strong  French  sci*ftora  curved  on  the  flat  side,  shown  in  profile  in 
Fig-  2a;  uwd  Tor  diviilmi^  the  posterior  pillar  and  other  resisting 
bandSi  and  For  paring  the  edges  of  the  £aAure- 

Fig-  3.  Slender  spear-pojnted  knift^i  which  I  have  someUmes  usvil  to  pare 
the  edges  of  the  liaaure. 

Fig.  4.  Curred  Bpear-pointed  knife,  shown  in  profile  in  Fig.  4a,  irhicli  I 
originally  employed  in  separailng  tlic  membranes  from  the  palatine 
vault. 

Fig.  fi.  A  knife  similar  to  the  former,  represented  oXso  in  profile  in  Fig.  5a, 
liut  broader  and  fihorter  in  its  t-urve.  Tliis  h  thv  kiiife  wliirh  I  have 
usedf  for  the  lant  ten  or  fifteen  years,  !n  commencing  the  disaoftjon  of 
the  uorering  of  the  hard  palate. 

Fig.  G.  Curved  flri^pors,  Bu^allcr  than  those  shown  in  Fig,  1 .  and  with  points 
nearly  0hnr[j ;  u^ed  in  eompleling  the  dissection  of  the  membranes  from 
the  bony  palatine  vault.     Shown  in  profile  in  Fig-  tia. 

fig,  7.  Crorhet-aifTUillc  of  Sehwerdl,  r^-prcsented  as  closed,  and  wiJh  a 
thread  in  its  c^ye.  By  pressing  upon  the  lever,  the  eye  t^  opened,  and 
the  thread  disengaged. 


HABELIF*  143 


HARELIP. 


It  ia  of  much  importance  for  the  future  appearance,  and  even 
for  the  heulth,  of  the  child,  that  this  oj>eration  ehould  be 
well  (lone,  and  the  proper  time  selected  for  it,  I  have  per- 
formed it,  with  succeaa,  as  early  as  seven  hotira  after  birth ; 
and  its  early  performance  was  advocated  by  my  grandfather. 
Dr.  John  Warren.  Dr.  A.  L.  Peirson,  of  Salem,  has  also  pub- 
lished a  paper  advocating  this  being  done  enrly.  On  the  whole, 
after  much  experience,  I  ehould  advise  the  age  of  three  or  four 
months,  just  previous  to  teething,  and  after  the  tissues  have  ac- 
quired sufHctent  (irmnepa,  as  ihe  best  nge  to  Bclect. 

For  mnny  ycare,  I  have  advocated  nursing  immediately  after 
the  operation,  and  w^hile  union  is  ^ing  on.  By  this  means, 
the  digestive  organs  are  kept  in  a  good  condition,  and  diarrhcca 
avoided,  which  was  often  produced  by  change  of  diet  when  feed- 
ing was  formerly  practised.  The  muacutur  action  of  the  lip, 
induced  by  nursing,  ralher  favors  the  coaptation  than  the  sei>a- 
ration  of  the  edges  of  the  wound,  though  formerly  the  contrary 
wos  supposed. 

I  um  convinced  that  sutures  are  much  preferable  to  needles, 
no  matter  how  wide  the  reparation,  and  consequently  great  the 
tension  required  to  bring  the  parts  into  contact*  They  have 
these  advantages  i  first,  they  ore  more  easily  introdueeil ;  second 
tiicy  produce  less  irr!tati<m ;  and,  third,  they  can  generally  be 
removed  at  the  expiration  of  forty-eight,  or,  at  the  most,  of 
scvcuiy-two  hours,  without  danger  of  disturbing  the  tender  ad- 
]iesi<ms.  On  the  other  hand,  if  needles  are  used,  they  must  be 
left  until  they  are  aufKcicntly  loosened  by  ulceration,  otherwise 
there  is  great  danger  of  tearing  open  the  wound.  The  part  of 
the  lip  also  embraced  by  llie  figure  of  8  over  the  needlea  is 
ofieu  left  in  an  excoriated  state. 

When  the  stitches  are  uaed,  the  inter^-ening  parts  are  e3cpose<l, 
so  that  the  process  may  be  watched;  and,  by  the  apphcation  of 
a  small  comprc&s  kept  constantly  wet  with  water,  the  influmma- 
tiun  liable  to  occur  in  very  young  subjects  is  so  moderated,  that, 
on  the  removal  of  the  sutures,  I  have  frequently  found  the  line 


144 


THE    XECK. 


o£  nilhe^iDn  quite  perfect,  free  from  reJnesa,  and  after  a  aliort 
time  EGArcely  to  be  discin^uished.  In  iLict,  the  liBsuos  seain  to 
melt  into  each  other,  witliout  any  perce|}lible  cicntrix  rein!iiniii<^. 

Small,  fitrnight  suturp-reeilles,  Leid  firmly  by  forceps,  wiil  be 
found  miit:h  more  coiiveiiient  to  use  tlinn  curved  ones. 

In  reiriird  to  ihe  method  for  avoidiu"  the  irreuulantr  wliich 
80  often  takes  place  where  the  eUgei  of  the  lip  are  brought 
together,  I  flhould  say  {having  trieU  the  various  menna  that 
have  been  Ku<rj^ted  by  cutting  the  edges  of  the  lip  irregularly) , 
that  die  only  sure  way  is  to  remove  fl  liberal  portion  of  the 
margin  of  the  fi.isure  hpyord  the  red  horilpr  ju.st  befrire  it  begins 
to  curve  u[i\vards.  The  UEtlon  of  the  parts  is  much  facilitated 
by  taWng  n  very  fine  stitch  oti  the  ititiide  of  the  lip_  Ko  dress- 
ing.* are  required  until  the  stirches  begiu  to  loosen,  then  a  piece 
of  adhesive  (thislrr  of  a  dunili-bell  shape  is  of  much  nsststflnce  in 
mnintaming  the  appositiifii  of  ihe  two  sides.  With  infants,  the 
hands  ehoukl  be  H(!^ured  iluring  ihe  Ireatmeot,  aa  I  huve  known 
a  single  blow  defeat  the  whole  operuiion. 


Case  LXXXII,  —  Opet^ation  for  a  ITareJip  on  a  Child 
three  thtijs  ofiL  Ivhrrtiyt.  Ilemorr/i^f/e.  Reamrkabh  Cloning 
of  the  Fi^ffitre. — The  child  wos  a  fine  one  as  to  size.  He 
was  first  seen  by  me  on  the  day  of  tlie  operation.  During; 
the  operation,  it  wns  observed  that  thei^  was  a  yellow  tinge 
about  ibc  eyes  and  furi^hcnd.  This  was  so  slij^ht  as  not  previ- 
ously to  have  altracteti  attention.  When  the  incisions  were 
made,  1  remarked  to  the  bystanders  that  the  bleeding  was  un- 
usually free,  the  bhiod  bein-;  dark -colo red ,  and  comin^r  from  the 
whole  cut  surface.  The  bleeding,  hoAvever,  ceased  ;  and  the 
wound  wiiB  brought  together  by  autures,  A  wet  compress  was 
fljiplied.  Suspcetiug  something  wrong,  I  visited  the  child  im 
hour  alierwards.  I  found  the  Up  swollen,  and  bleeding  tpiite 
freely-  All  other  means  fuilinjr  to  arrest  the  hemorrhaire,  it 
wftH  found  necessary,  !n  order  to  save  the  life  of  the  patient, 
to  cut  awny  the  siitclies,  and  to  include  the  whole  ctit  edges 
in  a  series  of  ligatures.  Considerable  infiammatory  aciiDU  fol- 
lowed ;  but,  at  the  end  of  a  month,  tlie  whole  wound  wns  entirely 
healed,  leaving  the  fissure,  of  course,  much  hirgcr  than  before 


HARELIP.  145 

it  waa  interfered  with.  Shortly  after  tliis,  a  contmction  of  the 
parts  took  place»  commencing  at  ihe  upper  end  of  the  fiasurc, 
and  gradually  extending  downwards  so  as  ultimately  to  produce 
complete  obliteration,  no  ecar  being  left  except  on  the  very  edge 
of  the  lip,  which  was  rather  projected  downwarti  thnn  hitched 
up,  OS  it  often  is  nfter  the  operation  of  a  hnrelip.  The  pro- 
cess of  closure^  in  tliis  case,  was  so  rcmarknble  as  to  demand 
special  attention*  The  occurrence  of  hemorrhage  in  connection 
WLih  the  eymptoma  of  jaundice  is  interesting.  Dr.  Francis 
Minot,  in  a  valuable  paper,  read  to  the  Boston  Society  for 
Medical  Improvement,  has  shown  that  out  of  thirty-nine  coses 
of  umbilical  Kemorrhagd  thirty-two  had  jaundicC'  It  has  also 
been  shown,  that  the  bleeding  from  wounds  of  icteric  patients 
is  arrested  vvith  difficulty.  It  therefore  seems  proper  to  avoid 
operating  upon  patients  in  this  condition,  if  possible,  until  the 
symptoms  of  jaundice  have  passed  awoy. 


19 


CHAPTER  IV. 


CJTEST- 


FAHACENTEBia      TEORACIS. 


TiiE  operation  for  the  removal  of  fluUls  frcui  tl^e  cavity  of  die 
i:heflC,  W  jjuticture,  or  by  ihe  hitrodiiction  of  the  trocar  and 
caDul»,  has  been  for  a  long  time  employed  in  the  practice  of 
aiir^ery.  The  cnses.  however,  wljlch  generally  fall  umkr  tlie 
hnnd  of  the  eur^eon,  arc  those  of  chrouic  dbcaHe  where  collec- 
tions of  pua  have  taken  pkce>  In  the^e  cases,  the  simple  widi- 
drawal  of  the  fluid ,  followed  in  fiome  inaliinccs  with  iodine  or  other 
injectione^,  dues  not  seem  to  acconjidJAh  the  oliject;  and  I  have 
oute  or  twice  made  incieionp  into  the  chest  artcvwanU.  or  left 
the  canula.  in  pJaCe  to  allow  the  eacajie  of  the  floiil  aa  00011  as 
formed,  before  a  cure  was  accojnpliBhed. 

The  e\iatence  of  a  connection  between  the  bronchial  lubes 
and  the  pleuritic  cavity,  allowing  the  eocapo  of  air  into  it.  liaa 
not  been  an  objection ;  the  aperture  in  the  lung  being  obliter-' 
atcd  03  that  organ  cxpanJcU. 

In  tubcrculoua  caeca,  the  rcLcf  jiUbrdcd,  in  general,  ia  but 
tempfjraryp  ll  is  in  cases  of  simple  pleurir<y,  with  cftiision  of 
serum  or  pus  into  the  pleuritic  cavity,  that  the  4,Tcat  beneRta 
of  the  operation  arc  obacrvcd*  In  one  or  two  caaca  where  a 
ajjontancoua  or  artificial  opening  has  become  lialiUous, — the 
passage  being  narrow  and  dcvioue,  —  I  have  seen  serious  irrita- 
tion eet  up,  giving  rise  to  hcmurrhage  more  or  Jcsa  aevcrc,  anj 
leading  to  tiic  euppo&ition  tliat  it  was  caused  by  a  carious  condi- 
tion uf  the  rib  from  tlie  lon^  contivct  of  pus  with  it,  which 
occasionally  is  the  fact*  These  eymptums  have  all  been  i^elicved 
by  making  a  irce  incision  into  the  cavity  of  the  cheet;  one  or 
two  cases  requiring  the  removal  of  a  portion  of  the  rih  in  order 
to  keep  the  aperture  freely  open,  owing  to  the  iLickneud  of  the 
pleura  &om  intiammatorj  action. 


■ATUCETnrSIS   THOItACIfl, 


147 


• 


A  caption  may  be  given  in  some  old  capes  in  resnrd  to  punc- 
ture when  the  pleura  has  beconic  cxccf^eivdy  thickened.  The 
intitrumonl  shoultl  be  driien  in  with  &  ccrinin  amount  of  force 
and  decision;  otherwise,  the  pJcura  is  I'urced  before  ite  point, 
anJ  no  fluid  is  supponed  to  he  present,  when,  in  fiict,  the  cavity 
of  the  thorax  Ikfia  not  been  cntcred- 

Of  late  ycara,  the  removal  of  recent  dfiieionB  of  Huid  has 
been  practised  in  our  vicinity  with  uiitat  ^ucocsafiil  reanlte  bj 
Dr.  Morrill  Wyraan,  of  Canibridi-c,  Dr.  H.  I,  IJowditch,  and 
others,  by  the  uee  of  a  amall  cflnula,  with  euetion  applied  bj 
mcnns  of  a  syringe^  so  aa  to  prevent  the  odmisBion  of  atmos- 
phcrie  air. 

Case  LXXXIII.  —  i'w/jyemrt-  Fistidone  Communication 
icit/i  Lungs*  Pai'an'tnteMs  Thoracis*  Gure*  —  The  polient 
woe  a  youn^j  man,  aged  20,  of  good  constitution,  and  not  of 
a  tuberculous  family.  In  March,  1853,  he  waa  aciBed^  ftft4?r 
cspoenrc  to  cold,  with  a  severe  pain  in  hia  rip;ht  eidc,  which 
couBncd  bim  fur  blx  weeks  to  hia  liouac  and  l>cd ;  it  wn?  not 
attended  with  couj^h  or  expectoration.  After  this  period,  he 
went  out,  and  waa  able  to  employ  himeclf  partially  in  hia 
ordinary  avocj^tions.  In  June  he  waa  suddenly  seized,  wbilc  at 
dinner,  with  a  violciit  fit  of  coughing;  he  left  the  table,  went 
into  another  room,  and  e3(pectorated  about  two  quarte  of  pua. 
Prom  this  time  hia  cough  and  purulent  exjiectomtion  continued, 
being  more  aevero  at  intcrvala  of  u  week,  when  the  chest  emptied 
itself  of  about  the  eame  quantity  as  at  firat. 

1  waa  rcqiiEr*ted  to  ^ee  him  in  the  country,  in  October-  Tic 
waa  then  pale  and  emaciated  ;  hia  akin  hot,  and  pul^e  one  hun- 
dred and  twenty.  Ilia  appetite  was  good,  and  he  took  the  sanic 
amount  of  food  as  in  hcallb  ;  but  hia  system  wna  gradunlly 
giving  way  under  the  di^cnac.  He  wns  very  desirous  of  havin;; 
an  opening  maile  into  hia  client,  the  idcn  being  original  with 
him,  and  not  derived  from  othert^. 

On  exaininatj<*n  of  die  chest,  it  was  obaerved  that  the  right 
j^ide  was  enlarged,  and  that  the  lower  intercostal  spacca  wore 
ruthor  protruded  than  depressed-  There  was  no  decided  promi- 
nence or  pointing  at  any  pnrtienJar  spot*     On  percuseion,  tbe 


146 


CHEST  P 


riglit  Me  wns  quite  fliit,  fxcppt  fir  cue  or  iwn  indies  Ijclnvr 
die  tluvicle,  wliere  n  siibiL're[iit!]iiT.  r/tle  w.is  notjcciL  Succussiim 
caused  n  luiu1,  awju^hing  SLHind,  which  vaa  heiinl  by  ihe  piitient 
liiii]pelf»  jiml  luul  [inilmlily  Imni^ht  tu  liis  initnl  [\io  irit-n  of  relief 
fium  ji  puDi^curi;.  Tlie  respiraimn  an  llie  lefL  ^iJe  wra  dcciUeUJy 
puerile. 

The  cliest  was  pimrtiircil  witli  a  ddicate  trocnr^  nboul  four 
inches  IVorn  tlie  njiine,  liptvvc^ji  ilie  iiinlh  jind  tenili  ribs;  nnd, 
Gij<?rlna  Byrin<rK  being  iipplied,  ii  pint  ami  a  linlf  ijf  tliirlc, 
hedlliy,  modnruu;^  pun  wjih  witliilrawn.'  No  cougli  or  canstitu- 
tJGtiul  tIi(fiiirbftTH!e  fallowed.  Gri?rtf  ivlit'f  In  brearliing  wiis  nt 
oni:e  iiercepnljlt^ :  urid  lit  nrute,  ntid  wnlkcil  ubtmt  rlie  room  in 
liitfli  Rjiii'ila.  Tlie  liin^  eTipjmdod,  Jiti<I  res^pirntior  cutiU  be 
bejjrd  nlnng  tbe  ftplne,  iind  fur  one  or  two  int'liej  Iieltjw  the 
ECapulit,  alsit  muck  lower  down  tlmn  before  in  llie  fmut  jinrt  of 
tlie  L-hesf. 

Nov.  4lh,  ibis  pHticnt  was  ^d  imich  better  as  to  l>c  nMc  to  make 
ft  visit  to  Rofitmi-  Tlin  foiiyb  was  now  lesa;  lie  bad  n^iinrd 
flesh,  and  his  strength  was  Jncreasinj^.  Tbe  rpspiriilory  mur- 
mur emild  bp  distlnguisbed  all  along  the  ^pine^  rpiile  eloar,  nnd. 
frpr  from  rrcjiitua.  Tht'  j;ide  wns  fljit  on  pfrcusaion,  and  tbe 
respirjttiiJn  and  smincl-'s  cif  Itentl  bcrird  hh  if  ni  a  dintsmee.  Nov. 
ISfli,  finding  that  the  pua  was  again  collecting,  ihe  chest  was 
pntictLirrd.  and  twelve  ounces  nf  fluid  dmwn  off  with  relief. 
As  the  purf  uorlimied  to  i-olleL't,  and  die  aymplinns  lo  recur, 
there  seemed  but  liide  probability  of  a  cure  wiihout  having 
Teconr*ie  to  a  permanent  ripening.  Tt  wns  thf^refiire  derided  to 
intriidnce  a  large  trocar,  and  leine  the  tanula  in  tbe  wuLiiid. 
To  facililnle  its  intriKlurrion,  ng  it  wna  feared  the  thickened 
pleura  and  faUe  meinbmnes  might  resist,  an  incision  wa.s  first 
noLde  tbriHLirh  the  inteiTiiment,  and  tbe  trocar  then  pnsbetl  in 
fitrcibly.  Whiit  Imd  hecr  feared  as  a  possj^ible  oeCL[rrence  hiip- 
petieil,  —  the  ioetrument  did  not  penetrate  the  cnvity  of  the 
rbi'sr.  «nd  inilbia:c  but  u  Rw  dro|ir*  of  libiod  U'^j^ued.  Tt  was 
tbojgbl  best  to  delay  a  I'cpt'lilion  of  tbe  jmncluie  for  a  few 
dtiy!4,  and  wjitt^h  dte  HyniptoinH,  A  alight  irritation  took  jiUee 
in  tbe  wound,  mat  the  con^rb  subsided*  APicf  a  week,  be  pro- 
posed to  n-inrn  home,  nnd,  if  reccssary,  make  nnothf^r  vi&it  to 
town,  and  have  the  o|>c:rutiuu  rej^ieatcU. 


149 


TTc  was  not  henrd  from  a^r^in  until  J-in.  Olh,  Ifi.')!,  wlicn  I 
was  nillcJ  to  sec  liim  In  the  cmintry*  timl  fdunil  liini  Iftboi'ing 
uiwlei'  very  alnTiiiing  syniptums*  lie  was  cunfiiied  to  hie  bed 
in  nn  cxlretne  de<j;reG  uf  emncintion  ;  pu\K  coe  hundred  And 
fifty,  ekiu  cknniiy*  Tlie  expectornliou  wn^  pri>ru&e.  nnd  ho 
ofiensivc  as  io  niiikc  it  difficult  tu  remain  in  the  same  ruom  ivith 
liini.  lie  said  Ehat.  on  his  return  from  Buaton,  the  weather 
being  \cry  blealc,  he  wne'nmdi  expo,*ed,  nud  tw>k  a  severe  cold ; 
from  uhidi  liine  tlie  ^vitiptoui*  lind  slI)  been  unfuvorable.  The 
e7( pectoral i*»n  wfia  ao  nnuscous  n&  cnlii'Hy  to  destroy  Wis  nppe- 
tlrc,  nud  the  coii^h  -was  cunetfint  nnd  painful,  lii^  vilnl  powers 
were  eo  rednfcd  tli-it  »<»mc  lieAitation  wn.^  felt  in  aticmpiin^  any 
ojicrntion  ;  but  the  pnticnt  ivna  ao  urgent  that  it  should  be  (ned* 
and  it  being  the  only  chnnce  for  life,  it  waa  resolved  upon*  The 
fine  trocar  was  used  aa  nt  fir^it,  and  two  quarts  four  ounces  of 
fetid  pus  were  drawn  off",  with  ijnmediatc  relief.  Tbc  nir  pnascd 
freely  In  nnd  out  of  the  cnnula  during  rc^piriition.  lie  waa  di- 
rected to  keep  the  npertiirc  in  the  fjinuln  do'^ed  with  n  cm-k, 
whicli  was  to  be  removed  twice  daily,  nnd  the  pus  cvHcuated. 
The  pjitient  from  this  time,  under  the  judicious  mana<^nkeut 
of  hia  phraidan.  gradually  recovered  ;  and,  \i\  May,  he  was  aUe 
to  ]>re,^ent  himaclf  in  Boston  In  good  health.  I  saw  him  in 
November,  quite  fituut  and  healthy;  and  lie  had  no  cough  nor 
expectoration,  JIc  enijiloyed  hiui?clf  in  his  trade  cf  watch- 
tnnkin;r.  The  lower  piirt  ufthe  rigrbt  side  of  (he  cheat  wnfl  Hat; 
there  wna  no  contraciii»n  uf  that  i^idc.  lt«spirati<>n  wna  heard 
bidow  the  acapuln,  without  erepitus.  I  was  aaeiated  in  the 
iihove  cpi^e  hy  the  able  advice  of  Dr>  Bowdltch,  and  in  the  Inst 
operation  by  Dr.  Slade. 

Case  LXXXIV,  — PUnrlf^.  Ewpycnin.  Pus  drajcn  off" 
hy  a  PtiHCfiij-c  in  Bm:k,  Aflentttrdff  Pointing,  ffnd  nn  Op^n- 
in^  intuit  in  /•'I'ont.  Ifernorrfifitfe,  ttl  ikr*  eud  oj'lito  ytara  and 
<i  Jtt/ff,  fi'om  i/te  jiaterior  Opening.  I'*ree  Inoieion.  Qtirc, 
—  A  gentlcnmn,  a;^ed  45,  had  iin  attHck  of  pleurisy  on  the  left 
side.  Van  lia-mod  there,  and  waa  ilruwu  off'  by  a  puncture  in 
ihc  back,  with  q  Hne  trocar  and  canuln,  and  greut  relief  flffurdwi. 
Subsequently,  there  was  pointing  in  tlio  front  cf  tie  chest  •>  an 


CHFST. 


opening  WAS  mndo  with  n  lancGl,  fluil  the  pus  ovacunicd^  Tbo 
pjitient  recovered  his  health  ;  but  a  purulent  di9chnrge  continued 
to  flow  from  the  njwrtnre  maJe  hy  the  lancet,  A  few  weeks 
before  I  aaw  him,  a  eudil^^n  di^cliargc  of  blood  toob  place  from 
thia  opening,  find,  reeurring  onee  or  twice,  reduced  his  strength, 
and  incctpnclrAied  him  for  buaineas.  At  thia  period,  the  pua 
escaped  througli  two  openings  in  the  integuments  by  a  tortuoiia 
route.  With  a  j>rohe,  the  i"ib»  in  n  onrinus  stnte*  oould  be  <le- 
tected-  It  was  thought  probable,  on  eonsullntiou,  cither  that 
from  the  pua  being  retained  in  the  cliest  on  necouut  of  the 
small  size  or  irregularity  of  the  openings,  or  from  the  diseased 
rib,  a  eoureo  of  irritation  existed  whirh  guve  rise  to  the  heraur- 
rhjige.  With  this  idea,  it  was  decided  to  dilntG  the  eKtemnl 
openingfl  by  means  of  prepared  sponge.  This  wa**  found  to  he 
a  matter  of  ponie  difficulty,  on  ancoLnt  of  the  great  irritability 
of  the  wouod^  and  could  he  done  but  imperfectly;  still  the 
patient  received  a  temporary  relief  from  it.  The  heinorrhagei 
however,  was  shortly  repeat«l,  was  more  severe  than  at  first, 
acnompjmiod  hy  the  appenrani'e  of  purpura  over  the  whole 
Ijody,  and  brought  him  intu  an  alarming  state  of  prostration- 
It  wtia  now  clear  that  something  decided  must  be  done,  or  the 
patient  Avonid  sink;  and^  on  further  consultation,  it  was  agreed 
that  the  rib  whoidd  be  eut  down  upon,  the  carious  part  removed, 
and,  if  thought  expcdieTit  by  the  knowledge  ihun  aef|uired,  a  free 
opening  uifide  into  the  nhoat.  The  patient  being  rtherized,  a 
somewhui  lab'iridus  dissecrion  was  required  to  cKpoae  the  rib, 
on  account  of  the  accumulation  of  ly^iph  over  it,  xvliich  had 
gniduully  co!le<!lcrl,  and  obscured  the  opening  into  the  chest. 
About  an  iuch  of  the  lione,  in  ri  diseased  statO}  was  excised^  nud 
the  pleiini,  much  thickened  by  inflnmmatioTi,  expoBed.  An 
aperture  aibout  an  inch  long,  with  thickener!  edge><j  was  now- 
seen,  which,  being  enlarged  laterally,  allowpd  the  forefinger  to 
pass  freely  inttt  The  cavity  of  the  thorax.  It  was  ascertaineil  that 
the  interior  of  tbe  pleura  waa  lined  with  a  highly  vjiscular  »]"ongy 
tiESfiue,  bleeding  on  the  hlighti?fit  touch,  which,  probably  being 
irritated  by  the  retaineil  pus,  had  given  rise  to  the  profuse 
hemmrhage.  Being  turned  on  bis  side,  a  large  ({uanlity  of 
blood  and  puti  ran  out. 


PABAC£lST£die   THORACIS. 


151 


From  the  tim^?  of  the  operation,  be  be^n  to  improve,  nod 
with  the  exccplioD  of  a  very  eli^ht  iliatrJiarj^e  of  blood  from  the 
cheBt,  on  the  dtxy  ducccicdingf  had  no  farther  diSculty.  He  is 
now,  oiany  yciira  after,  ip  good  health.  Hia  chest  is  i!untraGte<l 
on  that  Hide,  and  bi^  shoulder  gi^atly  dcpreaacd ;  otherwise  he 
had  tho  appearance  of  a  very  strong  and  healthy  man. 

In  another  cjiae  (that  of  a  boy  about  H?  years  of  tLge^  re- 
ferred to  mo  by  Dr.  Bowditch),  where  severe  cough,  emaeia- 
tion,  and  other  di^ap-eeahlo  eymptome,  were  dependent  on 
^empyema  with  an  iiaperfeet  escape  of  pus  tluough  iietulona 
openingfl,  ail  symptoing  were  relieved  by  making  a  free  and 
direet  opening  iuto  the  chest. 

The  ludt  two  oosea  are  selected  from  quite  a  number  which 
have  oeeorrcd  to  mc.  As  a  general  rule,  I  would  repeat  what 
I  have  before  said,  that  a  free  iiieiaion,  with  the  removal  even 
of  a  pieec  of  the  rib  if  necessary,  gives  the  best  results  where 
repeated  puncturce  have  foiled. 

In  regard  to  tlie  excision  of  a  portion  of  the  rib  for  tumors  or 
other  diticoee,  gcDcrolly  spoakingT  the  danger  is  leas  of  pene- 
trating the  pleura  than  wilJ  at  Erst  be  BUpposed.  The  tcxtnrc 
ia  so  tiuekcned  by  indammation  as  to  bo  easily  peeled  from  the 
bone. 


CH.\PTER  V. 


ABDOMEN. 


BER>'TA.  —  STRASCrLATED   HE&_\1A. 


The  whole  trentraent  of  strangulate  J  hemu  has  been  allered  by 
the  itilroduction  nn<I  (i!c   o?  ether.      Mnny  atses  which  re^ieted 

the  i]£e  of  jcc,  Je{iletLon,  nnJ  dehililnrint;  rt^nieOiea,  ^ucH  nfl 
antimoD)'  acd  tobaeco  inJeclhrEia.  nre  now,  with  rhe  pjitient  well 
etherized^  and  careful  manriiulniionB,  reiluced  without  a  cutting 
operation.  I  have  aeldom  bad  any  dlfficully  in  reducing  hernia* 
of  large  aiie :  it  is  tlic  very  amnll  licrniM  tumor*  that  occur  Bud- 
deidy  after  (in  effort,  in  which  the  tnxh  under  ether  otleii 
fuild.  After  n.  moJerntc  nnd  c;niTfnI  oee  of  the  tnsis,  I  have 
never  delayed  the  ojjeration,  nnd  liave  nvftiJcd  rnys^elf  of  tho 
patient's  bemg  under  the  influence  of  the  nnte^thetic  to  proceed 
at  once  to  Up  In  ekUful  hands  this  is  aluiosl  always  successful  J 
and  I  have  never  had  reason  to  believe  that  the  patient  died 
from  the  effects  of  the  operation,  it  nimoat  always  being  from 
the  delay  in  performing  it.  Some  caeea  of  large  hernia  hove 
been  under  my  care  at  the  Hospital,  which  at  first  appeared  in 
a  fllrangnlateil  condition,  but  which  were  simply'  impacted  fronn. 
A  sudden  addition  to  an  already  pretty  firm  tumor.  If  tho: 
ayniptonis  were  not  urgent,  rest  in  fl  horizontal  pOdtlioE,  a 
Starving  diet,  0|nnte3  to  relieve  pain,  and,  in  some  enj?c*,  com- 
preflAion,  have,  after  a  Few  days,  succeeded  in  affording  relief. 

Jn  one  case  of  a  very  small  strangulated  liemia,  in  which  the 
aymptoms  were  very  urgent,  nnd  where  dciith  eecmed  ifnniinent, 
I  advised  an  immcUinte  operation ;  but  the  patient  positively  de- 
clined, preferring  to  die  as  ehe  was.  A  week  ailerwards,  to  toy 
flnrprise,  I  was  calletl  ta  her  a;;^in  by  licr  physician,  and  found 
her  fitiU  ulivc,  and  ready  tu  have  the  operation  done.    On  open- 


erttANOULATED   HEHNTA. 


153 


■ 


ing  the  tiimor,  the  aac  wne  found  entirely  j^an^^ronons ;  but  the 
pre^UTO  of  (liQ  stricture  had  Ijl-cd  expended  on  tliii4  pnil,  mid 
the  emull  loop  nf  the  intesline,  though  very  much  disccjiored, 
etdl  prcaervcd  ite  vitahtj.  The  i^tricture  wob  dirided,  find  the 
intestine  returned.  The  pnticnc  recovered,  Tliisoa^c*  however^ 
is  a  vcjy  rare  one.  The  nile  shouM  he*  where  t]ic  hernia  ia 
not  at  once  reduced  under  the  relaxinj^  cffecta  of  ether,  not  to 
dekytlic  operation  uitli  the  idea  that  the  tumor  mcy  be  re* 
moved  hy  looul  fippliciUlons. 

The  di&tiiiguiflhed  eursp^on,  Mr,  "William  Lawronco,  of  Lon- 
don, whose  trcatitie  on  Hernia  elill  remains  the  best  ailtliority^ 
^  afi  do  nil  hit  W[>rhr*  on  s<;ientitiL'  eubjccte,  — eojfl,  "  The  dan- 
ger to  whieh  the  patient  ia  exposed  by  the  operation  is  lesa  thiin 
that  whieh  ho  under^^oea  by  delay.  In  the  Inlter  case,  ixiHiun- 
mntion  and  gan^^nc  of  the  part,  which  is  thus  rendered  inea- 
paUc  of  exei-ei^ing  its  fiinctiuas,  nnd  cKteneii^n  of  intlanimatoty 
disorder  aluni;  tlie  canal  nhove  the  stricture,  as  well  tka  over  the 
eavity  of  the  nbdomcn,  with  rnpid  cxhuuetlon  of  the  vital 
powers,  ure  fiiirdy  produeed  hy  a  continuance  of  the  inearecra- 
tion,"  And  a^iin  lie  «ays  :  "  Our  eonduet  tnu^t  not  be  guided 
merely  by  the  duration  of  the  ease  i  tiie  kind  of  etrar;;uUtion, 
the  nature  of  the  flyinptojiia,  the  effect  of  the  mcjvna  ciLiploycd, 
&nd  the  state  of  the  pnrta,  mn&t  influence  our  determination* 
Small  and  reeent  hernin;,  or  such  as,  havin;^  Leen  kept  up  for  a 
longtime  by  mcnufl  of  n  Irufls*  arc  suddenly  reproduced,  admit 
of  little  delay.  The  atmngulalion  ia  violent  in  such  inatancea  ; 
inllanimaCion  nnd  gangrene  soon  come  on.  In  old  and  large 
rupturea,  whieh  have  been  often  down  and  oftcu  replaoed,  the 
fiymptoraa  are  not  ao  urgent,  nor  the  necceaity  of  operating  so 
preH*ting." 

I  propose  to  adduce  a  few  coflce  in  ilbiatration. 


Case  LXXXV.  ' — SlfUi^gttlatnd  Ftmoral  Jlcmift,    Omen- 

tum  forrnituftt  Cijet  QotUnhiiitff  the  InteHinc,  Large  Ab^i^eaa 
•icithin  the  ^ildomeii.  — The  fiibjeet  of  this  caf^c  waa  a  laborer, 
40  ycnra  old*  The  hernia  first  made  ite  appearance  five  ycarg 
before,  in  \6'61^  and  woa  ditHMivcrcd  HJIing  the  eerotum  after  a 
bard  day's  work.    Tiie  patient  waa  able  to  return  it  himself  with 

20 


154 


ABDOMEK. 


ffome  little  difficultv :  he  made  no  application,  however,  and 
wore  no  tmsa  ;  and  when  the  inteatinc  was  occivaionali^  pra- 
trudcJ  and  a^  liltlc  pinched,  hy  quiet  and  abstinence,  lie  9iio- 
cccded  in  replacing  it  without  mcdiciLl  assistance.  Two  years 
before,  tbc  hernia  suddenly  diauppeared,  and  did  not  m^peur 
again  until  the  time  I  waa  called  to  him,  io  1842. 

1  Wh13  rcquc^led  to  ecc  him  l>y  his  physician,  Dr,  Brown, 
under  the  following-  cii-euni3tancc9.  Forty-ei9;iit  hourd  before, 
while  raiain^  a  hejvvy  lo?id,  the  hernia  waa  again  suddenly  forced 
out,  and  severe  jiaJn  in  the  abdomen  imnie^lintely  enaucd.  He 
niiidc  repeated  eflorta  to  reduce  it,  and  the  following  day  even 
attempted  to  re^iuiic  liia  work,  but  faiulcd  from  pitin,  nnd  wag 
taken  home*  He  did  not  ace  hia  physician  until  the  next  morn- 
ing, not  apparently  being  aware  of  the  daugeroiis  nature  of 
the  diseaaep  He  vnxs  immediately  bled,  ice  w.ia  applied  to  the 
herniQl  tumor^  aad  a}]  the  ordinary  uieana  ibr  the  tasiB  resorted 
to.  In  tlic  afternoon,  the  s^'inptome  becoming  aggravated,  I 
was  retiueiitcd   by  Dr,   Brown  to  perfunn  the  operation. 

The  tumor  at  this  time  was  nbout  the  ^ize  of  an  oran^,  very 
tenee  and  painful  to  the  touch  \  and  the  scrotiini,  from  the  long- 
continued  effbrtd  of  the  patient  by  eevere  rubbing  for  its  reduc- 
tion, hftd  become  eonaJdcrably  indaiuej.  He  complained  of  a 
Bcvcre  dragging  aud  almost  insupportable  pain  in  the  abdomen- 
Ou  opening  the  hermid  aac,  a  large  niase  of  omentum  presented, 
very  red  ami  swollen  :  this  had  an  eiafllio  feeling,  aa  if  it  sur- 
rounded a  mnss  of  intestine. 

The  stricture,  which  was  formed  by  the  external  abdominal 
ring,  xviis  e,\tremely  doac ;  and  it  wae  with  the  utmost  difficulty 
I  waa  able  to  insinuate  a  director  luidcr  ita  edge,  and  divide  its 
£bree.  This  bein^  acci>niplisiiedi  the  strnnipiUtcd  parts  were  a 
little  loosened  so  as  to  allow  me,  after  some  ex.imi nation,  to  in- 
eei't  the  llltle  finger  into  an  aperture  formed  by  a  folding  of  the 
omentum,  and  discover  a  knuckle  of  the  intestine,  which  was 
thus  almost  completely  encysted,  IJy  a  slight  pres^jure,  this 
was  cattily  returned  into  the  abdomen.  The  reduction  of  the 
omentum  wns,  however,  a  matter  of  more  difficulty  ;  and  it  waa 
only  after  a  further  division  of  the  etrietiue,  and  by  considerj;hle 
management,  that  it  was  ultimately  i-edueed.     The  omentum. 


STBAJIOULATED   HERNIA. 


156 


though  much  swollen,  was  not  at  all  imiiiralcd.  and  wns  other- 
wise ftuUe  Jicrillhy-  He  esprcaecd  him^^cll'  immcrtiatcly  relieved 
DQ  tlic  complcEioD  of  tlic  openttioD. 

The  following  morning;  he  waa  free  from  pain  in  the  bowol&t 
which  ncted  well  after  a  doac  of  cjiator  oil.  There  woe  a  reten- 
tion cf  mine,  which  required  the  use  of  the  catheter.  Hia  pulse 
wna  fi  iittic  accelerated.  On  the  third  day,  I  perceived  a  slight 
rcdncflfl  in  the  gr*/in,  nnd  he  complained  of  a  decp-soated  paia 
in  the  left  iliac  regioUi  The  piilac  wns  quick,  couatcnnnec 
ftnxious,  and  the  tongue  considerably  conted.  On  the  tollowing 
day,  t]»e  redness  had  extended  itself  nearly  linlf  down  the  thij^h^ 
and  over  a  port  of  tlie  ntidoinen  ot  the  aame  side.  There  waa 
^cat  pnin  at  thia  point,  on  pressure  ;  but  tho  abdomen  generally 
waa  not  over-sensitive,  and  presented  no  iippearanec  of  extended 
peritoneal  infianinintion*  Ilia  bowels  were  freely  evacuated  by 
inenufl  of  castur  oil,  and  Iccchea  were  applied  to  the  scat  of  pain, 
followed  by  a  larg^  poultice  to  promote  tbe  How  of  blowj,  and 
incren*?c  the  capillary  circulation.  In  the  course  of  a  few  dayfi, 
an  indistinct  Huctuatiou  could  be  distingnisbed  deep  in  the  ilinc 
re^on^  whiub  finally,  ton  days  after  the  opcr&tion,  began  to  dis- 
charge itacif  through  die  external  abdominal  ring  at  the  upper 
part  of  the  wound  made  in  the  operation.  So  hu:  aa  conld  be 
ascertained,  about  a  quart  of  piia  wad  contained  in  tbc  abaecsSi 
The  parictca  ^rndunlly  contracted,  and  the  patient  recovered 
without  further  dirtieult}'. 

The  three  points  of  interest  in  tliia  case  are,  first,  tlie  disap- 
pearance of  Q  large  hernial  tumor,  which  for  three  years  iiad 
been  unrcstr^incil  by  a  truss,  and  he  sudden  return,  and  Imme- 
diate strangulatioti  by  tliC  external  ring,  two  ycara  nftorwarda. 
Second,  The  encysted  state  of  the  intestine,  which  waa  so  com- 
pletely concealed,  on  the  tiret  opening  of  tlie  aaf ,  that  it  could  not 
bo  exposed  i  for  it  was  only  after  the  protruded  parts  had  been 
relieved   by  a  free  division  of  the   stricture,  that   the  omentum 

Leonid  be  nnfolded,  and  tlLC  intestine  discovered  through  a  small 
aperture  at  ita  po&tcHor  portion.  Tj^iinl,  the  formation  of  the 
large  abscess  within  the  abdomen.  Nu  appearances  were  pre- 
sented, on  the  evacuation  of  this  abscess  through  the  ab<1ominal 
ring,  to  Justify  the  idea  that  any  portion  of  the  omentum  had 


IS6 


ABDOUEN. 


become  gnn^^nous  r  tlic  pus  wob  well  farmed,  nnd  in  all  probtt- 
ability  must  have  been  derived  fnmi  a  tiUppHi'iitiim  of  the 
proliipeeti  ojiicntuni,  wliioh  h^itl  bcea  inrtumod  partly  by  the  etran- 
gulntioQ  it  bad  been  subjected  to,  and  partly  from  tbe  iong- 
contiiLUcd  anfl  violent  efforts  of  the  patient  to  iorcc  it  back  into 
tliQ  abdomen. 


Cabf.  LXXX\\[.  —  Slranffufated  Hernia.  Hcdaction 
undf^r  iSt'ffffulfir  Cii-cHmstajices. — To  the  above  case  1  may 
add  one  of  eome  intereaC,  ebowing  the  powerful  iDdiioncc  uf  fear 
in  ctfeeiin^  the  rcthietiun  uf  an  apparently  irreducible  hernia, 
whieh  had  rosUtcd  all  ihe  onhnary  moans  of  treatment.  I  waa 
re'jueetcd  by  a  medic4d  Iriend  to  perforin  the  cpenition  for  a 
patient  laLoiing  under  the  most  urgent  and  dietreeeing-  symp- 
toma  I  bii^'e  ever  witnessed  in  thie  disease,  Tlio  hernia  was  an 
old  one,  and  had  firat  bceomo  6tran;^lateJ  two  day^  before. 
In  addition  to  severe  pain  in  tlic  abdomen,  the  palicut  bnd  vio- 
lent ^'patimodic  noti<»n  of  tbc  whole  bixly,  espeeially  of  the  lower 
cxtrGmJtica,  and  oti  almo^^t  eonrinned  vomitin^;:.  Before  I  saw 
liini,  ho  had  been  thoroughly  bled  to  avneope,  ico  hiul  been 
applied  to  the  tuiiior^  nnd  a  lohaeeo  enema  had  Ui^en  adminis- 
tered, but  nil  without  cirecl ;  mid  the  only  hopca  of  saving  life 
appeared  to  be  in  the  apcetly  reaort  to  surgicfll  means.  All  tbc 
preparations  for  the  opcratitm  being  made,  aa  1  waB  just  on  the 
point  of  eomnicncinj^  the  inoi^^JDU,  his  coiira;:(o  gave  way^  and 
he  obHtinntely  detoruiincd   not  to  submit  to  it> 

I  thtn  elated  to  him  the  great  danger  of  any  delay,  and  tha 
probability  of  n  very  spcctly  fatal  terniinntiou  if  the  inteatino 
waa  nllowcd  to  rcmaiin  lunger  in  ita  present  situation-  The  dan- 
ger of  death  before  hia  cyos  seemed  to  have  a  powerful  effect 
on  hini ;  and,  while  1  was  speakings  the  apaamodJc  action  of  the 
body  eeaj^ed,  and  tlie  patient  became  deadly  pale»  Having  my 
hand  on  the  tumor,  I  felt  R  slight  relaxation  in  its  eontents.  I 
immediately  ^ei^ed  the  intestine  throiigli  the  abdominal  pariotes 
with  one  hand,  and,  making  a  strong  extension,  used  a  slight 
uompre^flion  with  tbc  other  band,  on  the  aac  ;  and  the  herniA 
slipped  baek  into  the  abdomen.      His  recovery  wn^  complete* 

Had  it  not  been  for  the  oecurrcncc  of  the  accidental  circum- 


STRANGULATED   HERNIA, 


157 


Btanra  mcTitioncd  above,  1  have  evcrj  rcneon  to  believe  that 
the  mere  mtcntilty  of  eutrcring  must  have  shortly  Iciuiiaatcd  hia 
existence. 


IntrodiicfioH   of  J''ecal  MatUrs   into  jleV  J^a^ 


coraceous 
'J, 


Case  l^XXXyJI.—StranffiilaicdlTEmm. 
Vomit  tag* 

eagea.  Death,  —  On  Sunday,  Julj  6,  13€Sf  &  woman,  43 
years  of  a^.  wne  brought  into  the  Hospitfll  for  »trflt»;^dnted 
hemiii  uf  iive  Jnja'  Jumtion.  She  hitJ  autlcrcd  wiih  an  inguinal 
bemia  on  the  right  aide  for  four  ^^cars>  It  woa  rctluciblef  and 
she  wore  a  truae, 

A  week  before  her  admtseion  to  the  Iloapital.  aflcr  violent 
atrainingj  the  hernia  came  down,  and  could  not  be  reduced. 
Constant  vomiting  comiuenccd*  which,  for  three  daya  before  her 
entrance,  was  etcreomccoua.  When  ehc  entered,  she  was  in  the 
greatest  atate  of  ptoatratiim,  countenance  piUe  and  livid,  and 
very  apnlhctic.  She  answered  qucations  reluctantly,  and  only 
when  atron^ly  prcaacU.  Stimiilmits  were  iirat  admiiiialcrctl  to 
her*  After  sonic  rc-nclion  had  taken  place,  ctbcr  waa  given 
opnringly  ;  and  she  came  easily  under  its  influence.  The  opcnv' 
tion  waa  performed  with  great  mpidity^  only  oeeupyjng  a  few 
minutea.  Some  eerum  wad  found  in  the  eac,  and  the  inteetine 
much  congested-  The  atricture  waa  divided,  and  the  intestine 
WM  replaced-  The  ether  was  diflcontinued  at  about  the  inid<Hc 
of  the  ivpcrntioD. 

The  ed^'cs  of  the  wound  were  then  brought  in  apposition,  the 
patient  bi^eathing  tran^jnilly,  and  the  usual  preparations  made  to 
return  htr  to  her  bed  in  the  ward.  ,Suddenly  the  patient  (who 
had  made  the  u.*ual  ^Toana  and  sighs  of  a  pcraon  recovering 
from  ether)  made  an  clibrt  to  vomit,  and  was  placed  on  her  sidi^ 
tofacilitnte  the  cscaiie  of  the  fiuida  from  her  mouth*  Tlicse  efforta 
were  once  or  twice  repented,  when  the  face  l>eciinie  livid,  pulse 
begnn  to  faiU  and  a  loud  subcrcpitant  rale  could  be  her^rd  all 
over  die  cheat;  the  symptoms  rcsembhng  those  of  a  person 
asphyxiated  by  drowning.  All  ttie  uaual  rcniediea  were  em- 
ploycfi  to  re^^lore  the  vitid  powere ;  but  the  pulee  and  reapiratli>n 
gradually  tailedf  and  she  died  in  the  courae  of  ten  or  iillccn 
minutes. 


IM 


ABDOKE3E, 


0>  ajttnwtm  of  Ae  bodr,  t^  Mb>wui^  dav,  tke  ■ppor^ 
MW*fi§  pi'CMjiied  w^erc  1mm  :  — - 

The  Intwtitw  umI  itflpmrii  were  cntireh"  filled  wiA  m 
qvflntiij  oT  yeDow  fluid  of  a  tctt  fedd  tidor-  Tlie  moatb  mud 
boeci  were  al«o  filled  witik  s  uMOftr  fioid.  Ok  opta^  ^« 
mt-yammgtXt  tfau  Biake  fiiod  w  fisctad  to  faftTQ  pear  tried  tbe 
okmC  remote  ramtficaljoiu  of  the  brorkcJux. 

Tlie  mcarecAted  inCeMifte,   wiikb  had  beat  freed  1^  tfaaj 
operaiioD,  dkowed  the  ms^  of  dw  gn^  oonctnetioii  Id  iHudi 
it  had  been  subjected,  bat  would  probftbJr  Lav^  recovered  ic^ 
«elf. 

Al  Gnt  fti^t,  I  tboagbt  I  had  foec  with  »  cue  of  death  &md 
tli€  nsc  t>f  ether ;  but  the  mQt4>|»7  reTe^kd  tbe  nstsre  <»f  the 

Tbe  patient,  as  hae  been  et«ted,  bod  pariiAllv  recorered  from 
ethetizntion,  so  as  to  mike  articular  sotmdd.  The  medical  gen- 
tienien  who  were  present  at  the  operation  had,  in  ^ct,  mott  of 
tbem  retired,  thinking  the  caw  finiifhed*  From  the  rocnrr^iice 
of  the  cfforlB  to  vomit,  partlv  from  the  great  rcducltoD  of  tfaa 
vit4it  p<fwcr0f  in  connection  with  the  insensibility  of  tlie  glotlio 
from  the  cifects  of  ether,  ilie  fluids  had  gained  a  ready  entrant 
into  the  air  pa^aagea. 

The  fullovring  caac  from  the  ''  London  Jledical  Gazette^*'  to 
which  my  attentioa  has  been  called  br  mj  friend,  Dv.  Fraocia 
MiDOt,  ie  interesting  &«  IlluEtralive  of  a  simiJnr  occurrcncct 
though  of  a  diAercnt  origin.  As  the  oase  if  ia^tructiTe,  I  trao- 
ecribe  it- 

"St.  Thomfis's  Hospital.  April  23, 14(59. — The  following  case 
ilJufltmto^  flome  of  the  ill  clfcctD  of  drunkenness,  and  showa  the 
impropriety  of  leitvlng  pcreone  in  thid  condition  whoUv  uncarad 
for;— 

"  J^  W-t  <*  laborer,  32  years  of  age,  wju  brou;:hl  to  the  Hos- 
pital by  the  police  at  T  o'clock,  a.m.  He  hndf  somo  little  time 
prcvioiifily*  been  taken  to  the  station -ho  use  in  a  etutc  of  com- 
plete and  iielplcjjs  iiitosication  ;  bad  rcmaincil  there  a  few  hours 
without  having  much  uttcution  bcato^^-cd  on  him  ;  and,  at  the  cud 
of  that  tiinCt  hie  eondition  then  exciting  some  alarm,  he  woa 
brought  to  the  Hospital. 


BTBANOULATED   IlEBMA. 


159 


**  Oa  admiaaion,  he  -was  fijund  etill  tf>  be  somCTrhot  comatose  ; 
but  Ilia  face  wae  livid,  liis  Lrcalliing  labonoua  nnd  whceziug, 
his  pulse  dlmoBt  imperceptible  and  rnpiil,  hi^  akin  moiat.  He 
preseuted,  in  fsict*  moal  of  (he  fcnturtia  whi*.'h  chumctcrizc  the 
Uat  attgc  Iff  hroneLitia.      He  diod  in  the  course  of  a  tew  huure. 

''  A^utopfii/,  - — Bftly  in  good  condition,  but  nnasarcoiifli  The 
BupetficHil  veins  of  the  bruin  were  more  IcMidcd  with  blood  than 
usual,  and  the  eubctnnce  of  the  or^i^ap  waa  somewhat  con^cated. 
Pericardium  and  heart  healthy ;  the  cavities  of  the  latter  wcie 
dilatcdi  and  iilied  with  soil  black  caugula ;  pleura  ircc  from  ad- 
hcaione. 

^  Jjitngs* — Large,  much  in  Sated,  but  not  emphyscmatoue  : 
they  were  crepitant  throughout,  and  a  little  congcated  ;  but  there 
was  no  oedema.  On  BqiiecziTig  the  aectional  surface  of  any  part 
of  either  organ,  all  the  cut  bronchijd  tubes  yicMcd  teiiacioua 
cylinders  of  a  dirty  yellowish  hue  ;  and,  on  tracing  the  tubes,  It 
vaa  found,  that  all  of  them,  from  the  largest  trunke  to  the  uii- 
nuteat  ramilicationft,  were  Hllcd  almost  completely  by  a  material 
in  some  places  eoftcr,  in  some  more  tenaeioua,  but  cvcrywiicre, 
in  all  essential  imrticulara,  reeembling  that  squeezed  from  the  cut 
orifices.  The  mucous  membrane  of  the  tubes  waa  deeply  con- 
gealed tliroujirhout,  and  in  some  instances  it  ap|}eaitd  aa  thoug;h 
email  extravaentions  of  blood  occupied  tJie  &ubmucou»  tiraoc. 
The  mucous  lining  of  the  larynx  and  trachea  waa  likewise  in- 
tensely congested ;  bat  it  nas  not  thickened,  ami  there  waa  no 
exudation  on  tlie  avirfaco.  Under  the  microacope,  the  material 
occupyin;^  the  hronchijd  tubes  w^is  found  to  preaent  a  large 
quantity  of  free  oil,  cella  of  potato,  nnd  innumerjtblc  frapment* 
of  muscular  fibre,  together  with  a  good  deal  of  stuff  of  which 
the  nature  was  not  clear ;  the  whole  bcin^  iiiEermixcd  wi(h  ciliary 
epithelium,  and  some  imperfect  forms  of  cella  belonging  to  the 
luucua,  which  cemented,  aa  it  were,  tlie  varioua  subatanecs  inU> 
the  form  of  tenacious  cylinders, 

'* Peritoneum  healthy.  Liver,  of  uniform,  reddish-brown 
hoe,  congested,  but  heallhy.  Spleen,  of  usual  &\zg,  pale.  Hnb- 
by,  and  wriuklcd.  Pancreaa,  kiOneys,  and  supra-renal  capsules, 
healthy. 

"The  mucous  membrane  of  the  stomach  (cardiac  end)  was 


160 


ABDO^a:^^ 


aomewhat  coiipeated  and  aoftenei^ ;  but  tlint  of  the  real  of  the 
organ  and  of  the  intestine  was  lieaklij,  presenting,  however,  a 
more  tlian  ordinary  quantity  of  niucua  adliering  to  it.  Aorta 
health  J. 

"  lie  marks .  — It  ia  evident,  froto  the  resulla  of  the  esnniina- 
tiun,  that  the  mnn,  while  in  hia  drunken  ataXti,  had  bi^en  conlinn- 
ally  vomiting,  or,  rather,  regurgitating  the  conJcntB  of  Lis 
etoinnch  ;  anJ  that,  owln^tohiauneonaciousandperhapaijartially 
paralyzed  cmiditlun,  he  Liid  dmwn  ihesfi  continually  through  the 
laryui,  and  thence  into  the  bronchial  tubes,  wljicli  had  grailnally 
beeoEue  choked  uj}.  It  la  clear,  too,  that  the  irritation  of  t!ie 
forti^  matter  had  excited  in  the  latter  intense  congeation,  and 
coplour^  effusion  of  ninctia  ;  and  that,  from  the  combined  eiTecta 
of  the  abundant  accumulation  of  vomited  material,  of  ct ingestion, 
and  of  eirutiiun,  die  patient  had  been  anffoeated,  aiul  liad  devel- 
oped those  fiynifitorns  »hic:h  liad  ainiulated  bronchitit». 

"  From  the  complete  way  in  whicli  even  the  aiujdieat  bronchld 
tubea  were  filled,  fruin  the  history,  iniperfeet  thuugh  it  l>e,  and 
from  utlier  circumataocer^,  it  la  obviona  that  the  proeeaa  had  been 
a  gradual  one  :  and  one  cannot  help  regretting,  therefore,  that 
Le  had  not  before  bc^cn  pl^tced  under  competent  aupervic^ion  ;  and 
that  such  prci^autioniiry  mea*uro^^,  and  hnch  Ireatment  as  would 
have  etiggested  theraadvea  to  any  medical  pi^clitioner,  had  not 
been  put  in  force  at  an  early  period-" 


Case  LXXXVHI.  —  Case  reaeiitdliufj  tSO'atijulated  Her- 
n\a..  DiffhuU  Dltti/ntms*  —  A  girl,  n*,'ed  23,  entered  the 
Ho.spital,  in  the  iiiedieal  wanlrt,  Jnne  23,  IHGO;  »nd,  on  the 
following  day,  was  referred  tii  me  by  the  physieina,  under  the 
euppoAitioa  that  she  had  atrangulateil  henna-  She  amd  that, 
seven  weeks  ago^  from  a  alrivin,  she  felt  n  piiin  in  both  groins. 
Five  week*  ago,  while  lifting  a  washtub,  a  tumor  ap|)enred  sud- 
denly in  eiioh  groin,  vi'hich  had  Ixvn  painful  since.  For  the  laat 
week  or  two»  ehe  had  been  confined  to  her  bed,  with  ninch  pain 
in  the  right  tumor;  had  had  no  movement  uf  the  bowels  for  a\x. 
days,  in  spite  of  the  uae  of  medieinea ;  and  had  been  troubled 
wllh  vomiTing. 

The  right  tumor  waa   so  painful   that  she  could  not   support 


STRANGULATED   HERlflA. 


161 


jtijj'  ex!immatt*>ti  without  ether.  This  being  given,  a  flli;,'hLlj 
inflftmed  elastic  tutnor,  the  tize  of  a  hen  a  eg:g,  was  IbunJ,  just 
below  Poupart'fl  ligament,  on  the  riglit  siJe,  and  a  smaller  one 
on  the  left.  It  wits  Jeoided,  on  coneuJtntion,  that  though  it  was 
impri;bal)le  tlmt  tiro  hcE-nia^  should  appear  nt  once,  yet,  as  there 
had  been  vomitiurf  and  obetinjite  eonstipation,  there  wiie  reason 
to  believe  tlmt  the  bowel  might  be  in  the  tumor,  and  delay  might 
be  fatal.  It  \va&  therefore  agreed  to  make  an  sxplorntor}'  ojiera- 
tion,  aa,  in  cnsc  it  turned  out  to  bo  a  BLi|Jpu rating,  glandular 
tumor,  this  would  aiford  relief. 

The  ri!_'ht  tum^»r  was,  tiiercfore,  cut  down  upon  ;  nnd»  thofaseifl 
oovenng  it  being  expoeed,  there  was  a  dark  appearance  under 
itf  like  the  sac  of  a  hernia.  This  being  cut  into^  pua  escaped, 
and  the  tumor  was  found  to  be  glandular.  A  similar  operation 
was  done  on  the  other  ^idc, 

On  recovering  from  the  ether,  ebo  expressed  hereelf  greatly 
relieved,  the  pain  previously  being  alcioet  inauffernhle. 

On  the  following  diiy,  there  had  been  a  siitrbt  evacuation  from 
fin  enema  ;  but  no  further  cvneuation,  no tAvith standing  a  doae  of 
flenna.  The  senna  being  repeated,  at  stated  intervals,  on  the 
fiocond  day  after  the  operation,  and  the  flcventli  of  the  constipa- 
tion, the  brjwclj*  were  finally  acted  upon.  After  this,  she  began 
to  recover. 

In  connection  with  thia  case,  I  would  mention  the  following  :  — 

I  waa  requested  to  see  a  patient,  Jn  the  spring-  of  l^ijlj, 
who  had  had,  periodically,  for  a  number  of  years,  a  tumor  ap- 
jwar  in  the  ngbt  groin,  attended  with  flcverc  disturbance  yf  ttie 
digeetive  orn^ans,  with  constipation.  Thia  ha*l  recurred,  as 
iifiual,  and  the   symptoms   hnd   been  treated  without  relief. 

On  examination,  I  detected  a  hernial  tumor  in  an  Inflamed 
condition,  which  was  at  once  cut  dovin  upon,  and  the  sac  and 
the  iatestiue  found  ^rf^ngrenous.  The  upper  and  luvrer  open- 
ings of  tije  inteatine  were  aboat  largo  enough  to  admit  a  siuall- 
Bijsej  bougie,  their  pnrietea  being  greatly  thickened. 

The  patient  tlied  about  three  days  aftcrwartla  ;  it  being  impOB- 
eiblc  lo  get  any  evaoualioii,  though  injecliona  were  thrown  into 
the  upper  opening. 

At  the  autopsy,  the  upper  intestine  waa  found  fljitly  applied 

21 


in 


■o  ^  tigs*  «f  Ae  i^k  faaval  rn^,  m  m^  ■uyilin  viik  tfe 

of  the  ft»liMl       Ib^  Mne  ad»  oflke 

fifarm  lovor  Ae  a«  ^  in  on^e,  wkkfc,  by  tbe 

■MBt  of  tfaM  «^^  «i  1^  fifimrniil  pma^  ™^  poaUy 

t^p***  uw  wnodieal  mrcinc  uupu  of  tbe  lopuuv- 

Minr  rean  since,  whm  m  ■mJenl,  I  oonMvd  Dr.  Jolui  C* 
W«rrai  in  ui  opcnUm  on  &  Uj  vln  hod  bem  trntfed  h^ 
a  fknkimn  far  failio«»  «Qfie  ftr  m.  nHttber  of  ib^v,  wkcn  ft  laftll 

Da  Dr.  Wftfren't  bfliBg  olU,  he  lba>4  whot  appvovd  tti  be 
ui  cfiLATffed  ^uvt  tbere.  Aa  ilw  sjvipcoBS  buil  h^uUL,  w 
opesatioo  mu  dijiie-  Tbe  gland  trsa  expooed,  and  dMwtfd 
op.  f  oder  a  wi«  disfMvcr«d  the  end  of  a  knoekle  of  lateitme, 
in  a  dark  Aaie,  ju^  projernng  frum  tbe  tumoral  ftt^. 

Tbe  cnostrk-doti  tras  rvlkMred,  and  cbe  imeadne  reomieJ ;  but 
tbe  patient  died. 

1  hare  met  myself  with  a  dmiUr  imafl  sinngtdaied  b^iw*, 
coocealtd  by  an  enlarged  ^lud :  but  fbrttmatelT  ^oc  tbe  tmt  m 
tine  Ut  tare  ibe  paiieai.  As  a  poiaL  uf  pnecke,  tber^br^  U 
would  0«em  proper,  vhtre  the  $_TTDf>-Tums  ul'  strai^;iilaced  b«Bit 
ate  |nf<aant,  to  &x|ilofe»  ilthuugh  the  nanire  uf  tbe  anaor  bmj 
UdoobUbl. 


Case  TAXXrX.  —  Stran^lattd  H*m\a^  vcith  Untuwil 
^pptarHncet.^A.^VL^  30,  18^^,  a  woman.  37  veus  of  age, 
entered  tbe  Uo^pUal.  with  a  strongidated  m^iiind  bemu  of  the 
nght  Bide,  of  two  dav*'  dtiratioD-  She  bad  been  troubled  with 
a  «mkll  reducible  hernia  ^ome  rear^.  which  h?Ld  b^en  funded 
down,  and  Je^  easiJr  retuint.'d  for  the  la^t  fortnight.  She  liow 
bad  iutense  pain,  vomiiin^,  and  ^  tbe  trmptauu  of  strangu- 
Ution. 

Or  opening  the  6ae,  a  little  bloodv  fluid  escaped,  and  what 
aeeitteil  to  be  the  red  and  aivollen  inieiiiiuie  presented.  No 
probe,  however,  could  be  made  to  penetrate  arouod  its  tuargin 
into  the  ring.  I  requested  tnv  collen^e.  Dr.  Clark,  to  esjiniinc 
it;  and  }»  finally  di4coTerc>d  a  small  iiperture  at  the  inner  side 
of  tbe  tumor,  where  a  probe  penetrated-     Here  I  incised  the 


FTKIMJUUITED  QESNIA. 


in 


^id,  after  moeh  mftoipuUticQ,  the  tnrcff in#  n«  radu««dt 
amd  m  lar^  ipHiitiiy  of  ecro-«ui*nnMCi*;>«  mailer  «««i|>rtl  froio 
iko  Mkimhni  cttvitv.  Whokt  the  ob^tadc  wu  in  ihU  n««.  I  JUtt 
■Bfthk  ta  dcci^.  The  iDoeC  probftUe  ezpUnfttinti  U,  thjit  the 
iDlvftme  had  pushed  before  U  a  very  thin  ]av«t  of  ommtunia 
wUA  was  €nnJy  adherent  to  ii,  nnd  iil#o  tc  the  niftrxin  vf  (He 
with  tiie  exoepcion  of  the  ^m&lJ   opening   when    itio  ptvbo 


Hm  piiieat  had  a  good  recovery. 


Ca5B  XC.  —  iSimifjnl/itrfi  Ht^mitt  in  fx  Chil^  on*  ^nr 
aid.  —  A  dkild  v^as  brought  into  the  Ho«pitali  Mari-h  fO, 
[,  with  a  hard  tumor  in  the  npper  part  of  the  \vtt  ^ide  of  tltn 
Tl»crc  ha«l  been  ^rcnt  eufferin^  for  twenty-foar  hoiire, 
ttnutttnt  Tomitingi  and  complete  rctcnDr^n  of  urine.  The  mothor 
mid  dut,  erer  pinoe  birth,  the  ehilil  had  had  a  ttinior,  furnif^ltniiM 
on  one  side  of  the  fcrotam,  and  pometimea  on  the  other.  It 
however,  never  before  been  hanl,  nor  hai]  it  nt  nny  thno 
rue  to  anv  mcoDvcnieQce'  Ijotterlv  t^he  hjid  observed  % 
^teiDor  only  oq  the  lefl  side,  where  it  now  appears.  Dr.  BUke, 
rlj  booae-snr^eon  at  the  UotipitaJ,  £aw  the  caMt  and(  Mi^ 
pcctiDg  Eta  nainrc,  H^nt  it  into  tlic  hoo^.  The  chiM  PMmed  lo 
bctBgreatpaiD.  and  dtrennou^lr  rented  any  exanunation.  The 
waa  very  teiue,  gtobiUar,  and  had  the  appeannoe  of  A 
liyilrocdc  of  the  epennatic  cord>  When  pbced  ia  •Uoig  «»- 
fight,  however,  it  wad  not  at  all  tran^iuceni.  Ob  pftMWe,  It 
WM  qoiic  tmyieiding.  In  order  the  better  to  utvmtjgat«  thi; 
tkeeUd  WM  placed  under  the  infiuence  ofclbcr.  Xbtto- 
r,  bcmf  aei^ed  by  the  fin^cra  and  thumb  of  the  fi^  haadf 
Gndy  co^pruoied.  Tlie  left  hood,  being  pJaced  at  the  root 
the  tOBor,  BBade  a  t/aetion  aoasU)  wvrk  the  intf*tir»a  throogb 
of  the  nek,  in  the  ea«e  of  it*  being  a  hervia.  It  WM 
tktt  the  tumor  gradually  bccacne  «oAer  uaAa  tiM 
exerted,  aad  haif  of  H  diMppcaredt  loving  atill  m 
l^np  ia  the  groin.  Tbe  preawife  being  ponrinnwi,  the  n^ 
pniiiiMiMirtAiilj  niH  ■ImI  iiifiiik  ■fwfaiiMn  It  nught 
Jwfc  he«n  tfated,  ihnt  an  dBbrt  at  redntlMo  ^1  been  Made  bdbf* 
oT  the  ctW^.  but  vUbotf  pra&Miiv  dw  alight- 


IM 


AEDOMKN. 


e.«t  pjfect ;  an[1  n  fiurgicftl  ojioratitm  woiil*!  nniloithtedly  bave  been 
rrquired  Ijv  the  iiri;t'nL";y  of  tfie  symptiims,  had  it  not  been  for 
the  a8HiHlrLiicc^  Atr<]rdeil  }>/  the  ma  of  ether.  ThiH  is  tlic  earliest 
age  at  wbit^h  I  liave  ever  seen  fitniiigulutlon  occur  in  a  hernia. 


Radical  Cure  of  HERNrA. — Within  the  last  twenty  ye&rs, 
operfttion!*  fur  the  rad'tcal  cure  of  hej^ia  liave  nttracted  con- 
fliJerahle  iittentirm  ;  antl  fiir  Ji  ilisoase  sn  cctnmon,  so  incon- 
venient, and  in  some  c»se»  so  d^ngerouB,  it  \&  TemarkalAc  that 
no  wife  and  effectual  operation  haa  yet  been  discovered  for  iis 
relief.  Tn  IH.^2,  Dr.  George  Tlnywanl*  Dr.  S.  Pnrknmn,  and 
inysdr,  were  sippoinlcd  }i  Ciiminittee  of  the  AmcriL-Tn  JMedionl 
Asaoeifttion  lo  prepsire  \i  report  on  tliis  subject.  Tn  that  paper, 
I  fiieotioned  a  number  of  cases  of  smrall  liomiffl  which  hrjd  been 
treated  with  success  by  the  injectiun  of  stiinuliuin^r  hquids  in 
the  Mdghhi>rhr>™l  of  iho  nock  of  the  sin*,  in  the  manner  practised 
by  the  distinguished  Professor  Pancoast  of  Philadelphia.  In 
Bomt*  of  the^o  caspa,  as  I  have  since  been  able  to  coavinee  my- 
self, the  cure  was  permanent,  Sinee  ihen,  uiiiny  different 
methods  have  been  proposed,  abme  of  whieh  I  have  tried  with 
success.  The  one  must  in  fiivcir  at  the  pj-eeent  mcimcnt  is  that 
by  Mr,  John  AVood,  of  Ivin^VCollegc  llospitd,  London,  which 
has  been  fi^tiently  performed  in  thiij  city.  It  consists,  ess^n- 
tinlh'T  in  the  constriction  and  partial  ohiiieration  of  the  inguinal 
canal  by  means  of  a  subcutaneous  suture  or  ligature. 

The  method  pi^opofled  by  Dr.  Piincoast,  referred  to  above, 
luav  be  described  as  follows  :  — 

The  contents  of  tlie  liernisd  sae  bein^  retnrned  into  the  abdo- 
men* and  the  ring  explored  to  ascertain  that  no  portion  of  the 
intestine  protrudes,  the  pad  of  a  well-fitting  Irusa  is  slipped 
dmvn  so  as  lo  make  prcEJ^ure  on  the  inguinal  canal,  and  prevent 
any  escape  of  the  lierniii.  "VVitli  the  forefinger  of  the  left  hand, 
the  tpernmtic  cord,  as  it  pat^sce  out  from  the  external  inguinal 
opening,  i.s  (jreesed  upvTanls  on  [ho  pelvic  bona,  so  as  to  prevent 
it  from  being  injured.  A  delionte  trocar  and  canula,  the  latter 
Laving  fitte^l  to  it  n  email  Auers  syringe,  is  now  eai'efully  but 
firmly  forced  tiirough  the  inte^Timents  with  a  rotatory  motion  to 
facUitutQ  its  progress,  and  puslied  forwards  till  it  enters  the  ex- 


RADICAL    CURE    OF    HERKJA. 


165 


terniLl  in^innl  rin^,  or  neck  of  the  eac.  The  Irocnr  hemg  now 
witliJrawn,  the  canula  is  kept  £rtnly  in  place,  and  twenu-  or 
diitty  drops  of  the  tincture  of  iodine,  tincture  of  canciinndea, 
or  sulphuric  ether,  throim  in,  and  lodged  in  t!ie  neck  of  the  sac, 
when  tltts  is  prncticable,  or  eUc  in  tliG  vidnity  of  die  external 
abdominal  ring.  Subsc^quendy,  a  email  compress  is  itpplied 
over  the  minute  wound  made  by  the  trocar,  the  pad  of  the  truM 
slipped  down  over  it,  and  the  patient  directed,  for  a  week  or 
two,  to  muintuin  the  recumbent  puaition. 

In  addition  to  the  injection,  in  some  of  the  operations,  a 
tenotomy  knife  was  previously  introduced,  nnd  the  :nternd  sur- 
face of  the  nack  of  the  sac  BCnrificd.  The  wound  made  by  the 
knife  in  these  c^es  much  facilitated  the  enb^equcni  introduction 
of  the  trncar,  which  id  with  some  difficulty  worked  throuj^h  the 
integuments.  In  no  instance  did  any  bad  result  follow,  the  pain 
and  inconvenience  Lurdly  ami»uniing  to  that  presented  in  a  case 
of  hydrocele  treated  by  iujectif>n,  or  in  any  simple  operation. 

The  tullow'ing  case,  attended  with  success,  will  serve  aa  an 
illusLraiion  of  the  eourac  geneintlly  pursued  :  — 


Case  XCI. — Hitdictil  Cure  af  Conf^tnilnl  I/trfninaf  Her- 
nia^ —  A  mule  child  3  years  uf  ajje^  with  con^^enlliLl  inj^ainal 
hernia  of  the  rjj^hc  side,  was  brought  to  the  PIoi«pitnl  to  obtain 
relief,  if  it  was  possible,  i\s  no  triwa  had  been  found  to  retain 
ibe  protruded  inteelinc  in  the  abdomen*  and  the  ]iain  ami  incon- 
venience from  the  infirmity  were  great.  A  lumur»  the  eizo  of  il 
small  umnge,  was  found  to  occupy  the  Hcrotum.  By  a  little 
manipulation,  the  contents  were  aacertniueil  to  be  a  portion  of 
onientmn.  a  loop  of  intestine,  and  the  testicle,  —  llic  whole 
of  which,  by  care,  could  be  easily  returned  into  the  alxlutoen. 

The  question  wna,  whether  the  testicle  could  be  BOparatwl  from 
the  other  parts  (the  adhesions  bein^  fjuite  intimate  between 
them)  so  as  to  admit  the  return  of  the  irtestlne  and  omentum 
into  (he  abdomen,  leaving  the  testicle  in  tlie  scrotum.  Thia 
bein^  found  possible,  the  operation  was  performed  as  tollows  : 
The  intestine  and  omentum  being  retunied  into  the  abdomcn» 
and  the  testicle  preventeil  from  following,  the  spermatic  chord 
was  held  out  of  the  way  In  the  manner  stated  nbove,      A  sub- 


166 


A»POAIE^< 


cutaneous  int^ision  was  then  ninde  with  aciLt»rac:t  needle,  llic  poinl 
of  whii;li  wnfl  rairii-d  into  the  aac,  mvl  tlie  neck  flCiirifieJ  In  Jif- 
ferfTDt  dtrectioDs.  Thiougb  tbe  aperture  thus  made,  a  emnll 
trocar  mid  canuk  were  Introduced  :  tlie  former  being  rtithdrnmi 
the  syringe  xvos  ailapted.  and  thirty  drops  of  t^ulpliurio  ctber 
were  injected.      The  trusB  wa**  then  iipplied. 

The  opcr:tlion  w;ls  performed  Oct.  28,  1647-  There  was 
everj^  pros^ject  of  eucceea  untd  Dec*  9lh,  when,  during  a  viujeot 
paroxysin  of  eryin^,  the  hernia  was  fon^ed  down-  On  the  12th, 
the  hernia  was  returned^  and  the  injection  repeated.  It  result- 
ed, on  the  following  ilny,  in  a  swelling  of  the  acrotuui,  such  us 
is  observed  »fter  the  iiijfction  for  hjdi^ocele.  Dec,  22d,  the 
report  waa  nmde  that  tliE?  hernia  come  ellghtlj  down,  and  waa 
returned  with  difficulty,  "the  aperture  being  apparently  quite 
Mnrdl.**  By  tlie  end  of  the  month,  it  was  stated  that  the  herula 
was  perfectly  retulncd,  I  have  been  informed  eijice  thnl  the 
cure  xraa  permiiuenti 

During  the  treatment  of  tliis  cape,  a  sliglit  superficial  sup- 
puration took  phuM!  under  tlie  pad  uf  tlie  trups,  whicli.  tbc 
patient  being  i^omewhnt  fraetioiiB^  v/bb  nece^arily  applied  pretty 
firmJy,  to  preyent  the  recurrence  of  the  iiemia  after  tlie  opera- 
tion. 

Id  a  lurge  proportii^n  of  tlie  other  cnaes  operated  on.  the 
patient  experienced  much  relief,  though  still  obliged  to  weiu"  a 
tniflfl.  In  one  cjiec,  where  the  heriiia  wna  quite  bu'ge,  no  relief 
was  experienced,  A  female,  with  &  double  femoral  hcrniai  on 
whom  tbe  scarification  and  injeetion  wpre  onci;  or  twice  repea-tcd, 
expresacd  bciself  much  l«^neiiled  by  the  opcriition  ]  tlie  hernia 
being  retained,  and  the  suffering  previously  experienced  much 
relieved.  Another  patient*  i\  lalxjriug  man,  was  seen  by  me  six 
months  after  the  operjLlion  :  the  rupture  liiid  not  recurred,  but 
he  still  wore  a  tnise*  Previous  to  tins  time,  be  had  been  unable 
to  work  without  forcing  down  tbe  intestine  under  the  pad,  cas- 
ing him  much  pain  and  ill  health. 

From  a  compariilivcly  limited  experience,  I  derive  the  fol- 
lowing concWions  :  — 

First,  That  the  operation,  when  cmefully  performed,  is  safe. 

Second,  That,  in  ruptures  where  the  neck  of  tbc  sac  is  small, 


RADICAL    CUKE    OF    TIEEIMA. 


167 


an(J  the  abdominal  nfipriuve  not  loo  innoh  enlsirgcd  by  rejieat©! 
dei*ccnta  of  tLe  hemiu,  there  ia  a  proapeet  of  a  radical  cure. 

Third,  Thai,  in  moat  cases,  llie  operation  mitigates  the  infirm- 
ity, aiiowJn^'  the  hemin  to  be  more  readily  retiiined  by  the  or- 
diuftry  mecltanicol  means. 

Since  the  above  operations,  I  have  frequently  performed  that 
of  WiiUer,  which  coDsiats  of  the  iEvagiaation  of  the  skin  of 
the  ecvctum  into  the  mguinid  cthdjiJ,  and  retniuing  it  there  by  a 
proper  iufltrument  uutU  adhesions  have  been  foiTiied.  I  ha\e 
also  done  some  operations  by  invaginatiTig  the  akin,  retainiu^r  jt 
in  pJaL-e  by  means  of  a  atiteh,  and  applying  caustic  to  the  cul- 
de-saC|  for  tlie  purpose  of  producing  iuttamniation,  adhesion, 
and  a  solid  plug,  tiome  of  Uiese  cases  have  succeeded;  others 
have  failed,  tlie  hernia  forcing  itself  down  again  behind  the 
in  vacated  ekin- 

Cabe  XCII, —  Wiif^ers  Operation  for  Cure.  —  In  Juno, 
1?*I>0,  a  young  man,  28  years  of  ape,  entered  the  Hospital  for 
the  purpose  of  bavin<T  on  operaliou  performed  to  eU'eet  the 
radical  cure  of  an  inguinal  liemia  on  the  right  side^  which 
had  existed!  for  thtee  years,  and  was  as  lar^  as  a  hen's  egg. 
Ho  wna  jdnteJ  upon  the  Oficratini;  table ;  tlie  jjemia  was  re- 
duced, and,  after  introducing  a  portiOD  of  the  skin  of  the  scrotum 
to  form  a  plug,  Wiitzer'a  iastrument  was  applied,  the  needle 
passing  through  the  invaginaled  acrotum,  the  hernial  sac  above 
the  internal  ring,  and  the  abdoininiil  parietes,  and  secured  by  a 
clamp. 

On  the  second  day,  there  wa«  slight  inllamination  around  the 
needle ;  and  on  the  iifth  day,  when  the  needle  was  removed,  jms 
flppcaired  in  the  wound-  On  tike  eleventh  day,  lymph  was  dis- 
cernible along  the  course  of  the  spermatic  cord,  which  after  five 
dnyfi  furmed  a  firm  plug,  sufficient  lo  confine  the  intcetine  in  ihc 
abdominal  cavity,  excepting  upon  violent  exertion. 


Case  XCIIl.  —  WatzCT's  OpGrntion  for  Cure.  —  .Sum 
after  the  above  oporjUion  was  yicj-f  »rmcd,  a  boy  five  and  a  Jmlf 
years  old  was  brought  to  the  Hospital  on  account  of  a  congeni- 
tal inguinal  hernia  on   the   nght  eide,  which  formed  a  tuujor 


168 


AB  DOMES. 


<le8cending  nenrly  to  tlie  kne^s.  It  wns  easily  re(liip«l.  He 
waft  ctln?ri7-ed,  ami  Wlit^er'^  insirument  was  npplictl>  its  in  the 
previous  case.  The  needle  rjiused  sufficient  Trritntion  to  give 
rifie  tci  ulceratinn^  Uy  wh'ttih  a  passage  was  ma*Ie  alhnvm<^  it  to 
slip  down  about  ihree-qiiazters  of  an  inch.  On  the  Hevenlli  clay, 
an  effusion  of  lymph  had  oceurreJ  along  the  track  of  the  sper- 
matir  cord ;  but,  two  days  later,  the  hemtal  protrusion  vraa 
noti^^ed  behind  the  phig. 

Subsequently  he  wjls  again  etherized,  a  fold  of  the  Hcrotiim 
waa  mvaginated,  and  three  ligatures  were  passed  through  it  and 
the  ahdnminnl  parietee,  and  secured  by  jneiins  of  piect-s  of 
bougie.  There  waa  mnt*h  inflammation  and  swelling ;  mul,  on 
the  fifth  day,  the  ligatures  were  removed-  The  result  wua  in 
every  way  Batiefaciory, 


ARTIFICTAI.    ANUa. 

Artificial  anua  is  an  affection  generally  oansod  bv  the  flough- 
ing  of  the  intestine  in  ritmngulalt'd  hernia,  nlthough  occasionfllly 
the  result  of  abeoees  and  penetrating  wounds.  SometimeB  a 
amail  portion  only  of  the  calibre  of  rhe  intestine  is  de^Troyeil, 
the  bowel  becoming  attached  to  the  parielea  of  the  abdomen,  and 
a  flstuloua  opening  is  the  result,  usually  amenable  to  the  ordi- 
nary method  of  treatment.  At  other  times,  a  whole  loop  of  the 
bowel  alougiii*  off,  and  both  ends  of  the  mtefitjiie  unite  to  the 
fdidomimd  walls,  leaving  an  opening  from  which  the  feces  are 
constantly  dischnrgedf  only  to  be  remedied  by  surgical  meima.    - 

Cases  of  the  latter  character  are  of  umjsual  occurrence;  and 
the  means  for  tlieir  strictly  seientific  treatment  by  surgical  opera- 
tion have  not,  until  within  a  few  years,  been  fully  established. 
The  one  I  intend  to  relate  is,  as  fur  as  I  nni  awarc^  one  of  the 
first  BuccostiCullj  openiied  upon  after  the  motliod  of  DupiiytJ^eti 
in  this  part  of  the  country. 

A  patient  with  this  affliction  is  one  that  may  fullj'  claim  the 
Bympatbies  of  those  called  upon  to  acTminidier  to  and  alleviate 
human  suffering.  Sus|»ended,  as  it  were^  in  the  po^^efsion  of 
his  mental  faculties,  between  life  and  death,  he  is  destined,  ud- 
Icas  relieved,  to  drag  out  a  miserable  existence,  an  object  of 


ARTTFIOIAL   AMT3. 


lUJ 


iTTsgnKt  to  filiuficll'  aiid  ii  bunJen  to  Lia  t'rientls.  or  to  smk<  vs'i>m 
out  hy  paiu  :ii]"]  tlie  emrn."iatii?n  prmluced  hy  deiicient  uutiiti'in. 
It  IB  a  auurce  of  greoi  flflliafHCtion,  therefore,  to  the  BurgeoOf  if 
he  can  be  ilic  mea-as  of  relieving  so  dietreaaiog  n  miafortune. 


Casr  XCIV-  —  Artijii:ial  Anna  from  SlningulaUd  Iler^ 
wm,  Flffi'douf^  Opeiiiiii/!*  in  iht  Thlfjh  dlHchmgtitg  Fncul 
Matter,  Ojieralttrii,  Ctirf. — Tiic  patit^nt,  of  whose  cjirte  I 
propntie  to  givo  an  account,  wlu  ^cut  tu  mo  hy  Dr.  Dro\vu,  of 
Nova  Scotia,,  in  June,  1847.  She  whb  thirty-four  yeara  old,  tiie 
uiothtr  of  eix  duldrcn,  and,  ]irevioLk8  to  the  occurreoL-e  of  the 
present  ucoidcnti  oi'  g^ioU  conatitotiun.  A  email  crurjil  heniia 
had  exiHted  on  the  ri^ht  eidu  tor  iin  indcRnite  period  of  time. 

Dr.  Bi'LUvn  w!is  czdL'd  to  liei'  loLirlecn  montlw  hHorc,  and 
found  her  labuinn^  under  u  atni ululated  huroiji  of  Ibitj-ciglit 
huufft^  duriition.  An  o[)eration  was  iniutediji.tely  [jerfonucd ;  hut, 
on  openhi^  ihe  «iic,  the  inteatine  wna  c?cposed  in  a  gun^Tenoutt 
state.  Tlitr  f^Lrlctui'e  ;viL»  therefore  divided,  and  tlie  intestine  lefl 
in  the  wound.  At  the  end  of  a  week,  the  sphiicelalcd  [lurtiori 
aeparaiedt  itnd  tlie  feces  ilowed  freely  through  the  o}>ening- 
Aftcr  Bonie  tlnic.  ^lit  partially  regained  licr  licalth.  waa  able  to 
Bit  up,  and  fiiiiiliy  tu  work  moderately,  until  tlie  folhrniJig  Sep- 
tember, when  abitueaacs  begun  to  form  jji  diflei'eDt  pnrtd  of  the 
lliigh-  From  llua  period,  ehe  ^'raduaJIy  loat  her  flech.  and  de- 
clined in  Htrengtlii  Two  of  the  absci'saes  were  opened  Ijy  ilie 
hmcet ;  the  others,  on  the  under  eurfare  of  the  limb,  opened  and 
diseliarged  sjjonlaneously.  Pun  ut  first  iesncd,  fulhivnl  by 
fecal  matter;  and  jfreat  suffering  attended  the  dfusion  of  the 
latier  into  tbe  floft  parts*  Until  within  a  tew  weeke  prcviuua  to 
her  coniiDg  under  my  care,  there  wei'e  occasional  Iccnl  discharge* 
peranum;  hut  the  pealei  proirortjon  af  mutter  was  evacuated 
tlirough  the  various  lisud'^ua  openiiigaH 

She  arrived  in  town  in  tbe  early  part  of  JunCf  1847,  and 
entered  the  Jlu&pital, 

^he   wa4   cxtrcoidy   weak    and    emaciated;    the   countenance 

pale,  nearly  exsan^^uineoua,  hidicating  the  almoat  totjd  failure  of 

the   a*»iniilafing    piucuss.       From   long  cuniiiiciLient,    she    hud 

hccoicc  nervooa  and  timorous,  hardly  allowing  the  ahghleet  ex- 

2-J 


170 


ABJJOMKJfl. 


am  ma  tic  II ;  sinJt  un  i\i\i  day  Ijcfnit!  her  entrance,  elie  waa  «a 
completely  hoiueaii:k,  thul,  notniLliatandiiig  tlie  p;reat  IrouUi; 
and  expetiec  undergone  by  her  pliy^idaD  and  tricndd  to  cnEdjI< 
her  to  accomplJah  her  journey  to  Bostin,  she  insisted  on  retarn- 
mg  heme  at  oucn  by  tl:e  ?miie  ve:wel  m  which  *iie  cuiiie.  After 
VL  djt/  01'  two  of  couaidenitioLi,  huwever,  and  by  a  liltic  per- 
Huasion,  ahe  wa*  induceil  I"  diaiige  her  mind. 

Tlie  fioaitlon  of  the  patient  waa  ahiiost  entirely  on  her  back. 
The  ftves,  in  a  vtry  licjuiJ  ^tale,  wtrc  conttLantly  ruiiuing  out 
tlirough  two  cpeniugia  in  the-  ^^rum,  and  three  in  the  podlerior 
pnrt  of  the  ihi^^li.  Thu  ri^dit  limb  v^m  drawn  uji  almost  to  a 
right  anglL'  witli  tho  budy.  and  llie  whole  thigh  much  enlarged 
and  hardened.  The  ekin  around  the  a|>cn[ngB  in  the  grom  had 
a  redf  ixritated  ]oi>k,  wns  thickened  :dmo!it  to  calJo^itv.  and  ex- 
coriated. The  openings  were  i^mte  ^niall.  so  as  hardly  to  oduuL 
an  instrument  larger  than  a  eoiamoji  director. 

A  nuurithing  diet  wiw  alli>wed,  and  great  cleanlinesa  of  the 
wounds  eniuined*  with  ihe  more  espeeitd  object  of  preventing 
the  painful  excorintionj^. 

The  situation  of  the  intestine  could  net  at  first  be  determinedi 
whieh  added  to  the  frabaira&sment  of  the  caee.  In  those  of  a 
tainiilar  nature  AvhiiJi  1  had  i\n  opportunity  of  aeelng  abi'oad, 
under  the  care  of  Diipiiytren.  the  lutestiDe  opened  on  the  but 
face  of  the  abdomen,  by  a  hivge  aperture  ;  and  tliere  was  no  dlfli- 
ciiliy  in  exploring  at  once  the  end  of  the  Ijowcl,  with  tlic  finger 
or  by  instruments*  In  the  present  inj^tarice,  the  liatulouB  open- 
inga  rpin  in  every  directiim  :  those  in  the  groin  wei'e  immediately 
in  the  ncigliboi'lnmd  of  the  probable  critice  of  the  artificial  anna, 
ollowin^^  a  probe  to  peiicti-ate  for  ita  entire  length- 

I  therefore  determined  to  dilate  the  two  latter  ojH:nings,  wliich 
*vas  dbne  very  gtadually,  by  apongc-teiita,  on  nccuunt  of  the 
aetiaitiveneaa  of  the  |>jtticnt  to  any  manipulations ;  and  it  re- 
quiretl  the  peraeveting  application  of  this  method  for  a  month, 
bcfure  the  two  ends  uf  the  intestine  could  be  with  ccrlaiatv  di*- 
titiguirfhed-  This*  however,  was  tinsJIy  accomplished,  and  a 
gum-^laatic  bougie  pa^ed  iuto  the  upper,  and  another  into  the 
lower,  orifieca  uf  the  interline.  The  bougie  first  penetrated 
tlirough  a  thick,  callous  muss  of  tategumcrt,   then   through  the 


AliTIFICUl,   ^NOS, 


171 


niiiHCKlnr  nv 


• 


ti^nrlinoiiiiJ  fcivi?j'mg  nf  tho  abdoHicii,  in  nil  nbimt  an 
in<?h  in/leptJi,  when  the  septum,  or  spur,  us  It  hue  been  (bulled, 
whiuh  aeparateB  the  twn  ends^  waa  encountered,  and  with  diffi- 
culty euteretl,  hem<^  s*i  clospiv  applied  to  the  pariete?*  of  the  nb- 
donien  as  to  prevent  the  Ia*9t  pnasnge  of  mntier  from  the  iip[fer 
into  the  lower  part  of  the  hoxrel.  There  hnd  not  been,  in  faet, 
for  two  months,  the  Nlighreni  fconi  discharge  per  ftnum.  The 
intesLinal  ends  f<eeme<l  to  lie  parallel  to  efich  oth^r^  ho  that  the 
hougies  introdiieed  for  exploring  nuide  but  n  very  i^li^lit  angJe. 
The  patient  still  remained  nerroiia,  and  cjuite  feeble. 

I  direeted  Thtit  the  Hpufige-Ienra  should  be  rontinuwl  ;  slflo 
that  !i  pint  i>f  oatmeal  grup]  should  l>e  given,  per  aniim,  daily, 
Ibr  the  purpoi^e  both  of  atimiikting  the  intCHtiiial  coats  to  the 
performnree  of  their  nntnrni  fnnettonfl^  and  with  the  object  of 
enlarging  the  esilihre  o('  the  boweli  which  must  hnve  become 
miich  contractcvl  from   hm^  disitse. 

On  the  following  day,  I  fbumi  that  some  scyU'da  ha^l  oorae 
nway  with  the  eiienm;  and,  on  the  neirt  day,  the  injenied  duid 
niwde  its  appearnnee  at  the  apertures  in  the  groin- 

In  the  course  of  a  few  days,  tha  prircipal  opening  had  he- 
come  so  dilated,  that,  hy  a  siendy  and  pjitieady  applied  force, 
I  could  insinuate  the  liule  finger  fpiite  down  to  the  intestine. 
The  septum  eoiild  now  be  distinctly  felt  lying  against  the  wall 
of  thp  abdomen,  nurl  be  hooked  up  so  fis  to  permit  the  end  of 
the  finger  to  be  earried  into  the  lowtr  portion.  Its  sensation 
was  that  of  n  delicate  membrane,  like  ifie  ci:»ronary  valve*  of  the 
aorta,  though  somewhat  more  reaistijig-  A  director  was  now 
carried  down,  at  iho  side  of  the  finger,  for  the  purpose  of  koep- 
Ing  the  inte.atine  open,  a  giim-elnstic  enthrter  passed  In,  nnd  a 
quantity  of  warm  water  injected,  to  make  sure  that  Uic  lower 
orifice  had  been  found.  Thi*  water  afterwards  Appeared,  and 
was  diHcbarged  per  viim  niiturnlcs. 

The  pfilieut  being  well  prepared,  T  determined  to  apply  the 
eaiprofomc,  whieh  wa^  doap  Julv  1  ^ih.  FLiving  made  aiire  of  the 
lower  opening  by  a  iiirector.  as  on  the  day  previous,  the  male 
hranclj  of  Oupuytrcn'e  enieroiome  wjis  carried  inti>  the  lower 
inter^tiiie :  the  director  was  then  withdrawn,  atid  the  fetnalo 
hnincU  introrluced  with  ease  into  the  iipjier.     The  two  part*<  of 


172  ABDOHEX, 

the  inBtniment  now  occupied  nearij  the  whole  calibre  of  the  di- 
lated \Ass»^e  leadiD-r  M  the  '^t.  I  found  ai  <*nw  that  it  was 
impi^^ible  to  lock  them;  for  ihe  jitws  nf  the  female  portion 
would  not  allow  of  sufficient  muiion*  at  [he  hin^,  to  lock  with 
the  other  part  of  the  instrument.  If  the  inie?iiine  had  opened 
directlv  on  the  abilomiDol  surface-  there  wnuld  liave  been  bo 
diffieultr  ;  but  the  I'x.kin;:  of  the  forceps  under  the  eii^ting  <nr- 
cum^tuncei^  m-vlS  imfiracticablc. 

I  therefore  witlidrew  the  inr?trumeut.  and  had  recourse  to 
nuother,  wliich  ha.^  .-ince  |irove<l  much  betlcr  than  the  enterci- 
tomc  *}t  DupuytrcQ.  Thi!^  in^truniCDt  wn?  four  and  a  half 
inches  in  len^h.  It-*  handle  was  cun?lructed  with  a  gcrew- 
vii.-C»  and  th(:  joint  wilh  a  movable  pivol»  a5  in  that  of  Dupuv- 
Iren  :  the  hlade^i,  however,  were  dltlcrent.  In  the  jilace  of  one 
blade  b<:injr  recelvcil  inVt  a  jrroijve  in  ihe  other,  thcv  were  ser- 
rated, like  the  jwlvpufl  fijrct'j>s,  lor  ihc  s|>ace  of  three  inches, 
The  hiaileri,  Itcinjr  intnwluccd  in  tbe  manner  already  described, 
were  locked  witliout  diffifulty,  zind  at  once  brought  together  as 
ti^hlly  a.i  tliu  screw  wiruM  pormil. 

On  the  next  day,  I  fouml  her  free  from  pain.  She  had  cotn- 
plaincfl  a  littJc  for  a  few  houra  after  the  instrument  had  been 
put  in  ]ilace  ;  but  there  waa  a  question  wlicthcr  tlii^j  niii^ht  not 
liave  arisen  fnnn  itmr. 

The  te<^al  matter"  pUJ^J-c^l  by  llic  ^dt?  uf  tlic  instrument,  nnd 
w^arm  water  wii:^  daily  iuji-r-ted  lui't  tlie  wound,  to  prevent  any 
obstruction.  She  hud  al^i»  an  enema  dailv,  wliich  kept  the 
lower  bowel  in  ar|ii>n. 

On  July  loih,  ihree  day?*  after  it.-^  a))p!ication,  the  instrument 
ciunc  away.  In  the  jaws  of  the  ibrteps,  and  l)eurinir  the  im- 
prcart  of  the  Iccth,  was  a  blackish  slou;rli,  two  inches  and  a 
half  lon^;,  four  Unc?^  wide,  ami  about  three  thick.  Tlie  finger, 
lioHseil  into  the  ori^cc,  could  distinguish  an  ojK.'ning,  conespond- 
inj;  in  size  to  the  slough,  betwi^-n  tlic  two  enils  of  the  inte?itinc, 
the  cdge^  of  which  were  ;:rcaily  llijckcnc<l  and  fleshy,  imjiarting 
a  sensation  entirely  unlike  tliat  nf  a  \g\v  davs  previous. 

This  examination  was  couduc-tcd  with  the  greatest  delicacy, 
from  fear  of  destroying  the  adlic^ioiis,  ;\liieh  mu^'t  have  been, 
of  course,  at  tlus  early  period,   ol'  cIjc  ^lighte^t  kind. 


-VLTtJlCLU.  jtvr*.  '  17S 

In  (he  aiieni<v^ci-  ;iw  Lki  a  ?ciall  :V-il  *i:M.'!vir'^  ihn*u:;h  clu* 
wound-  She  o^mr-uu::**!  ci  ro  p-^L:;,  acJ  Uwrv  was  n^>  ceniier- 
ne*^  ol"  the  aNiomer,. 

On  the  tV»lI"»wiiLj  'h.v^  i^^  I">i>  ?m  tra?  »]tiiie  oonitortable* 
haJ  had  a  n^e  -ie'Tt^ri  n  r^r  azuiii  ^.-m  an  enema,  more  slimv  ui 
its  diaracitr  than  ^ifuai-  Th-frir  ha^l  ''*ea  n-t  Ji^char;^  6vm  th* 
wound  ffin'?e  the  dar  h-;T>re,  A  jentie  Ci'niprfc*i:>>n  wis  made 
bv  mean^  oi'  a  i^-mrr^^i  azd  V-i:>i3_:e  i.»n  the  ^■■pealair?  in  the 
gn.iin,  and  ihe  orlli'^c^  vrier^i  :■:■  be  loLi-jberl  dailv  with  the  ni- 
trate ut"  silver, 

?^he  iDiprivtil  b  healtii.  nroUj  aoiuirtil  her  itreiLzth,  u»l 
had  nij  larther  di-H-hirje  a:  xiji  artin:bl  anus  ir.'m  the  dav 
of  the  sej-arari'^a  ■:'  ii«?  iL*m;x»rnt  un:il  sht  Kii  the  U'>?pital. 
at  which  lime  th.r  ■jj'-enisj*  in  the  i^-Ati  liad  aliu'j^t  eomj»IeteIv 
cicatrized. 

On  -July  ii'th,  }^ln^  very  ea_-er  to  rettira  b'ime.  she  wa?  dis- 
charged at  her  own  rw>:"?t-  but  ni'ain^t  my  wi-he^.  aa  I  was 
anxi<iu^  to  uacch  the  ^■rj_Tt:-.*  ■;jt'Ebe  *"a.*e  to  it-  very  clore. 

From  a  d-^rire  t^^  bam  ::.-  linal  result  "f  tlnr  ca:?e-  1  attei^ 
ward:*  addjvsr^l  a  lett«rr  t»  I'r.  iSr-.wn,  '•{'  H-^rr'-'U,  N.^..  her 
physician,  and  reiveivt^i  a  r-j-lv  Tearinj  <iare  May  '»,  1^4'*.  In 
hi*  an=wer,  this  ^rentktii:!:!  i;it'.-nae<l  Tiie.  that.  iniuLeiliaiely  upon 
her  return,  ^he  wx-  jreatly  impr-*ve«J  b-»th  in  health  and  sj'irit*. 
the  li'Ccd  had  tb*-ir  tiutural  <:\\l,  and  every  thin_'  b>»ke<i  very 
pTomHiD;/.  In  a  ^b-^t  time,  b-iwever,  owtn;j  to  over-indulir^noe 
in  the  u^e  of  coar-i^.  rijfulorit  t'-A,  and  the  want  of  that  Ltneral 
eurvei]lant.-e  -■*  nei^e—an-  t^-r  tbi*  cla-'*  of  [taticnt?.  tWal  matters 
had  a^in  n^pfieare^l  ;it  the  oli|  --fritire.  a?  well  a>  ut  several  i>lai.vs 
on  the  hip.  p*>nie  ot  whi<b  «i;re  fre-rh  outlets-  This  wa^  the 
condition  of  thiniz-  in  liertniJ^r,  when  1)t.  lirown  war  s^um- 
moned  to  a  nn.-tEin:.'  uf  ibe  leiri^bnurc  at   ilalltax, 

"On  my  return  in  April,"  writ^-  tbi-  jrentleuian,  "aUmt  a 
week  ago,  I  w^a^  fpiit*-  luken  bv  surpri-e  to  find  our  patient  |ter- 
t'cctly  recDVLTt^l,  b'-tkini'  a^  plump  and  jiiy  a-  ever,  and  busily 
employed  almiii  b*;r  b-m-e,  It^riuL'in  bsu-te-ajid  she  Ivini;  busy- 
I  did  not  e\aiijinc  Iter :  buF  ^be  inforrLii.-i|  me.  that  all  the  ubvrs. 
aa  well  a?  the  oriixitiMl  i^utlet,  were  entirely  hialed.  ixivpt  "ue 
new  one,  and  tb^it  bail  not  dL-ehar^td  fe^.-al   matter  fi-r   «'n.r 


174 


.liiiJUMEN. 


timR,  iLTiil  wii^  in  fnrl  neJirly  healwl ;  thnt  tl»e  lilp  liRfl  ^reuhly 
Uecn^asttd  in  si/e,  and  had  3w*smueil  quite  a  nalural  ii|i|»enraiice ; 
thnt  lier  IiowcIh  were  entirply  regular,  anil  she  nuuld  take  \wy 
kind  of  fuiKl  withuiit  tlie  leaat  iiicciiYCJiiiinnp,  She  even  hh!i1 
ehe  had  not  enjoyed  m>  good  general  healib  fur  several  years 
previous  it}  her  mififL>rCune   as  now." 

Oil  reviewing  lite  ubuve  ijaae,  il  will  be  percE^iveil  that  it  pre- 
aeiitcd  di&'uJtLe^  uf  a  funuidable  dianioler.  In  the  first  place, 
llie  extreme  deliillty  and  eniueiatiim  of  the  patient,  and  her  great 
mental  depression,  were  ohataclea  almost  a^  r.niuhleflnme  to  con- 
tend with  as  lEie  disease  !ls.elf.  Twli^,  atler  mncli  lahor  hud 
liifen  expended*  and  auinc  progieee  made  In  (he  [ireliminary 
treatment,  Mie  insisted  on  reJInquishinir  it  »t  once,  and  retiiming 
home;  and,  on  the  day  when  the  instrument  was  tjj  be  jvpplTed, 
the  Jeiihired  that  she  was  cerEahi  she  niust  die  the  fitllowing 
night,  und  that  !t  waa  quite  uaiilesti  to  attempt  the  operation. 
Tlicse  depicesed  tiirnt  geuerally  passed  off  atler  a  tinic,  and  tlion 
the  ptttient  waf*  very  urgent  lu  have  ti^e  Ireaiinent  eiuitinued; 
but,  for  the  moment,  ihey  were  aaffieienlly  diat'ournging  to  the 
sorgeuji. 

The  aiimeroufl  fistuloufl  openingi*,  with  the  effiieion  of  fei^ 
lUfitlrr  into  the  ^'uin  niicl  Imrk  part  of  ihe  thigh,  iKTaaioned 
conaidenible  end)arn<^!*Tnent  in  parMuinjr  the  treatntent  for  dis- 
eovcrinjr  the  end  of  the  intestine-  Added  to  thi>;,  and  cantfetl 
by  it,  the  thighs  were  flexed  neitrly  to  u  right  angle  with  the 
body,  and  were  con^tAiitly  in  the  way  of  the  inatrumenta  usecl 
for  exploring  the  artificial  openingH. 

The, instrument  uahI,  1  cijnccive  to  possess  great  advantages 
OTcr  that  of  Diipuytreo.  In  fact,  it  consisted  of,  or  may 
be  almost  exactly  represented  by,  a  coramoo  pair  of  old- 
frisliioiied  prdypiis  fureeps,  with  tlie  branehes  detaclied,  and 
united  by  a  movuhle  pivol,  instead  of  a  fixed  Joint ;  the  hiiudlcH 
perforated  with  a  ecrcw-vice,  and  the  jawa  serrated  tluxjugliont. 
It  IS  lees  ehmiM'  thji.a  thai  *if  Dnpuvlri^n,  enuses  more  coajplete 
atrangidfltion,  and  dues  it?*  wtFfk  in  leas  than  balf  the  time.  By 
an  examination  uf  the  cn^cs  of  tliis  diaiinguiehed  French  surgeon, 
it  will  he  foiuul  that  the  cnterotoinc  geuendly  sopiiraled  about 
tlie  seventh  or  eigbdi  day  :   in  the  [aescnt  instance,  it  came  away 


AKTBTICIAL    ANrS. 


175 


on  the  tliinl.  yvt  no  efTuHiui  iir  ollitr  cvU  [^[jriseqiienrp  refJuU;?(l, 
iilUi'tEigli  ilio  it^tlcnl  war)  lis  luilc  ^jruviilcd  with  ihi^  iiiaU'mls  for 
furmiiig  pWlic  lymph  ae  can  well  Ire  iruagineO. 

Ill  t}ie  ri'l^tiuii  lit'  lliiis  ca^c^  we  liitve  \Mi\y  iti^Dlioned  tlte 
euurwi  iif  ireiiliuent  ordinnrily  piirsuetl  hy  Du|iuytren,  witlniut 
allmling  lo  the  raethoda  of  Physit^k,  Gross,  fliiJ  uthera,  in  ihiti 
country  or  in  KuropC)  wliu  liave  done  ho  much  to  jiJ\iatce  thia 
branch  of  surgery. 


Cask  XCV.  — Artificial  Anuft  in  om  lufani.  Fratl  Dh- 
chari/s  fiw/i  ihf-  Naifel.  Pruhjpi^t*.  itf  thf  ffitt-atine.  Ojjcjtt- 
tian.  Thath^  —  A  case  of  a  siinilur  kind  to  thiit  luirrated 
occurred  to  nie  in  an  infunt,  some  ye.ar«  aince  ;  nnJ,  hpi  it  illufi- 
trates  one  of  the  accidejils  liable  tu  t;ikc  pluce  at  any  iTi£»inf?nt 
in  pBtieiilH  luLorin^  mwler  Uii.s  nnfortnniitc  nffeerion,  namely,  n 
|injhijise  (if  the  end  of  the  Ixjweli  the  dclaiU  may  he  here  given, 

I  w]t4  rtqiiesU-d*  by  the  iiiedicid  iittcndant  oP  [he  fLimilyi  to 
see  mi  iiif^tiit  fighn  inontlu*  nld,  aod  reeeixvd  the  followinj^  his- 
tory from  hi[U.  lie  wiid  5r8t  called  to  it  when  three  weeks  old  ; 
the  pHreiits  sUited  to  him,  that,  for  a  few  days  after  its  Lirth»  Jt 
was  in  nioeh  difitres.St  and  had  no  ulvine  evacuiition  onlil  the 
cord  se|]arule<l,  wlien  an  eiodnfion  took  place  at  tlie  navel,  fol- 
lowed hy  [nucb  relief,  Shortly  after,  a  t*iunll  red  tumor  ap- 
peared at  this  ftpot,  froiik  the  central  [lortion  of  whieh  tlit:  fecal 
evacuations  occui^red:  tliere  waa  no  dLfichai'<2;e  j)er  anaiti.  Fie 
dircctLHl  ihcm  to  nmkc  use  of  a  coiupre&a  and  binda^  over  the 
tumor;  and,  under  thU  treatment,  tlie  ehUd  lie^^'an  io  have 
evacaalione  by  the  aoiia,  to  ^xiva  strength  and  ilcBh.  I  advibed 
that  thi^  treatment  ahould  be  |jer:4evered  in. 

Aliovit  two  tuootiid  after,  from  a  sodden  exertion,  two  tumors 
protruded  from  the  naveJ,  attended  witli  Home  eoni^Litotiooa] 
symjitom.s.  and  an  entire  atop^Nige  of  Uje  evncuatiua^.  I  t^aw 
the  pacietit  two  days  af^erwardd,  »nd  at  onee  recoguizeJ  n  pro- 
Up3iis  of  both  ends  of  the  intcaCiae.  The  tuaiora  lay  aerow  the 
abdomen,  one  to  the  right  aide,  the  other  to  the  left  \  one  |ior- 
IJoiii  whieh  proved  to  be  the  lower,  waa  dark-colored,  ami  more 
conlmclcd  ihau  the  other.  The  second  or  up[»er  pari  of  the 
bowel  was  lari'c,  covered  with  mocus,  and  tlic  vcrmiealar  motion 


176 


ABDOMEN. 


cnuld  bo  difltint^tly  Rccn  in  it.  An  ctfiirt  hnJ  alrca<Jy  been  raado 
to  rcilucc  tlicm  intt)  the  (Llfdomcii,  but  wltliuul  cUcct;  and  a 
prupottition  hoA  been  mode  by  ^Qine  phyeici&n,  who  had  ficen 
the  oiLse,  to  upply  a  li^^iture  to  tlie  roott  Thia  was  admed  in 
doubt  ns  Ut  the  CKa*it  niitiirc  ut'  tho  aficction ;  atid,  in  fart,  tiio 
parts  were  bo  changed  that  thoy  wero  with  difficulty  diatui- 
guiehed  ae  l3c]on*;iii^  to  the  mteatiaal  onnaL 

The  child  ho3D<r  cold,  ite  piilgo  siuliU,  and  hiivin^  every  ftp- 
pearapcc  of  rapidly  sinking.  I  dccliuod,  for  tho  inomcnti  any 
operation,  but  advised  stiukulantg,  and  n^^rced,  if  it  revived,  to 
attempt  nn  operation  on  the  t'ollowint^'  day,  lor  the  |>ui'pi)ae  of 
retuniiui-  the  bowel. 

On  the  next  morning,  the  child  having  revived  under  the 
Ireatmenl  Bu;^L;eatedj  the  following  operation  ivaa  pnictieed  :  A 
[ftxiiill  nock  or  tunnel  esiated  iit  the  nivvei  wbore  the  intestine 
protruded,  boin^,  in  fact,  the  comaion  evorted  orifioe  for  the  two 
opciiin^8  of  llio  bon'(?l.  An  incL^ion  was  miide  at  this  spiit, 
being  \vitij[ji  the  peritoneum^  though  protruded  from  tlie  abdom- 
inal cavity*  The  two  ends  of  the  intoMine,  as  iheyissued,  were 
now  seized  with  a  blunt  hook,  and  »hp;ht  traction  made  on  them. 
The  inverted  portion  slowly  began  to  recede  ;  and,  by  ctintiiiuiog 
tliia  manr^uvre,  at  the  same  time  L^ing  some  external  pre^gurc 
on  the  tumor,  it  gradually  returned  into  tho  interior  of  the  ab- 
domen. Tfie  neck  of  the  Inmur,  wlierc  the  inciaion  was  made, 
and  which  reprc^Gutcd  the  tunneK^liaped  portion,  was  retaiiiei.1 
outside,  so  as  to  prevent  tho  cffuBion  of  fecal  matters  through 
it  into  tlie  peritoneum.  Immediately  on  the  relnrn  ot  tho  bowel, 
free  evaeuations  took  place  from  the  anus,  nith  ij;roat  apparent 
relief-  The  patient,  however,  lUd  not  rallvi  but  airnk,  and  *3icd 
on  the  next  day. 

An  examination  after  death  [iroj^ented  no  peritt>neal  intiam- 
luatioti,  or  ertn^ion  ;  and  no  at1em|rt  seemed  to  have  been  made 
by  nature  to  close  the  incision  of  the  operation,  ehowin**  the 
low  s^ate  of  tho  vital  jKiwera  at  the  time  it  was  done.  The 
upjjcr  portion  of  liie  bo^vel  which  had  been  returned,  loolced 
comparatively  healthy  :  the  lower  was  quite  dai-k-colored,  and 
ehowetl  the  clfectis  of  the  ))rirfial  strangulation  ;  an  invagination 
of  ita  ciMits  for  about  un  inch  aUo  wa^  dt^erned- 


ARTLFICLAL    ANUS. 


177 


Case  XCVI-  — Art\fictrtl  Afui^/mm  Injnrif.     Opernfinu 


fmni 


Oure. — May,  1859.  A  man,  ageU  ^ll,  wii?*  irirowii  tmm  a 
fileigh  about  two  ycHrs  since,  and  nli^htral  un  tht;  sharp  pulni 
of  the  rjiil  of  a  Fence,  whit-h  ptnoiniletl  the  l(?ft  Hide  of  llif 
Abdomen,  in  llic  iliac  ami  inguinal  r^^giuns,  jtrodjicing  a  wonni] 
four  or  five  inehi?*  m  length,  allowing  the  inteatinea  to  eacupe- 
A  physician  being  called,  the  contents  of  ihe  abjonien  were 
replaced,  and  the  wound  cloBtd  by  sutures.  Pretty  severe  nb- 
doruina]  syinploms  supervened  ;  and,  at  the  end  of  a  wei?k,  feral 
matter  be^n  to  issue  frora  that  portion  of  the  wound  aenr  the 
anterior  wiporior  spinGus  process  of  tbe  ilium-  He  wna  confined 
twelt'e  weeks  to  his  bed,  after  which  he  wiis  able  to  get  up  and 
move  about,  ihougli  much  reduced  in  atrengtli.  The  fecrd  mat- 
ter coniinued  to  discharge  from  the  wound  from  that  time  until 
the  present  operation. 

The  patient  was  a  large,  powerful  raauj  over  h\x  feet  in  height ; 
and  although  he  was  able  to  do  some  work,  yet  hi^  usefulness  Uatl 
been  in  a  great  meiwiire  impaired  by  the  accident,  and  the  in- 
firmity consequent  upon  it.  He  entered  the  Flospital  on  May  6, 
1859,  tc  see  if  any  thing  could  be  done  for  hia  relief.  I  wae 
encourageil  by  the  eucceas  of  a  prevtous  case  to  operate,  ibe 
condition   of  things   being  aa  follows:  — 

On  tlie  left  side  of  the  pelvis,  about  an  inch  below  its  brim, 
and  in  the  neightMirhood  of  the  anterior  superior  spinous  process 
of  the  ilium,  was  a  puckered  npei-ture*  about  large  enough  to  per- 
mit the  entriinee  of  the  little  finger,  surrounded  bv  a  red,  indu- 
rated margin.  Extending  from  this,  a  little  upwards  and  also 
dowQwar^ls,  to  die  pubes,  wa^  a  long  sear,  which  I'cmained  from 
bija  previous  wound.  A  probe,  l>eing  passed  into  tlic  wound  up- 
wards, penetrated  three  or  four  inches  freely,  as  if  superficially, 
and  under  the  integumenrs  :  it  could  ije  pnseed  downwards  in  the 
same  manner  without  obstruction.  The  impression  given  by  tliis 
examination  would  lead  one  to  euppose,  that  the  fecal  nmttera 
must  have  an  exit  under  the  integuments,  and  afterwards  pnae 
out  by  a  fistulous  passage-  This  supposition,  however,  proved 
eubeequently  to  be  incorrect.  The  fecal  discharges  took  plaeo 
from  tbe  artificial  opening  at  irregulnr  inten^als,  two  or  throe 
times  in  the  day,  were  beyond  the  control  of  the  pntient,  and 

as 


178 


ABDOMEN. 


were  partly  solid,  partlj  Jiquid;  Uieir  coEsietence  depending 
jircttj  much  on  the  clmriictcr  oi  the  fooil  mnilc  uee  (^f.  In 
iiilditioQ,  he  hud  a.  timaJl  operation.  ;>Dce  or  twice  a  d^y.  From 
the  natural  passage;  tins  being  Yoluntnry,  indicated  that  tho 
barrier  between  the  two  portiims  of  the  mleatine  was  not  com- 
plete,    lie  did  not  Buffer  particularly  from  cclic  or  iiidigcation. 

The  patient  being  etherized,  the  little  finger  was  passed  freely 
in  an  upward  direction,  into  the  nrtiSctn]  nnus,  and  ;in  ineifilon 
made  upwards  of  about  an  inch  in  lengtli,  lowjirdd  the  ^Igc 
of  the  pelvia,  which  at  once  expotied  the  LUte»liLie»  showing 
that  the  two  cads  tiame  quite  up  to  the  external  orifice.  The 
septum  between  the  two  could  now  not  only  be  readily  seen, 
and  taken  between  tlie  fin;iers,  but  could  even  be  drawn  out 
externally.  The  finger  was  piiflaed  up  into  the  upper  portion  of 
the  intestine*  and  downwania  inti;  the  lotver,  which  seemed. 
00  far  ^B  could  ihua  he  aiscertalneil,  to  be  the  bigmoi<l  flescure 
of  the  colon.  The  very  euperficial  upj^earance  preeenled  by  the 
probe,  when  puascd  in,  was  found  to  be  due  to  tlie  thinness  of 
the  integuiuenta,  occaeioned  by  die  injury.  The  i^eptuui  being 
carefully  exiinilned,  the  (?ritei\jtome  of  DupuyEren  was  applied, 
and  screwed  up  to  make  a  moderate  amount  of  preaaure.  In 
order  to  inaiiiLaln  the  iiiarrumi'nt  perfectly  firm,  H^  it  wai^  ou 
the  bide,  a.nd  not  on  the  front,  cf  the  liody,  it  waa  neccHHary  to 
jind  it  with  cot  ton -hatting,  and  secure  it  by  a  bandage  around 
the  hip8. 

Ou  recovering  from  the  ether,  he  made  no  complaint  of  pain. 
Pie  WHS  put  on  a  diet  nf  wjiter-rrruel,  pjtssed  a  good  night,  and  on 
the  fidlowing  day.  May  llrh,  was  quite  free  frmn  piiin.  Tic  was 
art  well  on  the  next  day.  On  tlie  13t.h,  I  finmd  that,  during  the 
night,  he  ha<l  complained  of  Bciine  pnin  in  the  right  side  of  the 
abdomen,  rc([uiring  rhe  application  i>f  hot  fomentntionft  and  nn 
0|>:ate.  At  the  time  of  my  vtr-il,  he  was  rclieA^ed.  He  paeseJ 
wind»  boih  through  the  natuml  and  nrtificial  anus,  I  stopped 
the  drinking  of  ciiM  water,  in  which  he  had  been  indulging  freely 
without  my  consent. 

On  the  15th,  he  wna  doing  well :  two  small  pelleta  of  fecal 
matter  paase^l  from  the  artificial  opcnmg  im  the  night  pi'evioua ; 
wind  was  pa^od  through  huih  the  natural  and  arlificiiil  passages  ; 
the  pulae  eighty-one. 


ILIAC    TCTMOR. 


179 


Oa  the  17tli,  I  found  the  instrument  hnd  come  awny  doriop; 
the  night  wirboul  the  knowledge  of  the  putieDt,  ucid  tliJiooveTetl  a 
Bnudl,  ihin,  dried  jnece  of  inteatine  in  lis  jaws,  nn  inch  and  three- 
quarfei^  in  length,  looking  like  a  bit  of  (mrchiuent-  He  waa 
entirely  free  from  pain,  and  without  nnv  distention  of  th(?  abdo* 
men.  The  wotind  woe  dressed  with  a  pledget  of  lint,  and  a  hit 
of  adhesive  pliuter  was  placed  o?er  it  to  produce  a  aliglit  oom- 
presaton. 

From  thifi  time,  the  feGol  matters  reauxned  their  aatund 
course.  It  was  found,  however,  after  a  time,  that  an  obstruotioa 
OccurTcd  In  their  passage,  iilwul  a  oi>uple  of  inches  below  the 
aperture  ;  oiid,  ou  investigation,  it  waa  discovered  that  the  intes- 
tine, at  thia  epoi,  turned  short  on  itself.  A  second  operation 
was  therefore  done,  of  hooking  up  this  second  apui',  pulling  it 
up  to  the  external  afierture,  and  iipplying  the  enierotome.  The 
reauh  was  the  same  a^  before;  the  instrument  coming  away  on 
the  third  or  fourth  day,  without  having  produced  any  constitu- 
tional sj-mptouis. 

The  oontcnti*  of  the  inteetines,  after  this,  took  a  natural  eourse. 

Tlie  following  year.,  I  did  a  plastic  operation,  for  sliding  a  bit 
of  skin  over  a  fiatuloua  opening  which  still  remaine<l,  and 
through  which,  occaslonallyi  there  waa  a  serous  dietiliarge. 
Since  tliea,  I  have  not  heard  from  him. 


ILIAC    TCMOIt, 

In  this  connoction  may  be  mentioned  some  tumors  in  the 
right  iliac  region,  which  occ^ieionally  lead  to  abscess,  and  fistu 
lous  openings  on  the  parietefl  of  the  abdomen.  In  one  inalanee, 
a  man  who  had  been  a  tailor  changed  his  vocation  at  a  Inte 
period  of  life,  and  turned  farmer.  Tiio  etoopin;;  position  in 
working  waa,  after  a  timCt  tbilowcd  by  a  pain  and  aweiliog  in 
the  right  iliac  region.  Very  sovcre  eympioms  followed;  and, 
finally,  abdue?scs  brnke  tu  different  directtone  over  the  abdo- 
men, througli  which  fecal  matter  wa^  discharged.  In  this 
condition,  a  year  or  two  ailerwardi*,  he  CQtcrc<l  the  Hospital, 
completely  diciiLblcd,  and  unable  to  use  hia  right  leg,  piirtly 
from  stitfnet^fl  of  the  lup-joint,  owing  to  the  inflammatory  action 
in  tlie  neighborhoudp 


IBO 


ABDOMEN. 


After  n  ^eT]p»<  of  operations,  die  various  fistiiliP  wore  explored, 
(li]a(«l,  iind  henJeJ^  with  tlie  exception  of  oeo  lending  to  the 
iniestinp,  which,  «o  far  as  could  be  diaocverod  from  its  very  deep 
aitiialion,  or  a.cj*ouiit  of  the  Ivmph  deposited  over  it.  wna  the 
ccecum, —  being  nearly  three  inches  from  tbe  surface  of  the  ab- 
dcimen.  The  fecial  ujjilter  was  nowdischnrged  tlirough  a  single 
opening.  Fy  this  meiins,  the  irritation  in  the  integuments  wa6 
relievml,  nnd  he  partially  rc?corered  the  use  of  his  right  ]cg. 
He  went  into  the  country  to  recover  strength  for  the  final  opera- 
tion, anJ  died  there  suddenly  a  nionlh  or  two  afterwards,  so 
far  ns  1  eoiild  nscertajn,  from  some  other  aHTectJon. 

Shortly  aftem-ards,  another  jmtient  applied  to  me  in  a  similar 
oonditjon,  the  abseesfi  liavini^  been  brou^rht  on  bj  a  aimilftF 
change  of  life  and  exercise.  Probably  it  waa  id  some  wny  con- 
nected Mith  the  iJiao  muecleis.  He  was  too  emaciated  and  feeble 
to  undergo  any  operation,  and,  in  fact,  decliaed  any. 

1  removed  for  lum,  however,  a  cancer  situated  on  the  end 
of  hts  loa^JT^ie,  by  ligature,  which  had  cftU9e<i  him  much  trouble, 
and  prevented  him  froni  taking  his  food  tn  comfort. 

Not  long  eince,  I  had  under  my  care  a  lady — paet  the  crit- 
ical season  of  life  —  who  was  seiKcd,  Jan-  1st,  with  a  ehnrp 
pain,  with  tendcraeaa  in  the  right  iliac  region,  pre*'eded  by 
some  daye'  uneasiness  in  thnt  quarter.  She  waa  treatet^i  by  rest, 
mild  pui'gatLvej:^  and  fomentiitinud.  She  recovered  in  about  a 
fortnight,  F(?l>.  l=tj  four  weeks  fj"otn  the  first  attack,  she  was 
again  Ptiaed,  more  violently  than  before,  lifter  having  taken  a 
long  walk,  and  been  much  exposed  to  a  cold  drought. 

An  clnetic  tiLmor  appeared  gradually,  in  the  course  of  two  or 
three  weeks,  fiJling  the  iliac  region,  and  extending  up  to  the 
ribs,  and,  laterally,  to  the  medifLU  line.  It  was  exfjuisicely  pain- 
ful, 60  that  it  was  examined  with  difficulty ;  Btill,  I  deteclei]  a 
dccp-seatcd  Huctimtion  midcr  the  ctncimi,  and  my  dirtgnoJ^is  was 
an  iliac  abscess,  reeembhng  somewhat  those  deneribed  hy  oh^ietrie 
writers  as  occurring  in  puerperni  women.  The  ubecees,  how- 
ever, which  in  lhi?sc  cases  can  <ronerally  bo  felt  through  the 
oiLlural  p:i!^KageB,  and  often  breaks  into  one  of  them,  could  not 
be  found  in  this  ease.  At  (he  end  of  about  three  weeks,  after 
ver3'  eerioua  symptoms,  1  detected  a  small,  hard  lump,  deep  in 


tae  ^rnn.  usiaci  rinniXTS  i^^wnMir,  nut  ni.  tm  nmf^ui!  re  at* 

I'T^c  iLwo.  in*ia  tthi-  .r^^m:  ^jti      PTiil-  in.   rETi!!im:r  x.  4  ^onLL 

car**  iiv~*-  rji;  ^'^miiriiu?  t'-s*  ic  ;iii^  yttl±f*^L^  Z*ie  *ja^ 
n^^^tnuti  T-te^    ir   !:i»iir-^  siiw       Sits  iinimicii7  srarsiSr  ;r!- 

Ii  isi.intir  at**?-  i  ji«£"'-  ^iuur  tL."n.  j.  »c™!t  uH  r:''fr^  vj^ 

Si:ct*ciiitr  iUii  r-""*?!  ir»xT  ji  xd  ^ndj^^  mint  -i«*rT?T  f*-~T  r^ 
ti^n^  1  £11  liX  **t-;  its  mnl  i'.aut  ▼'f^ki  tisr  ^  a.-^'o^a^ 
?ro=  iflvi  -ea  Tiiuiiui  7.  ▼'lTc-  zl  -dn  ntttLT  umi-  '"r:^;fa:  fr«a 
[«£=.  i  :i»  i-'jii.raisL  tn:  iaii  ilu'.:;  Zi*c:=r:iiafri;  ::i  ;m  irrwdaa.! 

w»f  fch-j*  ::   -_*ar  ^  E*.idi;c  :^'  t  a^rii^-  -wiir-c:  aa?£ix  4 

"i  j^--^I  ^;^iii:^  ireor  lue  >i-:r32-'  W  tit  »:■:' lilida^ ."^ ,  *OQi^ 

1  hjve  Trif{>^zlj  ^^ir^.  l<e:' -T^  ^zri  ^s-^  lii*  paf<er  w*j  |>^^ii:^b«d. 
A  paii^nd,  «Ij^:  r^:::^^*.  '-^  ^^r^axer  or  !&»  fiz«.  b  leit  la  the 
re^I'jD  of  tot  f^tcr^Hk.  anes'i^l  •-ith  iVver,  iMaf«=i.  i>-»D?tipa;ion» 
and  a  ^rtai  ft^Iisj  ^,f  .i.it«;:; >a-  ReLet  U  c^ned  irom  ^iihar- 
lics,  which.  h'^ir^Ttr.  I  have  ^enerallj  been  ?paTiD^  ot*  having 
tnifted  CO  r^l,  f'^m^Eitaii'^nf,  and  ^>mp[im«s  leeeho:^.  In  <>ni- 
ca*e.  Id  whi?h  powenul  pur^ativea  had  been  tried  for  >  W(vk* 
wiihoui  effect-  the  sufferins*  became  dreadti]].  and  intT\\*u*oe[*- 
tion  na.?  foar««l.  I  advised  that  the  patient  should  bo  pta^'^l 
under  thcr  iuduence  of  opium,  and  mean«  uf«d  to  nnln^^  Uh^I 
inflnmmaEiijD-  Thb  being  effected,  evacuations  to^»k  jdiX^v  *]h»*n- 
tanei»U!-lv.  and  the  patient  recovered.  In  one  instance,  I  hn^e 
eeen  the  i]iH?a?e  recur  twice,  with  an  interval  of  one  or  two  ycjir** 
The  duration  of  treatment  bjis  usuallv  been  About  two  wovk*. 


182  AMDGMEN, 

Thii  tumor  ii  important,  as  it  ie  often  not  detected  by  s 
pbyiidan  unBOcnutomed  to  it ;  and  I  hare  leen  a  number  of 
CAMS  wbich  hftTO  gone  on  %  week  or  more  before  tbe  cauae  of  the 
fljinptonu  woa  found  out.  With  Dr.  Jackson,  I  bare  never  eeen 
it  anppnrate,  thougb  it  ia  difficult  to  say  exactly  how  it  differs 
&om  thoae  that  do.  The  principal  distinction  seema  to  be  that 
it  ia  more  eluggiab,  and  its  oonfinea  more  definite,  than  in  thoae 
tomora  of  the  iliao  region  which  terminate  in  suppuration. 


CHAPTER    VI, 


ANUS. 


IJEHOICICHOIDB. 


Thb  nimmon  oppmlicm  for  hemorrhciHMl  tiimorn,  for  the  Inst 
thirty  yrairn,  han  been  by  lignture,  BefLire  thnr  time,  I  Imve 
seen  exr.iKion  practiBeil,  but,  1  may  any,  fi1mr>st  alwny^  followed 
by  troublesome,  if  nut  dnngenms,  lieniorHingc.  The  li^tiire  is 
wife  ami  dfe^^lufLL  I  have  generally  [lertbrmeil  tlie  openidon  aa 
follnws  :  — 

The  bowela  are  cleared  tJie  day  before-  On  the  same  day, 
prior  li»  tlic  operalloti^  no  Htilid  fowl  aliould  be  taken.  The  pa- 
tient bting  etlieriKed,  the  tumorti  nix*  e>Ltmded  liy  the  finger,  uml, 
one  after  the  other,  eehetl  with  liooketl  forceps,  ilie  bajie  tmns- 
by  A  double  ligarjire.  und  tied  on  encb  side  with  greut 
3e,  anil  the  ends  crut  riff.  The  riVm  of  the  edgea  of  the  arua 
should  not  be  impinged  npun  ^  nncl,  if  tbia  cjinnot  be  iivolded.  a 
griMive  shonld  be  in^jde  for  the  ligntui-e  widi  u  kidfe.  The 
tum^rA  lire  then  returned  M'itbbi  the  anim.  The  pAtient  m  kept 
veiy  rpiiet  in  beil,  avriidin^^  opiates,  if  possible,  and  can  almost 
(dways  go  for  eight  days  wilhont  an  action  of  die  bowfls,  unless 
the  tftomneh  is  disturbed  by  impniper  food.  A  mild  ctitfiiirtio 
may  be  then  administered,  though  fiometimes  tlie  bowels  are 
freed  qtonraneoubly. 

The  swelling  which  takes  plare  sonietimps  eauaes  a  retention 
of  flatus,  wbidi  gives  a  senjmtbni  of  great  preaaiire.  This  is 
relieved  by  the  eantiuns  introduction  of  a  large  gum-elaetLC 
eatheler  into  the  rer^tnm-  Retention  of  urine,  requiring  the  use 
of  the  catheter  for  about  ihree  days,  —  and  1  liave  once  fleen  it 
laj4t  eight,  —  ifi  not  an  unfrct|uent  tweurreuce.  I  have  onee  or 
twice  tried,  soeee^sfidly.  the  use  of  the  fjeniBeur;  but,  in  very  ei- 
trenie  case*,  slinuld  think,  unless  it  was  very  earefully  managed, 
tliat  its  lue  miglit  be  followed  by  hemorrhage. 


184 


ANCS. 


Cask  XCVII-  —  UtimoTrhQidv.  Operallon.  Cure.  — 
W.  A.,  42  years  of  iige,  u  iargo»  musuuljir  itian*  hud  been 
troublL'd  Tor  Hcventeen  years  wllli  exFcniiiJ  and  luternal  lieiuor- 
rliulda.  lie  was  habiluallT  constipated,  ;uid  fre^iuenily,  during 
iLe  previous  eevcn  yeiira,  ball  lust  bluod  when  the  bowels  were 
evac:iiHted,  ao  i\n\i  hid  puhe  w;ia  wcztk,  and  lie  cxliibiced  an 
aiiniTiic  coEidkiuD,  and  v/txs  unable  to  wark>  Sometimes  tbe  reo 
luin  witB  prolftpaed  tg  tliB  extent  of  two  at  tbree  indies. 

(Jii  tlic  30lb  May,  1803,  1  o^itrulL-d.  He  vraa  ctberized  ;  and 
^VQ  birge,  liemorrboidal  turaore  were  dniwn  dovrn,  transfixed  by 
doulile  ligatuffs,  and  tied  at  tlic  base-  Care  wiia  taken  not  to 
include  liny  of  tbe  skin.  Two  Inrge  cjtternal  Lemonhoida  were 
also  cut  off.  On  tbe  aeventb  day,  tbe  ligatures  uuueaway; 
and  at  tbe  end  of  a  furtnight  tbe  bowela  were  opened  by 
caatur  oil  and  enema.  On  tbe  2'2d  of  June,  an  cxnaiinatioD 
showed  that  tbe  internal  tumora  were  entirely  removed:  tbere 
was  no  pain,  and  no  blood  waa  passed  at  etooL  Tbree  more 
external  piles  were  cAcIseU,  wbich  completed  llie  cure.  Tina  is 
au  extreme  case ;  and  I  have  faclddui  found  it  Deceasnty  to  in- 
terfere with  tbe  external  tumors,  the  remoTai  of  tbe  internal 
onea  generally  euffioing  for  a  cure. 


Case    XCVm.  —  ll^worrhoUh.      Opcrafion,      Curt^  — 

A  man  rij;ed  47  entered  the  Hospital,  June  II),  18(13,  suffering 
with  beaiorrhiMdal  tuiuurt^,  nad  much  bluai^bed  from  luss  of 
blood.  He  bad  bad  ao  attaek  of  bleeding  from  tbe  rectum 
tfiirtecn  years  before,  and  another  attack  seven  years  al\cr. 
Tbe  Inat  five  years,  Le  Imd  bad  frequent  ntticks,  lasting  iwu 
or  three  days,  the  tumors  and  inueoua  membrane  in  tbe  vicinity 
remnimng  in  a  prolapsed  condition  during  the  paroxyamfli 

Oil  the  2nth,  an  ereaia  having  been  pi'eviously  aJniinislered, 
tbree  cr  i'uui  large  [umors  were  dragged  dowa  ^\ith  hooks,  and 
included  in  ligiitures ;  care  being  taken  to  avoid  every  thing  but 
miicuas  meinbrane. 

Aficr  the  opcratioji,  he  required  an  opiate.  There  waa  for 
n  few  daye  conniderabic  Jiffieulty  in  micturition.  The  bowela 
were  kept  rjuiet  Jbr  seven  or  eight  days,  and  were  tlieu  emp- 
tied by  niciins  of  a  mild  purgative. 

He  waa  shortly  diachiirycd,  entirely  cured. 


HKUORfillOIDft. 


185 


Case  XCTX-  —  Hemorrhoids^  Opemiiou,  Cure*  —  A 
woihaDt  27  venra  of  a^,  enler^  the  Hu^pttal  in  Morcrh,  180U, 
in  an  anii?iDic  BEate,  and  f^iDtin»,  even  in  the  «iipiDe  posi- 
tion, from  confiUiDt  and  profuse  Iom  of  blood  from  IjemorrhoicU 
of  t^velve  years'  ftanding,  brought  on  by  constipation  of  the 
bowelA.  She  aaid  that  eometimee  she  had  lo^t  a^  much  ti5  half 
a  pint  or  a  pint  of  blood  a  dav,  for  three  months  at  a  dme ; 
bill  ihU,  doitbtle^a,  was  na  €xa^;^ration. 

Fctirin^  to  u|>crale  on  her  in  her  r^xlijeed  <v>ndiUotti  she  wns 
kept  fk>r  about  a  week  in  a  horizonlAl  pu^iCion  in  bed,  a  tannin 
injeetion  r;dniinia1ered  daily,  and  noumhin;:;  food  <;iven  in  aeon- 
e^ntnted  form,  ao  a^  not  to  excite  action  of  the  botveU.  Br  tliis 
menns,  the  bemorrhn^^  was  aloioet  completely  checked,  and  ehe 
rftpidly  ^aincd  etrcogih  enough  to  qUov  an  operation.  At  the 
erul  of  about  ten  days,  four  or  five  tumors  were  drawn  down 
and  tied  in  the  wav  mentioned  abo^^. 

Very  liitle  febrile  aetiijn  followed  the  opemtion,  and  the  pain 
was  relieved  by  the  local  application  of  ice.  By  tbia  incau^, 
opijitea  were  avoided  and  her  nppetitc  prcsert-cd,  bo  ttutt^  ai  llic 
end  of  three  daje,  she  was  allowed  to  lake  animal  food. 

On  the  ninth  day,  having  ?omc  nausea,  a  doee  of  oil  vrod 
administered,  bringing  awny  a  large  evacuation,  without  bloi>d. 

For  the  first  few  daya,  there  waa  some  retention  of  urine,  re- 
quiring rhc  udc  of  the  catheter^  She  gradually  recovered,  the 
bowcle  bt:ing  only  allowed  to  act  erery  third  day-  I  aiiw  her 
two  months  atcerwanl^  in  good  health  and  tletih,  and  with  a  fine 
color.  She  complained  of  some  local  irritation  on  making  any 
extraordinary  exertion,  or  atanding  for  any  length  of  time; 
which  ahe  waa  then,  for  the  accond  tinie,  cautioned  against. 

External  bemorrboid?,  aa  alreadj  stated,  do  not  olten  require 
interference,  generally  diaappearlng  with  the  removal  of  the 
internal  alfectioD.  Where  a  trotibleaomc  exuberance  of  integ- 
uments is  left,  it  may  be  eafcly  eicised.  When  esiernal 
hemorrhoids  become  inHuncd  and  painful,  tbey  arc  generally 
dependent  on  a  derangement  of  the  digestive  organa.  If  this 
is  rectlficil,  the  paroxysm  pnasea  by.  ^Vhen  one  of  tlie  tutnora 
becomes  atrangulateil,  so   a.a  nut  to   retain  it^   position  witliin 


186 


ATCtjS. 


tin?  nniifl,  relief  h   almost   at  once  obtained   from  %  puTicture, 
wliicfi  irives  issue  to  a  clot  of  blood. 


risscRE  or  the  anus. 

It  wouW  be  difficTili  to  find  any  disense  nttended  with  such 
unmitigatel  Buffbrinj  as  this  appiirently  triTial  affection.  Tlw 
symptoms  arc  us  follows  :  pnm  ns  of  the  papsage  of  a  hot  iron 
through  the  anue,  cooibinaj  with  a  aousalion  fia  of  cutting  willi 
a  Icnife,  aometlmes  ntionihint  on  the  net  of  defecation,  at  others 
coming  on  at  !in  interval  of  a  few  mirmtes  or  half  an  hour  nfter- 
warila ;  and  lasting  ofren  for  ^ever^d  hours  with  sucli  severity  as 
to  confine  die  sufferer  to  hia  bat^k,  ot  even  ta  Lib  bed ;  this  r&- 
nurring  day  after  day,  and  sometimes  for  months  or  yearH. 

Generally  a  alight  mucous,  [iiirulcnt,  or  bloo^ly  disehar^  is 
voided  with  the  fec^ca^  giving  the  idea  to  the  piitient  and  hi*  phy- 
siciun  that  he  is  lulioring  umler  fistula.  Witli  this  impression, 
he  often  nsks  advice  of  the  eurgeon.  Oti  examination,  hy  care- 
fully pulling  down  and  separating  the  folds  of  the  anun,  a  small 
fiseure,  or  crack,  is  discovered  just  within  the  margin,  and  ex-* 
lending  inwanla  for  an  ireh  or  more.  If  the  diseafte  is  of  long 
standing,  an  ulcerated  surface,  with  elevated  edfrettf  take^  the 
plaec  of  the  fisauto.  The  sent  of  the  dieeafie  is  often  the  centre  oFi 
a  hemorrhoidfti  tumor;  and,  ao  fitr  aa  my  observation  goes,  it 
occurs  1:wice  or  thre9  tiuiea  as  often  in  woraen  as  in  men.  In 
nine  eases  out  often,  I  have  fiiund  it  on  the  coccygeal  side  of  the 
B,nu«,  on  the  median  line,  scarcely  ever  on  the  sides.  Sometimes 
two  fissures  are  found,  one  behind  and  one  in  front.  In  regard  to 
Irenimenf,  T  have  seldom  seen  it  yield  to  the  vaunted  astringent 
injections  of  rhaLiny,  ^c.^  as  used  by  the  French,  or  to  emollient, 
or  aoodvne  cnemata,  A  numljer  of  timesT  when  ihe  disease  warn 
recent^  I  have  found  it  yield  to  a  thorough  cauterization  with 
a  stick  of  nitrate  of  silver;  bnt  it  seldom  gives  w^y  under  any 
treaTmcnt  short  of  the  use  of  ihe  knife.  The  surgical  operations 
which  I  liave  seen  practised,  many  years  ago,  for  tlic  relief  of 
this  affection^  were  of  a  eavage  description  ;  comprieing  not  only 
the  incision  of  the  stricture,  but  n  cut  through  the  whole  sphinc- 
ter muscle,  extending  nearly^  if  not  quite,  to  the  coccyx.     My 


nSSUEE   OF  THE   ANDS- 


187 


OTTTi  practice  hoe  been  us  follows  :  to  have  the  anua  well  diluted^ 
and  the  mucous  membrane  drawn  down  so  as  fully  to  expose  the 
diaenaed  aurJace,  If  there  was  an  ulcer  of  lon^f  eCondinir',  the  an- 
terior part  of  the  ulcei*  was  eei7ed  with  torvo[)a,  and  the  whole 
dibFcaee  carefully  exL*ised  from  without  inwards,  hy  mcane  ot 
ecissora;  the  wuund,  after  its  i^moval,  making  the  centre  cf  a 
portion  of  ligeue,  witli  a  mar;[^4n  of  heiilthy  mucous  membrnno. 
In  case  there  luia  been  much  8|>aamodio  contraction  of  the  sphinc- 
tor,  Avhioh,  however^  ia  uhnost  alwaya  dependent  on  tlic  ^rcnl 
irrttahihty  cf  the  fissure,  I  have  Gomctimee  made  a  aubcutaneoua 
division  of  that  muscle-  In  otlier  coeee,  by  passing  the  fore- 
finger into  the  rectum,  and  hookinf^  it  under  the  gphinctcr,  a 
Bninll  opening  is  made  into  its  shciith  ;  tlie  muscular  hbrce  ure 
then  exposed  by  brining  them  out  upon  the  fin^fcr,  and  di^ 
vided,  Tiiie  plan  I  have  also  i^ilopted  witti  Eueee^,  in  opera- 
ting in  cases  of  rupture  of  the  pcrinspum  :  its  advantage  is,  that 
it  avoids  a  lar;^  wound  cxtGudin^  into  tho  rectum,  which  may 
cause  deep-seated  heniorrhu^T  and  allows  the  blood  to  escape 
externally,  if  there  should  b>e  any  tendency  to  bleeding  af^r  the 
division.  I  should  have  etnted^  in  Bpcaking  of  the  treatment^ 
that  in  one  case  in  which  there  was  frreac  ^utferin^,  and  violent 
contraction  of  tho  sphincter,  tins  was  relieved,  and  tho  fissure 
allowed  to  heal,  by  wearing  a  short  metallic  rectal  bougie,  of  a 
dumb-bell  shape,  with  on  aperture  in  the  centre  for  tlie  cacapo 
of  Jiotue. 


Case  C,  —  JV**ttre  o/  the  Amia.  —  A  man  35  years  old, 
who  bad  been  subject  to  honiorrhoiils  for  a  year  whenevor  ho 
had  an  action  of  tho  bowels,  was  attacked  with  a  most  aeutc 
pain,  not  only  during  tho  passage  of  the  feces,  but  for  an 
hour  or  two  afterwards.  Ha  had  been  under  constant  medi- 
cal treatment^  both  local  and  general ;  and,  from  the  feces  being 
oecasionally  streaked  with  blood  and  pus,  it  was  supposed  to 
be  ft  case  of  listula,  although  nothing  of  the  kind  had  ever  been 
discovered  on  examination.  He  was  mueh  worn  down  by  auf- 
fering,  and  was  entirely  prevented  from  doing  any  buaiticss*  On 
aepantting  the  nates  forcibly,  and  making  traction  on  each  sldo 
of  the  anua,  so  as  to  pull  down  and  expose  the  folds  of  tho  rec- 


188 


AUVB. 


turn,  T  lit  once  clisijrjveretl  tlir  commencement  cjf  a  fissure,  jii&t 
Miiliiti  thir  uiiub.  Tito  jkutit^ut  Letiig  nindc  to  brace  liim!^i;lt  up. 
rln-  lissure  wa-s  graduitlly  forced  duwu,  nnd  exposed  to  vjcvr 
lljcoit^diout  iieiiHy  it>4  vkhole  extent.  Its  wlmle  fiurrace  was 
then  tliorougldy  cjiiilerized  with  the  auliil  ultrute  of  ailver, 
whielt  npplit^iition  seemed  like  tlie  lunch  of  a.  red-hot  iron,  Af- 
ti^r  the  I'tim^  whii^h  liiateil  for  un  hour  or  two,  hjid  eubaldedi  & 
distinct  relief  wtis  eJtperienctil.  At  tlic  ueit  eracuiition,  which 
(i(5turred  two  days  JiftLTM'anla,  there  was  uhfloliiu-ly  no  jmin» 
Suht^t'queiitly,  In  the  ('.ourse  of  n  fortnight,  tlicre  was  a  relam 
of  jKJin  [liuing  defecaliou.  A  second  n£)|jlicLttion  of  the  cou^tJC 
coni[>Ieled  tlie  cure* 

One  or  tvra  other  ca«es  of  this  di»ea?se,  wbieh  h&re  come  un- 
der my  observation,  in  males,  Lmve  been  cured  under  a  similar 
uieihod  of  treatment. 


Case  CT.  —  Ftsmre  ttf  (lie  Anux. — A  lady  S-")  jeara  old, 
who  hiiJ  tfiiffcred  severely  fi'um  hemorrhcidd  during  pregnHiioy, 
aifter  her  luHt  confiacineiit  (wlunli  was  two  ywira  before  I  saw 
her),  began  to  have  severe  buruing  mid  Inneinating  pain  after 
every  r)|ieratiozi  from  the  bowels.  Her  ttiiflbi-irigsi  gradmilly  in- 
crea>ii>di  uutU  th^y  beennie  almost  inanji^iortjdde,  and  eonEiied 
Tier  to  the  beil  during  the  grenter  part  of  the  day,  nfter  each 
evacuation,  wlilch  caused  severe  constitutional  diHturbance.  sueh 
aa  chilla  and  fever,  with  profuse  sweating-  Every  kind  of 
treatment  had  been  tried,  in  the  way  of  liwial  applications,  iu- 
jectiona,  lUid  laKuti^'eg,  together  with  occatfi(»naI  opintefi,  but 
witiiuut  permunent  benefit.  As  uny  ex  am  inn  lion  with  the  finger 
WHS  utterly  insupportable,  nlie  waa  etherized,  and  pieparaiicn 
made  for  an  operation  if  it  should  prove  to  be  necessary.  On 
sepnriiting  the  folds  of  the  anuB,  n  brond  fissure  was  diacoTcred, 
or  rather  iileefj  with  depressed  centie  and  elevated  edges, 
which  exiemlcd  into  the  rectinn  for  some  distimce.  The  anus 
was  now  drawn  well  open  by  two  itssistantj*,  and  the  extenjal 
portion  of  the  ulcer  firmly  seized  witli  toiitlied  foreepa,  and  a 
careful  dissection  niFulo  with  pointed  scissors;  the  ulcer  beino- 
gradually  dra«,fged  down  w*  tlie  dissection  progreaaed.  In  this 
way,  the  entire  diseased  surface  was  thoroughly  excised.     Alter 


FISSURE   OF   THE  ANT'S- 


IS9 


tho  opcmtioTi^  no  evacuation  was  permitted  for  a  Tvcck :  tlic 
iirst  iU'jcction  naa  attcudcti  with  aomo  [min ;  but,  r&  the  wound 
healed,  |!ic  \mn  bocrtnio  loee^  and  a  goad  recover^'  toob  plucc. 
It  is  nijvr  neiLrly  nine  jcore  siaco  tlio  operation,  aud  Bhc  has  been 
entirely  vidl  since. 

Case  CII,  —  Fii*siti'e  of  the  AjiJts.  —  About  tlie  jcar 
1850,  I  anw,  in  consultntian  with  Dra.  Jamea  Jn<^kai>n  and  J, 
C-  Wiirrcn,  a  Irtdy,  about  40  ycare  old,  who  for  a.  number  of 
ycftrs  hfld  aurtcred  from  symptoms  of  fif^anrc  of  tbc  aaua.  Sbe 
wns  very  fccMe,  and  in  nn  anicmic  etfitc*  There  waa  very 
violent  spasmndic  cuntrnction  of  the  sphincter,  whieb  almost 
prevcnttti  the  cinicuntion  of  the  bowels.  The  pjiticnt  being 
etherized,  I  was  requested  to  opcroite.  Tbc  iisaure  hcirg  of 
Iting  standing,  and  much  lirm  nmtcri^d  oEluacd  about  it,  it  waa 
eutirely  exciacd,  txa  In  the  laat  ciiae.  A  tenotomy  knife  was 
then  carefully  workctl  in  under  the  aphincter,  which  was  put  on 
the  etrftoh  by  two  iingera  in  the  anu>'»  and  the  muacle  divided  by 
a  aubcittaucoua  eection.  Tiie  patient,  aWcr  the  ordinary  trcat- 
uicnt,  waa  cUbctuaily  cured. 

Case  CITl.  —  FUmre  of  the  Anng.  —  Nov,  1862.  Alady, 
^'a  yeara  old,  bc^rnn  ahoxii  a  year  and  a  half  botl>re,  and  not 
long  ntler  tbc  bii'th  of  a  child,  to  eulfcr  (rom  n  pain  in  the 
region  of  the  rectum,  after  defecation.  This  pnin  she  referred, 
not  to  the  anua,  but  to  a  epot  in  die  rectum  opposite  tlkc  Jower 
end  of  the  eacrum.  In  the  course  of  the  day,  n  email  collco- 
tiun  of  pundcnt  matter  would  take  place  in  the  rectum,  and 
the  discharge  of  thia  was  attended  with  moel  terrible  suftering. 
The  pains  gradually  extended  to  the  Bciatic  and  other  ncrvos  of 
Ibe  pclvia.  She  gcneniUy  enjoyed  pretty  good  hcnith ;  wus  mar- 
rial,  and  bad  one  cliiid.  The  cnlanicnia  were  regular,  and  there 
was  no  a^iparent  trouble  about  tJie  uterua.  She  was  seen  by  a 
dj^in^uished  surgeon  in  tlie  army,  who  exhausted  Gvery  avail- 
able means  of  relief*  but  to  no  puipoee.  I  had  no  doubt,  from 
the  deecriiition  which  she  gave  me  wlien  I  iir^t  aaw  her,  that 
ehe  bad  a  tia^ure  of  the  onua ;  atthou^'h  she  could  nut  beheve 
that  the  pain  which  appeared  to  be  ao  high  up  within  the  rectum, 


190 


Ai^a. 


nnd  the  pAins  in  ihe  limba,  coulJ  be  attributed  to  tlus  cause. 
On  se[nmitmg  the  foJds  uf  the  anus,  H»i  uk'eia^lcd  fissure. 
Opposite  the  coccyxt  vro^  at  once  manifcBt;  but  an  attempt 
to  explore  It  with  the  fiog^r  vrns  attended  with  aucli  eutferiog 
tLat  it  Wild  DCCL'Fjsaiy  to  desist.  I  udvJsed  Ler  to  tako  n 
private  mora  at  the  Hc«plbdf  wliere  the  o[icnitLUii  was  per- 
furmcd  uoiler  ethcr.  Aa  eoon  as  the  irritability  of  the  sphinc- 
ter was  overcome  by  the  inHucoce  of  the  aiiffifllhetic  agent,  the 
finger  could  be  pu^s«cd  up  into  tlic  rectum,  whlehf  so  far  as  could 
be  aaeertnined  by  the  eense  of  touch,  waa  in  a  perfectly  lieidthy 
eoaditien.  The  liastire  exteiidcd  from  jii^t  within  the  margin  of 
llie  aQU3  into  the  rectuiu.  The  ulcer  waa  of  moderate  depth, 
witli  hard  and  elcvnted  edgCfl.  I  iirmly  grasped  the  whole  ulcer 
witli  tiMjthed  forceps,  uud  dissected  it  out  with  seissors.  Tlie 
night  uftcr  tJic  opcnttioii,  she  wus  free  from  pain,  and  in  fact  had 
no  pain  for  ^vg  or  &bL  days,  during  which  time  she  had  no  eiac- 
uation  of  tlie  bowela.  At  tlie  end  of  thia  period,  she  took  & 
laxative;  and  the  evacuation  which  folbiweil  wnfl  attended  with 
a  little  pain,  as  might  have  been  exper^ted  while  the  wound  r&* 
mained  unheided.  During  the  ne?tt  week  she  did  well,  so  far  as 
reganis  pain  about  the  auus  ;  but  she  bad  one  or  two  severe 
atljicks  of  sciatica,  which  rcj^iiired  the  use  of  remedies.  At 
tlie  end  of  a  fortnight  a*\er  the  oi>erationT  she  left  the  Hoa- 
pitnl,  at  her  own  requeiit,  to  go  tu  the  house  of  a  friend,  appar- 
ently well.  A  week  later  I  w^as  requested  to  ece  her,  and  found 
that  all  the  old  symptoms  had  returned.  Her  bowels,  from  tlie 
want  of  proper  manugeinent,  had  Ijecome  quite  costive,  the  did- 
ehargps  inking  p]ii<ie  in  hanl  lumps.  On  examination,  the  wound 
WHS  found  to  he  nearly  healed,  and  in  a  healthy  state;  it  was 
touched  with  nitrate  of  silver.  This  application,  conjoined  with 
a  laxative  diet,  gave  relief  for  several  days,  when  it  li^ul  to  be 
repeate*!.  At  this  time  she  was  compelled,  by  the  illue»3  of  her 
huriband,  to  return  homo. 

In  Mm^h,  18G3,  flhe  Came  again  to  Boston,  havirg  a  recur- 
rence of  all  her  troubles,  with  all  their  former  seventy-  I 
advised  lier  again  to  enter  the  Hospital,  and  to  stay  there  until 
cured,  if  po^ttible.  She  was  ethcrizcil,  and  a  crack  was  found 
in   llie   tiuiue   place   as   before,  but  not  i^tricLly  In  an  ulcerated 


FISTCl^A  IN  ANO. 


Iftl 


COTirJidon.  A  cut  wns  ntiw  mnde  direotlj  tlirmigh  it,  jim!  :iljoiit 
n  thinl  purt  tif  ihe  thi<:kness  uf  llie  fibrva  of  ibe  exlemiil 
fipliincti-r  included  itt  the  inoiskm.  Tills  opemlion  ngniti  uf- 
fi>ril«<l  relief  fur  a  wt^ck  ur  1*^jj  diLVH,  wIil-ii  [In?  jitiackrt  uf  pMiti 
hegnn  to  return  at  iiregiilnr  imprvalB,  often  in  the  niiiMlc  of  t!ie 
ri^lit,  and  ussumed  a  vrolenily  hystencal  chnraclpr.  Cuiiteri- 
ziLlinn  iLgjiin  guve  prirtinl  refi^^f.  Durin*^  tliia  time  tlie  cutainenia 
IjiLil  been  irreguhir,  thu  discluLrge  taking  place  tlin^  H-Ays  ever; 
wei'k- 

She  wna  kept  under  trentnienl  for  her  general  health,  and 
mum  entirely  ret?uiered.  I  snw  her  n  lon^  time  nfterwarda, 
wirhi>ut  any  reL^mrence  uf  her  former  tiTJuhlea. 

This  coae  U  ini[)ortniit,  r»howti)g  how  ncccufiiiry  it  in  to  perse- 
Tere  in  treatment,  where  tlie  mind  of  the  surgeon  is  confident  of 
the  ciLuse  of  the  nyinptoms.  Here  it  was  neccssnry  t<J  work 
cijnshmily  ngainsl  the  persuiLBiona  of  the  palient,  who  pprsisltil 
t^int  her  J4utleri]i<rs  had  ^me  other  ori^n.  TWia  idea  whs  8till 
farther  eorlirme<l,  when  ehe  did  not  get  complete  relief  fiy  a 
rdtii^le  opera.Lioii. 


FIBTULA    IK    ANO, 

The  operation  for  fiatuk  in  nno  is  mo  eonimon,  and  the  treat- 
ment so  s^^ttled,  that  it  is  Rertrcoly  worth  while  dweliinff  on, 
I  would  simply  say,  that,  in  those  ea^^ea  of  fiHtida,  running  tnr 
up  into  the  rectum,  it  ia  unneeessnry  to  follow  the  internal 
cnl-tle-sac  to  its  terminnlion^  wliich  is  often  n  hloody  nnd  dnn- 
gerou^i  proceeding.  Generally,  the  incision  should  comprise 
thnt  portion  which  is  included  [letween  tlic  openings  of  tliG  fis- 
tula on  the  rectum  and  outside.  The  internal  aperture  of  the 
fistuhi  I  hnve  nliuoat  invarinldy  found  jii*t  wirhin  rhe  amis,  and 
more  cunnnonly  on  tlie  nnierior  fhiin  the  posierior  side.  The 
treatment  of  injociionat  na  used  hy  empirics,  is  gererfllly  inef- 
fectual, and  not  only  involves  the  I'tvs  of  niueli  valunhle  dmc, 
but  gives  ujucli  discojnrurt  to  the  patient. 

In  regard  to  the  ruTe  for  operiiting  on  phthisical  patients,  I 
should  SUV,  that,  if  the  fistnia  causes  no  irritation,  avoid  inter- 
ference.    If  inueb  inflao  mill  ion,  with  numerous  external  ii&lulous 


192 


AKU8. 


ofieiilnga.  is  prcffpnt,  caiismg  great  sufTerino;,  preventing  excrGiBC, 
aiii]  ilevangiHg  tlie  system  geaerallj,  tiu  opunaioii  ufteu  reatorea 
almost  new  life  to  the  patient. 


Case  CIV,  —  FiflTur-oira  Ofentno   xear  tiir   Hoot   or 
THE  Coccyx,  IK  tiie  Mbdia>"  Lenb  between  tjie  Nateb  ; 

THE  Fistula  containing  Kair,  —  TLe  following  cnse  wna 
pn^ecLitcrd  fur  consultation  ;  and  is  similar  to  those  which  I  have 
frequently  hnd  imJcr  observulion,  but  Lave  nowhere  seen  dca- 
cnhtd.     ThemcKje  of  its  origin  hps  not  yet  been  clenrly  mwle  out. 

Jan*  18<J4:,  — A  young  niiin,  25  year*  of  a^,  with  very  full 
dcvelutuncnt  of  hair  on  the  body,  apj>hcd  to  mc  on  account  of 
a  atnall  fistuloLis  opcnin^i  %vhLch  he  hiid  njion  the  sacrum,  juat 
between  ihc  foldj  of  tfie  n-itcfln  The  first  intimiit.ion  which  he 
had  of  it  wns  from  the  exudation  of  moisture  from  this  epot 
about  one  year  ago.  At  first  the  discharge  was  tliin,  but  nftcr' 
wards  assumed  n  pundcnt  character.  Recently  the  diacaec  be- 
came more  ser^>uu,  and  the  soreness  and  inconvenieucc  resulting 
from  tlie  di.iclii\ry;e  led  him  to  seek  medicid  aid.  On  examina- 
tion, a  amall  cireuUr  opening  w-is  aeen,  just  large  enougl»  easily 
to  admit  i\  probe,  looking  aa  if  the  skhi  had  become  inverted  at 
fliat  point,  and  tjuito  unlike  the  raggedy  iuHamcd  orifice  of  a  com- 
mon ti^inla.  A  BCfo-purnlent  matter  oozed  out  from  the  interior- 
Tlio  probe  penctrnted  upwards  between  one  and  two  inches,  I 
at  once  recoguiaed  an  oifcction  which  1  had  freijuenlly  obacrvcd. 
On  opening  thid  Hrttula  in  eimilar  caae^,  a  amall  curl  of  hair  has 
generally  been  found  occupying  tbe  bottom  of  tlic  cul^dc-sac. 
Thia  hair  aecma  occnsionnll y  to  act  as  a  foreign  body*  gLViag  rise 
tu  inflammatlun,  with  the  formation  of  abscess,  rejiulting  in 
£stulotis  openings  c:itendin^  in  various  dircctiona,  thus  often 
concealing  the  original  difiicultyi  By  a  card'jl  exploratory  op- 
eration, however,  the  Utile  widp  of  hair  may  be  dliicovered  in 
ttomc  part  of  tlie  elnuat  lying  [icrfectly  looae,  and  unattacbed  to 
the  BLirroundiag  tissues,  I  have  once  seen  thia  in  a  woman 
wfiose  hair  was  dark,  and  more  tlian  usually  developed  in  that 
region:  all  tbe  other  casca,  uiimbcring  jKirhnps  eight  or  ten, 
have  been  in  men. 

The  origin  of  thia  singular  affection  ia  involved  in  obacurity- 


FIBTULOUS    OPEMyO    NEAR    COCCYX, 


193 


Tl  would  ecem  [K)j?ftible»  however,  that  it  may  Iiegin  in  thp  atout 
hnir  or  hairs  arising  from  a  single  falhole  hecoming  in  some 
way  diverted  from  their  normal  direction,  and  irverled  upon 
themHclves  within  the  fiillfcle  itHell":  tfie  oontiuued  growth  of 
the  liiiLr  would  then  renidt  in  the  formation  of  a  tnugled  knot  or 
brdi  of  hftir.  which  might  readily  gi\e  rise,  after  a  time,  to  irri- 
ijinon,  just  as  a  similar  aceumulalion  of  aebaceous  matter  in  the 
follicles  of  the  faee  may  excite  thnt  form  of  inHarnmatory  action 
known  aa  acnc".  Tlie  occurrence  of  the  diseflBc  in  the  median 
line  between  the  folds  of  the  nates  mny  perhaps  be  explained  by 
the  constant  pressure  ftnd  moisture  of  the  part,  j^ortening  both 
the  newly  formed  hair  and  the  epidemiic  cells  surrounding  the 
mouth  of  the  follicle. 

Tlie  treatment  of  this  affection  consists  in  laying  freely  open 
the  cavity  or  cavities  where  the  oocurrence  of  intiamniiition  has 
involved  the  akin  nnd  subcutaneous  tissue;  or,  in  case  the  skin 
still  remivins  healthy,  the  eac  may  be  laid  opei^  and  then  dis- 
sected out-  The  intcKumentp  should  be  broup^ht  together  with 
one  or  two  sutures^  thus  insuring  a  more  speedy  eure  than  if  & 
simple  incision  is  practised. 

This  affection  U  interesting,  in  connection  witt  whnt  has  jnet 
preceded  it,  from  the  fnct  that  the  persons  who  apply  for  relief 
almost  always  auppoae  that  they  arc  laboring  under  tha  diaeaae 
of  fistula  in  ono. 


Case  CV,  —  Fistnlous  Opening  in  the  N^eifjhhoi'hood  of 
the  Anaa^  rontttijiinfj  Hair* — A  man  entered  the  Floapital, 
July  31,  iSGfi,  to  he  operated  on  for  what  be  supposed  to  be 
fitituhi  in  uno.  Ho  had  received  a  kick  on  the  nates  a  year  be- 
forej  and  a  emnll,  hard  lump  Lad  boon  lof^,  which  hod  recently 
suf>pitrate{lt  There  wo^  nn  opcniitg  near  the  nniis.  and  an- 
other near  the  coccyx^  neither  of  whkh  communicated  with  the 
rectum.     A  director  passed  freely  from  one  to  the  otlier. 

On  laying  the  whole  track  of  it  frocJy  open,  a  tuft  of  hair 
was  found  between  the  two  openings,  quite  free,  and  entirely 
devoid  of  hidhs.  The  patient  led  the  lloepitJil  in  about  a 
week,  in  a.  fair  way  for  recovery. 


194 


ANDfl. 


PHOLAPaUfi    ANT. 

TliG  disease  which  p^oea  by  thie  Jiarne — ami  it  ia  nBuaJJj  eon- 
fountW  with  an  cveraion  of  tiic  mucous  membrane^  attendant 
on  extreme  uriBCa  af  iuternjil  hcmoiTUoiJs  —  h  u  very  rnrc  fltfoc- 
tion.  The  pntienta  in  my  pmctioe,  in  wliom  the  wholo  calibre 
of  tlie  int*?Ktine  prola]>se[3  nt  each  evacuution  of  Iht*  bowel*^, 
\m\e  p;enernJly  been  oliildren  of  a  scrofulous  habit,  who  hurc 
suffered  &oni  ohetinate  confltipation,  irom  irFcguJarity  of  tlie 
bowels,  from  dysentery,  or  from  awaridea  of  the  roctuna.  The 
disease  has  nimoet  always  yielded  to  an  invigorating'  course  of 
treatment  with  iron,  a  noitriehiug-  diet,  whicL  leaves  but  a  little 
residue,  and  aeCringent  injections.  Before  an  evacuution,  an 
eaemn  of  cold  water  or  a  polulion  of  tannin  was  adminia- 
tered-  I  have  also  sgcu  it  in  old  pcreons,  and  in  persons 
sutfering  froni^  Atone  in  the  bladder,  where  the  straining  is 
extreme. 

Tbc  records  of  the  Massaehusetts  General  Hospital  give  the 
following  numbers,  for  a  period  of  forty  ye&rs ;  and  probably 
one-half  of  these  are  misplaced,  bein^r  caaes  of  everted  bemor- 
rboidfl  :  — ' 

Total  number  of  caMS 19 

Cured n 

Much  relieved 4 

Keliavoil * 

The  treatment  generally  seema  to  liave  beeu  by  ligatures 
applied  to  poitions  of  the  tnucoii^  membrane  nruund  the  anus, 
ae  for  hemorrhoids.  The  following  case  I  trcfited  by  i^uter* 
ization  wdth  acid  nitrate  of  mercury. 


Cask  CVT.  —  Prolapitua  Ani.  Cauterizaiion,  Cure.  — 
A  boy,  aged  14,  of  English  birth,  entered  the  Hospital  May 
20,  185^-  He  [?iud  that  he  had  :t  prolapsus  when  only  two 
years  old,  which  dieappcjircd,  and  returned  eight  years  after. 
The  whole  calibre  of  tlie  rectum  whs  ftirceil  down  for  one  or  two 
inches  during  every  act  of  defecation » 


POLYPfta    OF    THE    RECTUM. 


195 


The  boy  bem^  etherized,  die  iatpatine  waa  everted,  arid  n 
ring  of  it  cauteriaed  with  the  fteid  uienlioucd  above.  The  pro- 
lipsua  wfla  then  redueed.  The  bowela  were  kept  quiet  for  n 
nurober  of  days,  but  tjo  recurrenee  of  ibe  prolsipse  oecjrred 
when  they  itet(?d.  He  waa  kept  under  observation  until  it  was 
certnin  that  the  cure  woa  complete. 

Where  prolapsus  ts  compJicated  with  bemorrhoida,  ibe  trent- 
menl  wliich  relieves  the  laiicr  will  also  relieve  the  former;  i,e., 
the  hgature  or  ^eraseur. 

POLYPUS  OF   THE    RECTUM. 

Polypus  of  the  rcfMiuzn  i^  a  very  rare  iifieetion,  and  usually 
of  mild  ehamcter,  1  do  nol  remeiaber  having  fleen  more  than 
five  or  flix  caHGS  of  it-  The  first  of  the  following,  operated  on 
by  myself,  is  the  only  one  recorded  on  ibc  books  of  the  Hos- 
pital up  to  lJ^(iO:  — 

Case  CVn.  —  Polypus  of  RBctvm.  Usmoval.  Cnre^  — 
March  21,  1860,  a  boy,  time  years  of  age,  entered  the  lloapkal, 
for  a  Vftseular  tumor,  which  oecasionally  projected  through  the 
Bphineter  aui,  it  having  been  first  discovered  four  ye^vs  before. 
It  frave  him  great  discomfort.  With  the  finger,  I  could  die- 
imguish  it  about  two  incheB  above  the  sphincter,  of  the  size  of  a 
ehcHTnutf  attached  by  a  broad  base  to  the  intestinal  walls. 

The  patient  being  etherised,  the  tumor  was  draggeil  down 
outside,  and  removed  by  tbe  fcraseur.  He  waa  discharged  well, 
on  the  26th. 


Cabb  CVllI-  —  Polj/pns  of  liectum.  — AgBntlomnn,  who 
bail  onre  or  twice  HiifFered  from  fissure  of  the  anus,  ctmsulted  me 
nbrmt  a  tumor  which  occasionally  came  down  while  tho  bowela 
were  being  eva^^uatpd,  and  became  pinched  by  the  apbiticter. 
By  a  distal  examination,  a  hard  tumor,  the  Bi3:e  of  a  small 
walnut,  wan  found  hanging  to  the  parictes  of  the  rectum  by  a 
niirroiY  eiljdk,  al)out  two  inches  from  the  external  orifice.  I  ad- 
vised its  removal  by  twisting,  or  with  sciasors.  His  mind,  bow- 
ever,  being  relieved  rts  to  tlie  diaraeter  of  it,  and  being  much 
occii[iied,  the  operation  wa8  deferred,  and  I  beard  nothing  farther 
from  hiin  In  regard  to  the  tumor- 


196  A^■us.       « 

A  ycnr  after,  hn^in^  fisfiurc  of  the  a.r\%i6j  which  vroA  Dpcratod 
apOD,  it  woB  tbutid  that  the  tumor  hud  diaap|icurcd-  In  oU 
prolralility,  it  hod  been  twisted  o^  and  ditiuhnrgcd  by  the  action 
oi'  the  bowcEfi- 

Case  CCX.  —  Polypi  cf  the  HKctutn,  Fiesvj^e  of  Anus, 
Operation.  Cure.  —  In  April,  1(166,  I  wae  roqueetcd  to 
operate  on  a  ludy  who  had  beta  euflcring  for  n  number  f>f'  yeora 
fhrm  a  bad  fiBsuro  of  the  aaue,  wliich,  on  examination  by  her  i)hy- 
eician,  woe  found  to  bo  complicated  with  poij'poid  tumora  of  the 
rectum.  The  fieeure,  whioh  was  found  to  bo  in  n  very  disc^ed 
and  thickened  state  from  long  ulceration,  waa  disaccted  out  with 
the  wi&sora.  Three  or  lour  polypoid  tumota  were  then  hooked 
down  from  the  roctum,  and  citlicr  cut  off,  or  Lied,  wlicrc  the 
Toaculnrity  seemed  uiiusual.  She  had  a  dow  recovery;  but  I 
lieaid  of  her  two  mobtha  afceru'orda  in  fine  heiilth  and  ^[lirita. 

Case  CX-  —l^olypue  of  Hectum.  Jiemoval.  —  A  woman, 
about  35  yonra  of  ag;o,  very  nervoua  and  delicate,  who  had  re- 
ceive<l  much  treatment  without  avail,  entered  the  Kofipilal  in 
April,  1SG6t  — tJie  eame  week  that  I  operated  on  the  last  ca*e< 
The  functions  were  goncrolly  deranged,  ond  there  wna  scarcely 
on  organ  in  the  body  which  was  not  complained  of.  She  re- 
mainedT  for  the  moft  jiart,  in  bed,  earing  that  ^hc  wjis  too  feebls 
to  ait  up,  and  attributed  her  troublee  .mainly  to  a  tumor  in  the 
rectum. 

On  examinatioti,  &  tumor  wna  discovered  similar  to  tlioee  de- 
ficribed  above-  It  woa  dragged  down  and  tied ;  the  li^ture 
coming  away  about  the  fourth  day  after  the  operation, 


IMPERFOHATE  AlffDfl   XSU   RECTTDM, 

It  may  not  be  congiderod  inappropriate  here  to  introduco  the 
subject  of  malformation  of  the  anua  and  rectum,  wluch  ia  one 
of  great  latorost,  aa  involving  the  question  of  operation  and 
the  life  of  the  patient. 

The  following  cases  of  imperforate  anus,  with  malformation 
of  the  rectum,  present  several  points  of  interest  in  connection 


IMPERFORATE    ANUS    ANU    RR^TUM. 


197 


witli  the  question  of  nttempting  to  nffonl  relief  by  a  surgical 
o|ieration-  In  simple  occlusion  of  tbo  Jtnus,  tliere  cnti  be  no 
JouLt  of  the  propriety  of  0|veDing  it,  either  by  puncture  or 
crucinl  Inrisionj  mm'ntitining  the  passage  afterwnrtla  l>y  the 
use  of  bougies-  The  great  nmjority  of  eases,  however,  aa 
they  oecur  in  practice,  are  by  no  meana  so  easily  dispoeeil  of; 
being,  as  a  genernl  rule,  pomplicated  with  an  imperforate  eon- 
dition  of  the  lower  pnrt  nf  the  rectum,  and,  in  many  ini^tnnces, 
also  with  an  abnormal  opening  communicating  either  with  the 
external  surface  of  the  body,  or  more  commonly  with  the  blad- 
der or  Vftgina-  In  a  very  conniderahlt:  firoporrion,  a1so»  the 
anua  is  perfectly  f<rnne<l  CKternaMy,  but  teruiinales  within  in  it 
eul-de-flac ;  and  a  few  inatimces  have  been  rccordeil  in  which 
there  was  a  total  nhaence  of  the  reetum,  and  even  of  the  whole 
large  intestine.  Of  thia  latter  malformation  I  have  seen  one 
case,  in  which  the  large  inteetine  was  absent,  with  the  exception 
of  dIic  cfficum ;  and  the  specimen  ha^  been  preserved. 

Upon  the  fliibject  of  operating  fjr  the  relief  of  imperforate 
rectum,  surgecns  are  by  no  means  unanimous.  The  grenC 
fatality  which  attends  these  o]ier&tionB;  the  difficulty  oiilen  ex- 
[lerienced,  in  the  after-trejitraent,  to  prevent  the  closure  of  the 
artifieial  ikpemng ;  »nd  histly,  and  jicrhapB  chiefly,  tlio  very 
imperfect  cliuracter  of  many  of  the  so-called  curcs^  resulting  In 
lifo-long  diecimifort  to  the  patient, — hjive  induced  many  sur- 
geons of  experience  altogctlier  tu  discountenance  operative  inter- 
ference^  On  the  otlier  hand,  the  certainty  of  death,  if  left  to 
nature ;  the  fact  that  tlie  <iperation  has  sometirues  liecn  fully 
Bucx'esflful ;  the  pronusc  afTonled  by  improved  operative  inetfiods  ; 
and,  finally,  the  natural  relm^tance  of  the  surgeon  and  friends 
to  leave  any  thing  untried  whieh  may  podtsihly  save  life, — 
combine  to  justify  any  rational  attempt  at  relief  The  tJioory 
that  the  re^nlL^  are  necessarily  imjH'rfect,  which  allbnls  the  only 
real  argument  against  o^ierating,  ib  disproved  by  the  very  sue- 
oeasfnl  cases  recorded  by  i3eigamiii  Bell,  Amusaat,  Latta,  and 
others. 

The  operation  whii^li  promises  the  l>cst  results,  and  which  I 
have  several  times  performeil  with  succcas,  consists  in  freely 
dissecting  through  the  tiasues  whicli  intervene  between  the  cul* 


198 


ANU8. 


de-eiic  of  tlie  rectum  anJ  tlie  external  eurfece  of  tlio  bod>',  then 
drawing  down  and  puncturing  the  liowd,  an<l  finally  securing  it 
by  sutures  to  the  ronrgiiiB  of  the  dividetl  inte^meut^  thus 
£urniiiig  a  new  cannl  vrith  a  continuouB  mucouB  lining,  instead 
of  the  long  fiatulous  paaniigc  which  reftuha  from  a  mere  punct- 
ure with  the  bistoury  cr  trocar. 

During  the  year  ending  June,  1864,  I  mw  four  cases  of 
iiD;>erfomtc  nnus  and  rectum.  In  two  of  them  tliere  wqa  a 
fistulous  i>a&aagc,  communicating  in  one  Cfi^e  with  the  vngino, 
And*  in  the  other,  opening  in  the  pcrinfeum  hnlt'an  Inch  in  front 
of  the  normal  poaition  of  tlic  onus-  In  both  of  thc^  caacs,  I 
was  nhle  to  re-estflbliah  the  natural  paseoge  by  the  operation 
just  deecribod.  In  a  third  oaee,  upon  which  I  operated  by 
punotaring  the  diatcndcd  rectum,  the  child  died;  and,  in  a 
fourth  ease,  i  advised  agninet  any  operative  interference,  Theec 
four  caece  I  propose  to  rclate- 


Casr  CXI.  —  Itnperforttle  Anu3,  toUk  Abnonrval  Op^n- 
ittff  of  ihe  Mectnm  ^xtGniMy.  Operation.  Oure, —  A  female 
child  wiifl  bom  with  a  small  fiatuious  opening  directly  be- 
hind the  vagina,  and  half  an  inch  in  front  of  the  normal 
po&ition  of  the  anu^,  through  wjiieh  tiie  fecal  matter  was  die- 
charged  very  slowly  and  with  much  difliculty.  The  child  wna 
therefore  hrought  to  the  llospita],  w'herc  liie  opening  wae  en- 
larged by  one  of  the  surgeons,  who  cnjoinal  upon  the  parents 
to  hecp  it  from  clofling  up  again  by  the  doily  employment  of 
tcDtfi.  In  epitc,  however,  of  the  attention  which  waa  given 
it,  the  aperture  became  gradually  eontraclcdf  so  ac  to  CMise 
much  distrcsa  whenever  the  bowcla  were  ovaeuatedf  and  to 
lead  the  parents  to  bring  the  child  again  for  operation,  in  tho 
spring  of  1865^  when  it  was  about  two  years  old,  Tho 
operation  wtib  performed  by  passing  a  curved  Inetrumect  into 
the  fifltuloua  opening,  turning  it  backwards,  and  pressing  tho 
intestine  down  upon  its  point  where  the  ephincter-Qni  muscle 
should  naturally  be  situateiL  Here  a  dissection  was  made  until 
tlie  aound  was  exposed,  and  the  intestine  freely  opened  by  a 
crucial  incision.  The  intestine  was  now  attached,  by  two  or 
three  puinu  of  euture,  to  the  skin,  and  a  tent  passed  into  the 


IMPERFORATE    ANUS    ANI>    liECTUM- 


Id^ 


• 


opening-      The  chUd  bore  tho  operntion  well.      After  n    few 

diiyn,  the  tent  wjia  removed;  and  the  ilaily  uhr  of*  bougies, 
gr;Lduatly  inirrvasmg  m  size,  was  coniDiencerL  By  the  end  of 
the  third  week,  it  hecnme  difficult  to  irmidnoe  die  hougie, 
owing  10  the  very  powerful  reaiAtanPC  offered  hy  the  Bpl»inoter 
muwle  :  thls^  however^  always  yielded  to  presaiire,  nml  the  re- 
moval of  the  bougie  wna  followed  hy  a  frei?  discharge  of  fecid 
matter.  At  the  end  of  a  mouth,  the  diild  lefl  the  Hoi^piliil ;  the 
mother  beln^  rei^ueated  to  bring  lier  twice  a  week  iu  order  to 
have  the  bougie  pa*ee<I,  and  the  abnormid  opening  cauteriz&l 
fur  the  piiqwse  of  closing  h.  Three  mouthjs  atlerwjird.'H»  th« 
cme  waH  h>F4t  ^ight  of^  a  smnU  fislidou!^  openin^r  t^idl  reniaiiiirig, 
through  wliic!i  there  waa  occasionally  a  flight  discliarge;  tJie 
new  ftnua  peHurming  itfi  fiinctiona  perfectly. 

Case  CXJI.  —  Imperfornte  Anus^  with  Rsctitm  ojitniuij 
into  ihf.  Vmjhia.  Operittioji.  Rf^Uf^f,  Death  frmn  Gas- 
tric IrntaLiou  tteo  ■nimrlh^  aff^r.  Mulpn^tlion  of  Iaf.e^tine. 
—  In  June  1863,  a  fine,  healthy  irirl,  six  weeks  old,  wiw  hron^ht 
to  me,  with  the  rectum  terminacing  in  the  vagina-  An  infisiun 
had  Ijeen  mnde  by  the  attending  physieian,  at  the  jioinl  where  the 
auus  wtndJ  lie  naturdly  siliLMted  ;  but  he  hud  not  succeeded  in 
establishing  the  pasaage.  On  account  of  the  very  early  age  of 
clie  child  sind  the  small  siie  of  the  organs,  it  was  verv  difHuuIt  to 
determiue  the  ex:Lct  eondition  of  the  parts.  The  mother  ^d  tlut 
the  child  was  perfectly  well,  except  that  die  dlscliarfree  took  place 
through  the  vagina-  A  prohc  parsed  into  the  vaginji  entered 
^jcut  two  i[]ehe9  :  in  front  of  this,  anolJier  prcl>c  eoulil  he  pasi^ed 
into  llie  nrethnt,  the^e  two  passages  being  entirely  diftintt. 
Alter  considerable  numipulaliim,  it  was  found  that  tlie  whole 
jwsterior  wall  of  the  vagina*  and  the  adjoining  antenor  wall 
of  the  rectum,  were  wanting.  The  operation  for  the  re^torit- 
tioD  of  the  natural  pa>fsage  was  done  us  follows  :  A  large  Mlver 
bunk,  with  a  ball  nt  ibe  end,  was  po/^^eil  into  the  vagina,  and 
lun!i.-d  dowa  ug;jiji^t  the  spot  at  whieh  it  wiib  pni[Ki'?eil  tci 
make  the  new  opening.  Here  it  could  be  inilistinelly  felt  tlirouga 
the  fiiielc  mass  of  rhe  s<»[V  jwirts  which  iatervenwl,  A  crucial 
incision  wa<4  made  through  llie  bkln,  aud  (he  Noll  [aiHn  dist^cctcd 


200 


ANDS. 


tij  dthirr  8ii]e,  nnlTl  tlin  HtTvnr  bn.ll,  presRiTig  down  the  intpHlTne, 
wjn  felt  in  the  wrutml,  the  wiill  of  the  intestine  only  inter- 
vening. A  small  aperture  w»h  now  tmule  m  the  giit^  And  the 
h(K>k  iWHsnl  Jhrim;rli  ^o  n^  In  lioM  tlic-  ]KiHj*ni  position.  Tlie 
(.>penin<r  in  tJie  inte^i^Iine  wiis  then  enlarge)],  nnil  its  mar^^ 
etitcheiJ  to  the  integiinient  by  four  sutures,  A  jilij*;  hus  tlien 
intniiluceJ  into  ilje  *>|ieiiir^  to  the  ileptli  of  mi  inHi  nnd  a  half  or 
two  inchef^.  Afler  the  operation,  a  fi'pp  Jisehargij  tiwik  pluce 
from  the  viiglim,  showing  t\int  the  plug  would  not  interftre  with 
the  pafiHage  of  the  i'ecea  while  the  new  anus  vrns  being  efltab- 
li  shell. 

A  large  anil  wcll-fonneJ  eannl  was  e^IaMUliei)  in  the  iiomial 
position,  through  whiuh  well-f<>rire(l»  solid  ilischarge**  took  place, 
from  time  Ui  time,  wlille  the  more  liipiiil  fecefi  still  mn*\e  tht'ir 
w»y  through  tb(?  Tagina.  The  child  wn»  too  yoimg  anil  tlic 
vugiua  too  luaccesalble  for  any  attcmjit  to  be  made  to  elose  llie 
stbiionud  [lOBsagc ;  tliis  it  wna  pro^x^ni  to  du  at  a  luter  i>erlud. 
For  a  while,  tlie  i^liild  eiyoyei!  perfet^t  heikh  ;  but  fiuK^eijuently 
waB  atliLcked  wkb  gastric  Liritationt  and  died  Aug.  4,  lH(ti. 

Tlie  t'oUowing  eKtracIs  from  a  letter  from  Dr-  Cox,  of  Salem, 
tlie  atteEiding  physician,  give  an  aecount  of  the  post-mortem 
appearaiicea  :  — 

'*Oa  Tuealny,  the  2d,  I  first  saw  her.  She  had  constant  natisfla. 
and  vomiLed  almost  every  Ihincr  she  Look  intii  her  sloraadi,  and  luul  no 
fllvitit!  di rrhnrjrcs.  Tho^c  aymploraa  toniinucil,  more  or  leaa  rirpoody, 
till  her  dealh^  i>a  tbo  4th,  except  th^t  the  bow(>1s  \\vr&  eUghtly  mcv^d 
J4e\-Qml  limes.  Tndfppinlf'iiily  of  ihe  atnie  or  iltp  aiinr^^pli^re  of  Eiite, 
ih'a  qutiditiou  waa  perhaps  remotely  caused  by  a  mfillbrruaiion  iioU 
tran^poailion  of  the  large  irjtcslineT  in  coasoqucncc  of  wliich  a  free  and 
lh<»fr>ngli  ei'ac!uation  of  ihu  organ  seldom,  if  ever,  look  piarv.  .  .  . 
TIm.'  i^i'Lotti  liACT'iultMl  fi-oai  the  aiiua  to  the  right  iliac  fuw^a,  ilituee  up 
through  the  right  lambar  ro^on  to  the  under  surface  of  tho  liver, 
touching  th«>  ^IL-bUiddtir-  Then  it  hcnt  stinqdy  don'nwvirdSf  and  da- 
sepndcd,  in  eontaet  and  pamllcl  wiLh  the  aflfenilhig  porrion,  to  xho.  right 
iliuc  fbasa.  The  colon  thc[i  cros^d  the  lower  part  uf  the  abdomen  to 
ll(t  left  iliac  rcfrion,  up  throu^^h  the  Icfl  lumbar  region,  almost  to  tie 
E(omflch»  tei'ininniing  iit  the  ccecum,  .  .  ,  Tlie  [>i:ir[E*>H  diseulored  willi  bilo, 
fri>m  it^  rniiturt  witli  the  liver,  iw  wliiire  ilit  sudden  uml  abnijii  bend  of 
the  organ  doivnwarda  look  pla(^c.    This  sharp  flexure  rauat  have  proved 


IMPERFORATE    ANUS    AKD    KECTDM. 


Kl 


acerioiJR  obHtriK'lion  to  the  evacuation  of  the  howel.  From  this  liirn  To 
ibrj  imput  colif  the  bowt^l  wo^  rcry  mucli  dial^uded  with  ilatii^,  and  ooti- 
tained  more  than  rt  quart  of  eoft  FccaI  matter  of  Eh<j  coiiAiHtoDt^jr  of 
Ihin  morfnr.  Tlie  only  other  mni^biil  cluing^  found  wad  an  injecri^d  and 
bulleiieJ  atdtc  of  Ibi^  idul-ouji  coal  i>f  iLe  atoimiciL." 

All  incision  being  mude  ;n  the  baclc  part  of  the  rectum^  near 
the  BnuBf  diBpl&yed  a  very  great  contraction  of  that  cuna]  just 
before  itd  ori<pnal  terminaliiin  in  the  vnrrina.  la  fjict,  fidlowing 
ihift  contraction  waa  n,  cul"de-sac  which  coiiimum rated  with 
the  viLgina,  about  its  middie^  iiy  a  delicate  vaJvulor  opening  :  the 
H.r1in<'i]J  anuB  continuerl  llie  inteHtiiic  down  to  its  nntund  exttit- 
nuJ  lonoiiintluu.  It  will  be  underj^tuMl,  therefore,  tliat,  iimtend 
of  a  free  eoiomunieation  between  the  inteblitie  and  vagina,  tliere 
nns  a  plnited  condition  of  the  nmcon?  memhrane,  au  in  tlia 
oi'dinary  terminiLtion  of  the  ecinal. 

The  descending  colon  id  this,  ne  in  anotlier  published  case, 
ivaa  trun^juised;  so  thnt  any  o]>eration  fcir  nrtiiicial  aaii«,  aa 
u^imllv  practij^ed  in  the  left  lumbar  region^  would  necessarily 
have  failed  of  its  object.  I  would  advert  to  the  very  inLerestiug 
fuct,  exetnplified  in  the  present  case,  and  to  which  attention  has 
D]i;ny  jeiira  sirce  been  enllerl  by  lir,  J.  B.  S.  Jaekaon  ;  viz., 
(he  very  eousCa.iit  terminaliiin  of  the  interline  in  the  vii^mi  in 
cases  of  imperforate  aniw  In  the  femnle.  Dr.  Jackson  has  also 
remaiked,  that,  in  all  the  irnsa^  of  simple  imperforate  anus  that  he 
has  examined  in  the  male  subje^^t*  a  aniull  opening  has  been 
found  betsveen  the  reciutn  and  ihe  niembranoua  portion  of  the 
urethra  ;  and  this  opening  in  the  male  he  reganis  as  analogous 
to  tfie  one  above  referred  to  in  the  female.  This  is  well  depicted 
in  I'hite  X,  of  Dr.  "Willijun  H<jdenhaiiitT*fi  valuable  wttrk  euti- 
iled,  "Congenital  Malforamtions  of  the  Heetuiu  and  Anus.** 


Case  CXIII.  — ImperforcUe  Rectutti^    OperfUton.    Death. 
— April  9,  16G4-     A  very  small  child,  three  days  old,  wlJch 

had  not  yet  nursed,  wan  brought  to  me  with  the  i"e<"tuin  imper- 
forate about  tliree  quarters  of  an  tneh  above  the  auus.  Though 
tlie  child  was  tiuiescunt,  the  abdomen  wa^  diHtended  almost  to 
burst  ingn  A  linger,  being  introduced  into  the  anus,  encountered 
tlie  ol^tiijction  -,  but  there  a^kpcareil  to  be  no  rounding  out  of  the 


202 


AlCUS. 


ttfUtm,  indkstiTTg  the 


of  ttw  cftml  abore-     It 


(kcMled  to  oiake  an  explorslory  ptmcttm  with  the 
irnctf-  Wlwu  the  inatruuipnt  vas  dimtl  in,  ihe  mcroDinm 
began  iAijw]y  to  fl»w  oui,  uniil  &l  ]ea^  half  &  pint  faad  cae^fd, 
and,  presnire  bdng  made  upon  the  abdorT>eii,  ftUofl  foBowed. 
The  finder  was  tben  paMed  op  above  the  ob^tmrrioTi,  m  as  to 
freely  dilate  it.  Xo  large  cavity  or  depot  of  the  fiuid  con)d  he 
detei^ted.  It  itm  advUeJ  that  the  Goger  should  be  pas^  up 
once  or  twice  a  diy,  wbif^h  the  medica]  attendant  promised  to 
do,  and  also  to  report  the  course  of  the  case. 

The  {.'hild  Untk  TixmI  irrifiuidiately  afier  the  operatjon^  and,  for 
a  time,  teeiufd  relieved^  It  illei],  however,  the  sarne  nighi, 
about  twelve  hoains  after  the  operation.  At  the  autopsy,  a 
fjoHDlity  of  blood  waa  found  in  the  abdominal  cavity,  hot  no 
meconium^  A  fibrous  cord  about  an  inch  long  intervened  be- 
tween the  rertum  below  and  the  cul-de-«ac  of  the  tmiierforate 
intefidne  al>n¥e-  The  great  distention  of  tlie  intestine  by  me- 
conium bod  forced  II  down  into  tlie  pelvut,  bringing  it  in  contact 
with  the  bottom  of  tbe  anal  cavity-  On  thrusting  in  tbc  trocar, 
the  inieatinul  contents  Freely  escuped ;  but,  on  the  with drawid 
of  tbe  cajiula,  the  upper  jiortion  of  interline  retr^ccedT  and  the 
npcrture  in  it  closed  so  a«  to  be  with  difRculty  distinguished. 
The  oozing  of  blood  into  the  abdominal  cavity  probably  took 
p\nrs  troni  the  lower  aj>erture.  The  very  unusual  state  of  tlie 
purtM  dinclosed  by  ihc  autopay  ehowed  that  no  openUion  could 
have  been  of  service. 


Case  CXIV.  — Imperforate  Rectum.  —  May  12,  1864. 
A  female  child,  not  quite  24  hours  old,  waa  brought  to  me 
with  imperforate  rectum.  The  alulomen  was  quite  diatendwi. 
v^inn  and  anu»  iiatund ;  the  little  finger  could  be  parsed  balf 
an  incli  wjUuei  tlic  atuis.  when  it.  was  suddenly  arrested.  \Vlien 
the  cliild  strained,  a.  ^enr^ation  was  felt  of  something  prensing 
down  on  tlie  Gngtr;  but  it  did  not  convey  the  impre^'sion  of  a 
portion  of  intcHtinc  diatendet]  with  fluid.  On  passing  ihe  little 
linger  of  tbe  other  hand  intn  the  vagina,  the  uterus  could  lie 
distinctly  felt  aa  in  itji  natural  position.  The  finger  could  dien 
l>c  pmised   over  tbe   iinger  in   the  anus   against  tbe  Bpiue,  but 


IMPEKFOKATE    ANUS    AKR    RECTUM. 


203 


detected  no  tumor ;  nor  could  any  appearnnce  of  distended  in- 
te^dine  be  difttinguishefl  elsewhere^  althoiigli  the  finger  could  Ije 
turned  round  and  felt  through  the  parietea  uf  the  abdomen.  A 
probe  was  pasM'd  a  little  naj  into  the  nretlirit^  hut  did  not  pene- 
trate the  bladder,  although  urine,  thick  iind  apparently  gernl- 
purulcnt*  wfts  discharged  when  the  cTaminatioiT  commenned. 
It  wiLs  thought  possible,  hut  not  prabublE^,  tbnt  the  intestine 
might  euinmuriciite  with  the  hludder.  Under  the  cireumstanceB, 
no  operation  was  ndviffeil.  Dr.  D.  W.  Cbeever,  who  had  ex- 
amined the  patient  the  day  before,  had  already  given  the  saine 
opinion. 

The  child  lived  nine  days,  tiLkin^,'  littlo  or  ito  nourir^huient, 
the  nl>dunien  becoming  gruduajly  ttiore  and  mote  diatendcil.  On 
posf-morteTn  cTamination,  the  intestine  wna  found  to  terminate 
In  a  eul-de-sac  between  one  and  two  iucliea  Jibove  the  imper- 
forate anus :  the  sigmoid  ilexiure,  instead  of  being  in  ita  pro|>er 
place,  was  found  tnineposed  to  the  ri^ht  iliac  regiou,  where  it 
lay  in  contact  with  the  right  side  <if  the  vagina,  from  which 
it  Cijuld  rcailily  have  been  reached  and  puucturEsl,  A  probe 
was  easily  psLssed  to  the  fundus  of  the  uterus,  the  ns  and  cer- 
vii  lieing  very  large.  I  wa;^  surpriaed  to  find  with  what  ease 
the  little  finger  eould  be  passed  wiihuut  violem'e  to  the  very 
bottom  of  the  vagina,  a  fact  which  may  be  of  material  impor- 
tance in  elucidating  some  of  these  very  obscure  cases. 

The  specimenB  of  this  aaJ  the  previous  case  are  now  in  my 
private  eolIeetiuQ- 


CHAPl'EE  Vn. 


"GKNITO-FRINARY     ORGANS- 


8T0NR    Ui    THE    UI^AliDEH, 


Sr\rE  the  intriHliictioii  of  lilhotnty  iiiid  tlie  use  of  ether,  ttir 
opemtiiin  for  Btime  in  llie  blmVIer  has  umlergone  a  vpry  ^Pflt 
fLUifilioriition  ;  nnd,  thougli  once  conHiderrd  nf  a  ma^t  fomiidjiMe 
naUire,  it  is  miw,  in  tniiny  caaca,  nlraust  Btripped  of  its  lcrrur8. 

While  jn  Eurdpe,  through  ihe  politencf^a  of  Sir  Astley 
CiMj;>er,  T  had  an  op^iortiinity  of  i<eeing  some  of  the  earlieat 
instanw?a  of  litliutntj  performed  by  the  impr\»ved  atone-hreRkrng 
instnitnentf*  of  Heiiiteh^iip  ;  and  iifttTAViird^,  having  witneanptl  the 
nnpiindleled  alvill  of  Civiale  in  breaking  the  stoiip,  and  hnvmg 
followed  the.  lessmifl  of  Armwflat,  1  was  early  led  to  adopt  Utho- 
triiy  ni&tead  of  lithotomy.  I  pnr^iie*!  this  practice,  though  nut 
tu  tlie  entire  exclusion  of  lithotoitiyi  for  about  thirty  years,  with- 
out ihe  lofla  of  a  single  life.  During  the  spring  of  186fi,  bow- 
ever,  T  hwt  Uvo  prJienla :  both  of  them  died  after  a  single 
operation  of  the  niiMeJ^t  character;  and  an  investigation  bhowed 
that  death  would  have  resulted  j  whatever  course  might  huve  been 
adopteil- 

The  cases  ir  whieh  h  may  be  well  to  employ  lithotomy  are, 
in  tlie  first  place,  nhihiren  ;  flecondly,  persons  with  large  and 
hard  stones,  or  with  organic  changes  in  the  bladder  or  proatate. 
I  have,  however,  frequently  relieved  old  persona,  even  where 
the  prostate  liaa  been  couciderubly  enlarged^  by  repealed,  but 
not  prolonged,  lithotrltic  operations- 

The  euccesd  of  lithotrity,  so  far  as  my  own  observation  goefli 
depends  upon  tiie  follov\LUg  circa uistanceif :  1st,  To  Inject  the 
bladder  modcralely  with  water;  2d.  To  use  an  inslnnnent  of 
moderate  size,  and  so  coiislnictcd  as  thoroughly  to  clear  itaelf 
of  tlie  fragmejita ;    3J,  Not  to  move  the  inslriimcnt  about  too 


STON^    IN    THE    BLADDKR. 


205 


freely.  By  not  oli&erving  lliia  l:ist  precaution,  inflammAtion 
may  be  cxcjiei!,  aod  even  gnngrcne  nnd  deiUh  ensue.  By  al 
once  gently  sinking  tlio  beak  of  tlie  m.^tnLincnt  into  the  moat 
depemlcnt  pan  of  the  bbnicler,  opening  and  giving  it  n  *liglit 
oscillating  niovenient,  iho  stone  will^  in  ahnost  every  inAtnnce, 
fali  reiwlily  into  ita  grasp,  ;ind  may  then  he  mised  into  tlie  middle 
of  tlie  Cftvity,  itnd  broken.  The  eame  proceas  nrny  be  repeated 
upon  one  or  two  of  the  Inrger  fmgments,  taking  enre,  lniwevi?r, 
not  lo  proiraoE  the  operntion  beyond  u  few  mtnutes.  A  Urge 
catheter  may  then  be  introduced,  and  some  of  the  finer  purtielea 
fillovvcd  to  eecflpe  through  it.  Usuully  two  or  fhree  duys  ela|jse 
before  the  bla^itler  recovers  sufficient  tone  to  expei  the  fragnier»t« 
spon  tan  eonsEy . 

In  old  persons.  In  whom  the  prostate  is  more  or  lesa  en- 
lai^otl,  the  Ktone  la  ofton  coneenlod  in  n  cavity  behind  it,  and 
requires  that  the  beak  of  the  instrument  should  be  turned  back- 
wnrtls,  and  the  stone  puaheil  out  from  its  lodging-place,  before  it 
can  be  properly  seized. 

Ether  ia  a  most  valuable  adjuvant  in  a  great  proportion  of 
cases  of  lithotrity.  When  1  first  urged  ita  employment  in  fhia 
operation,  in  a  paper  puhliahed  in  "The  American  Journrd  of  the 
Medical  iscicnces,"  in  l'^48,  many  aurgeona  objected  (and  some 
Btill  object)  to  itft  use,  upon  die  ground  thnt  the  congciousneas 
of  the  patient  is  necessary  to  give  warning  if  the  foM^  of  the 
bladder  become  entangled  in  the  jnwa  of  the  instrument.  In 
answer  to  this  objection,  it  may  be  stated,  that  the  mere  contact 
of  the  instrument,  in  an  irHlated  state  of  the  organ,  will  give 
rise  to  greater  suffering  than  the  actual  engagement  of  the  mu- 
cous membrane  in  other  cnees ;  and,  to  a  surgeon  at  nil  in  the 
habit  of  performing  this  operation,  the  interpoflition  of  n  fold  of 
Hoft  tissue  ia  at  once  perceptible,  although  I  have  never  known 
any  nnusuid  pain  manifested  from  ihia  cLrt-umslJince.  In  eases 
of  extreme  irritability  of  the  bladder  during  un  advanced  atnge 
of  tlie  disease,  where  there  is  an  entire  wiict  of  power  to  retain 
the  urine,  I  have  been  astonished  at  the  great  quantity  of  ether 
which  is  re<tulred  to  produce  |>erfect  relaxation,  so  as  to  admit 
of  the  injection  <]f  the  Bmnjl  amount  of  water  necessary  to  pre- 
pare it  for  the  sjbseqxienc  manipulations- 


SOS 


CEMTO-UBINARY   OEGAS'S, 


In  i*cganl  to  the  method  to  be  preferred  in  lithotomy^  I  have 
generally  fld£>ptcd,  until  Intcly,  thut  of  Dupuytren,  by  the  bi- 
lateral incbion.  This  ie  still  a  favorite  vith  some  French  and 
mnny  American  Biirgeona.  lie  chief  peculiarity  coneiata,  oe  ia 
well  known,  in  the  tranevcrae  incision  of  tfic  ekin,  whieb  j« 
made  directly  in  Itont  of  the  imue  ;  and,  eccondlyi  in  the  dtiubk 
divieioQ  of  the  prostate  by  tho  liiholomt  cach^. 

The  absence  of  important  ncrvce  tu\d  vcsficle  in  the  median 
niph6  affbrdfl  a  Etrong  argument  in  favor  of  the  median  over  the 
common  lateral  incieion  ;  and  tbc  revival  of  perineal  ecctimi 
by  &Ir.  Syine  has  dcmonsirnlod  the  fact  that  the  bladder  may 
bo  Bafely  and  easily  reached  in  thia  mannorn  Influenced  by 
these  considerofione,  I  have  eeveral  times  operated  by  a  nie<lian 
incision  in  the  raphtf,  dividing  the  prostate  with  the  dciuhlc  litho- 
tomc  or  with  a  bistoury.  The  aiKanlagie  of  thiw  method  uver 
the  Iraasverfle  incision  of  Dupuytren  ie  the  greater  room  wliieK 
it  afTords  for  the  widnlrawal  of  the  et^ne  through  the  cstornal 
wound,  while  all  ita  peculiar  oilvantagca  arc  securod  by  the 
double  incision  of  the  prostate. 

Lithotomy,  notwithstanding  the  oxtmordinary  eucecefl  anid  to 
have  boon  attained  in  certain  sccKoue  of  our  own  country,  ia 
ncvcithclca6»  in  tovni  and  hospital  practice,  an  operation  at- 
tended with  ccnaiderablc  riek. 

The  opcrationfl  for  stone,  in  New  England,  may  be  eaid  to 
be  very  rai-e,  but,  in  the  limestone  re-done  of  the  South  and 
Wefit  are  quite  common.  Dr,  J.  C.  Warren,  in  a  paper  pub- 
lished in  1>^41,  iatatcd,  thut»  in  the  course  of  forty  years,  he  hod 
been  called  on  to  [lerform  all  tlic  operatioTU  for  etono  which  hod 
been  done  in  Boston.  The  whole  number  had  not  exceeded 
twenty-five  caeee,  and  the  population  had  increased  duriniif  this 
time  from  twenty-six  thoueand  to  upwards  of  a  hundred  thou- 
sand. Of  the  twenty-five  coses,  not  more  than  three  were  in 
persons  natives  of  Boston  or  vicinity.  During  the  succeeding 
ten  years,  from  1844  to  1854,  he  operated  for  stone  quite  a 
number  of  times-  In  the  eourae  of  ubout  ninety  years  one  hun- 
dred Cftsee  were  operated  on  by  Dr,  John  Warren,  John  C» 
Warren,  and  myself,  and  the  flpeoimens  are  in  my  poeeeaaion. 
In  the  lost  thirty  yeare^  I  have  operated  on  rather  mora  than 


STONE    rS  THE   BLAI>UER. 


20T 


thirty  cases ;  and  the  operation  has  also  been  performwl  by  other 
aurgeonfl.  Most  of  these  cases  were  from  a  distance,  hut  four 
or  five  of  them  belon^ng  to  Boston,  Two-thirds  of  them  were 
opemted  on  by  lithotrvtj- 

The  following  onsee  are  selected  as  iJluetratiDg  some  particular 
featurea  either  in  the  history  or  the  operation  ;  — 


Case  CXV.  —  Vesical  Oalctilus  from  the  Introduction  of 
a  Bit  of  Senling-ifjftx,  Spaevi  of  Bffulder,  relieved  btf 
Opium*  Hepeated  Operations,  Recovertf.  — A  man,  24 
years  old,  entered  the  Hospital  April  11,  1^46,  who,  four  months 
before^  employed  n  piece  of  seitling-wai  to  remove  a  supposed 
stricture  in  the  urethra,  A  portion  about  an  inch  long,  and  a 
fonrlh  of  an  inch  in  diameter,  slipped  into  the  blndder.  Soon 
atler,  he  began  Co  have  eymptoms  indicnting  the  presence  of  a 
stone. 

With  the  straight  sound,  In  the  bladder  I  readily  detected  the 
calculus ;  »nd,  pissing  the  finger  into  tlie  rectum,  reached  it 
witfiout  much  difliculty.  It  appeared  to  be  on  tite  riglit  aide  of 
the  bladder. 

April  12th,  The  patient  being  properly  prepared,  water  was 
injected  into  the  bladder  ;  the  lithotrile  was  iniroduced,  and  the 
atone  seized  and  eruahed.  The  water  was  then  permitted  to 
escape  from  the  bladder,  brirging  witli  it  pieces  of  the  calculus. 
Tlie  bladder  was  allowed  to  rest  for  foui'  days. 

On  the  16th,  and  aiibsequently  several  llmeq  during  the 
month,  the  operation  wan  repeated-  At  length,  however,  the 
presence  of  the  litbotrite  caused  apa*tm  of  the  binddcr,  which 
grasped  the  insti-ument  so  firmly  as  to  interfere  with  its  free  use. 
The  patient  stifTered  so  much  from  these  tn'als,  that  he  requested 
the  operation  of  li(lio(omy.  At  a  consultation,  in  cnnscquence  of 
this  request,  I  iniroduced  a  very  large,  long  stafl',  wuch  as  I  pro- 
posed to  employ  in  the  operntton,  when,  to  my  surprise,  no 
spasm  ocL^iured. 

On  May  2d,  all  the  preparations  were  made  for  lithotomy 
and  lithotrity ;  and  the  patient  took  n  hundred  and  fifty  drops 
of  the  tincture  of  opium,  an  hour  before  the  time  fixed  for  the 
operution.     The  bladder  wne  injected  with  half  a  pint  of  warm 


208 


GENITQ-UItlSART  ORGANS. 


water;  tlip  lithcitrlte  wns  itWriHli^ceil.  no  ^Jjia^im  omincfl ;  ths 
tJfK:rntii>n  vnts  perfitrmri-l ;  nnd,  in  a  (juaiUr  iif  nn  Ijunr^  nWut 
a  teas[iooDful  of  fragments  w&a  Jiacliarged.  Tic  HuHcretl  no 
inconvcnltnce  from  the  tincture  of  opluEu. 

A  coil  s  id  emit  on  wliioh  Imil  inilueace  in  leading  me  t<t  fall  in 
with  tlie  iwLtient*B  wish  for  T4  culling  operation  waa  thia:  in 
tliree  iu£tanc<:a,  tiAier  repeated  oi^eratiima  of  litlioErltj^,  the  alone 
hnH  ap[)ear^  to  become  e^LCi^iiIated ;  owing,  I  BUpjio^ie,  to 
infljuDinatmn  of  tlic  nun'ous  coal  [>f  t.lie  lilailder*  Pcing  appre- 
heneive,  from  iJie  difficulty  of  discovering  the  remaining  fr»g- 
mentT  tliul  (liiu  proceaa  was  going  on,  I  wished  to  prevent  its 
corapleLioit^ 

He  e:iperienGcd  bo  much  relief  Ironi  ihe  use  of  the  opium,  that 
T  resolved  to  try  its  effect  when  injected  intu  the  bladder.  Two 
di'acbiiia  of  tlie  tincture  were  therefoi'e  injected,  on  Alay  4tht 
wiUk  half  a  pint  of  WiU'tn  water  i  from  tliia  he  found  much  ease. 
On  May  Cth*  I  Injected  two  dracliuts  of  tlie  tincture  of  opium, 
mixed  witli  two  ounces  of  warm  water,  at  9^,  A.M.  In  ao  hour 
aud  u  half  afterwards,  I  injected  aa  much  water  as  the  bladder 
would  receive,  not  exceeding  a  gill  and  a  half,  and  tlicn  intrc^ 
dueed  the  lithotrite  without  much  \i;ua.  Tlie  fra^iueut  not 
lieing  felt,  an  additional  pillow  waj(  placeil  imder  the  pelvis. 
It  was  then  dlacovered  in  the  upper  part  of  the  bladder,  seized 
twiee,  and  broken.  Ko  ^reat  pain  was  cxpericticed,  and  a  dis- 
ehiu-ge  of  about  a  teaspoonful  of  broken  calculus  took  place 
soon  after* 

He  nfierwards  eubmitted  to  several  similar  operations,  expe- 
rieiicin^f  qo  incoavcnicnce ;  and,  by  Juite  20tli,  waa  relieved, 
and  a  week  later  was  diachiirged. 

Remarks,  — The  atone  in  tiiis  case  was  very  soft,  and  ai- 
ways  broken  with  great  ease.  There  wna  never  any  lodgment 
of  h  in  the  urethra,  and  only  on  ojte  or  (wo  oeea^sious  any 
difliculty  ia  withdrawing  the  lithotrite  charged,  through  tl^e 
meatus.  A  pcculianiy  in  the  management  of  this  case  waa, 
that,  aPcer  the  npporeat  introduction  of  the  instrument,  the  atone 
waa  not  reached  until  tlie  handle  wna  earned  downwards  towards 
the  pcrinicum,  fonniu^'  an  angle  of  45°  with  a  line  i^rjjendicular 
to  the  body  in  a  horizontal  posture.     From  tliia  I  concluded 


200 

tlrat  tlic  anterior  part  of  llie  bladder  Iiad  Lecome  rontracU'd ; 
or  cIag  that  the  Atone  hud  fornictl  i'cir  itself  n  injiich  between  fna- 
Cicidi  of  the  bliidder,  an  occurrence  wljich  I  ihink  frequently 
takc6  place  during  the  lithotritic  treattucnt.  Tlie  introduction 
of  wfticr  ixn  a  jirelimiuary  step  always  brought  on  pain,  and  ren- 
dered the  patient  aomcwhaC  unmanageable,  Oocnaionally,  the 
water  was  umittcd,  and  the  operation  waa  performed  with  Icsa 
pain  find  in  Icfft  lime  than  ueiial;  while  there  whs  no  reason  to 
believe,  tluit,  under  any  ci/cumatances,  the  niucoua  ^oat  t>f  the 
bladder  waa  included  between  the  jawa  of  the  instrument. 
Ailer  the  etone  wa^  removed,  the  irritability  of  ihe  bladder 
yrn&  at  once  diminished,  so  that  tJic  patient,  who  before  wa» 
vtry  aeuflitive  lo  the  alig^hteat  motion  of  the  iustrnmi;nt,  allowed 
tlie  bkdder  to  be  explored  in  every  din^tion,  almost  without 
shrinking.  The  physical  flcnaibiUty  of  the  patient  waa  much 
increased  by  the  tear  of  being  cut,  Thia  case  illustrates  the 
great  advantage  we  have  etncc  derived  from  ether  in  overcom- 
ing the  contractions  of  the  bladder. 


Case  CXVL — Caiatius  of  Oxalate  of  Limt*     Stricture, 

Jjitholrtlfj  under  Ether,  PunthiU  Af/forptton.  l^ecovcry. 
—  A  ntan  W  years  of  age  entered  the  Hospital,  Noven»ber, 
1847,  having  auffered  with  urinary  difficulties  for  nine  ycara : 
eighteen  months  before  entrance,  he  contrncted  a  venereal  affec- 
tion, whifh  left  hiiji  with  an  urethral  discharge-  On  exami- 
nation, the  urcthru  was  found  to  be  bo  contracted  as  hardly  to 
admit  the  smallest  sized  bougie.  The  stricttirc  was  gra<Iually 
dilatL'd  by  the  introduction  of  bougies  increasing  In  Hij:c;  hut, 
DOtwitifcatanding  tlic  enlarged  paasago  and  the  free  egrcas  of  tlie 
urixi€i  he  complained  of  muefi  pain  at  the  extremity  of  the 
urethra,  and  was  obliged  to  paas  his  water  ten  or  twelve  times 
in  the  twenty-four  hours. 

In  March,  1S48,  he  eamc  under  my  core.  Suspecting  the 
cxistencQ  of  some  foreign  substance  in  tlie  bladder,  and  the 

ethra  being  extremely  sensitive,  I  plae^  him  under  the  influ- 

ee  of  ether,  and,  intro<lucing  a  dound,  detected  a  stone. 

Having  waited  a  few  days  to  allow  the  bladder  to  recover  from 
the  effects  of  eoundingi  on  IVIarcb  11th  the  o]}cration  of  litbotrity 

^7 


310 


GEMTO-UIUNAKT    UltGA^8. 


WAS  done.  The  pntienr  vtis  first  ethon^p^l,  so  thnt  fhomiisciilor 
B)'Stem  was  in  n  utate  of  complete  relaxatiun;  hnlf  -.i  pint  of 
vrarm  water  was  chi^n  injected  mto  the  bliuliler.  A  small  Ltho- 
trite  was  in trmluccxl ,  mid  the  stone  seized  \  but  it  prot'ed  to  be 
too  hard.  A  krgei-  iind  more  powerful  instrcment  wns  substi- 
tuted, by  which  the  atone  wna  broken  with  repeated  strokea 
from  llie  hanimer.  Sorae  difficiilTy  wna  found,  on  withdraw- 
ing thp  inplrunient,  in  pnsf^ing  the  seat  of  the  Htricture,  on 
account  of  it^  jaws  being  clogged  with  sand,  and  therefore 
iroperlbctly  closed.  The  patient  was  eniiTely  inaenflible  dnriug 
the  whule  ojienttion,  and  not  the  siighie&t  contraction  of  the 
bladder  iTn[>ei]cil   tlitr  ne("e»sary  mnnipulntion. 

The  coDtlnuatiLwi  of  this  history,  as  derived  from  die  Hospit^ 
records,  is  in  substance  as  follows:  — 

In  an  hour  ufLer  the  operation^  he  passed  urine,  with  several 
pieces  of  graveli  and  some  fine  g^nd«  in  alt  nearly  half  a  tea* 
spoonful.  The  nrine  contained  a  little  Uoml,  which  wae  npjiar- 
ently  frtJin  the  urethra.  In  the  afternoon,  he  had  a  severe 
rigor,  la-Hting  fifteen  niinuics  :  phased  urine  once»  a  quiiriity  of 
gravel  coming  nwHy  with  it ;  aome  small  piijci^s  of  the  gravel, 
which  hud  hiclged  in  the  uretlim,  were  remove^l  with  ihe  for^ 
ceps.  The  bladder  ^^as  washed  out  wiiJi  cold  water:  cold 
compresses  were  also  applied  to  the  uretlira,  from  which  a  little 
blood  bud  been  oozing.  In  the  night,  he  complained  of  head- 
aoije,  pulse  fnlj  and  hard.  He  was  bled  to  12  oz.  with  much, 
relief;  slept  well- 
March  12th. — Morning.  Comfortable;  pulse  06,  Soi 
Mmalt  fragments  came  away.  Alterntjon.  Pulse  140;  head- 
ache, no  tenderness  of  bowels,  imd  but  little  irritidnlity  of  uro*- 
thra;  passagt^  of  urine  free. 

13th.  The  smarting  and  pain  were  very  slight;  hut  tittle 
detritus  in  the  urine.  Twelve  leeches  to  perinwam,  with  a 
warm  bnth  nnd  enema,  were  ordered.  In  the  nftemoonj  hod 
chill ;  complained  of  uinLiise,  pain  in  the  shouhlers,  kick  i>f  tJteJ 
neck,  and  weakness  of  the  riglit  Ann  ;  pulse  130. 

16th.  Pulae  120-  The  countenance  aoniewbat  depTCssed. 
Comphuneil  of  great  pain  in  the  right  shoulder  and  arm,  aa 
well   as  between   the  shoulders;  sdso  in  loins  and  left  i^fde   of' 


SrONK    IW    TRE    BLAE^ORR. 


211 


liarlc;  tenderness  jilon^  the  course  of  the  left  ciinitid  iirtery; 
no  Iroithle  in  jiiiHsin^  nrine,  Htid  liui  little  Huraneps  of  the 
urethra. 

From  the  XTlli  to  the  220,  the  febrile  eymptome  oontinuod, 
the  pulse  heing  eoniewhnt  over  2LMJ,  ijerfc<"tly  diatirct  ood  reg- 
ular. The  patient  being  Tery  feeble,  a  atiniulatmg  treatment 
wftfl  pursued. 

2id.  I  oponed  nr  abacoee  over  tlic  tarao-metatftrsal  articu- 
Jntion  of  the  left  Jittle  toe,  ftiid  found  the  bf>nc  denuded. 

23d.  Pulse  190.  From  Ihia  period  the  frequency  of  the 
pttlfic  hcgan  to  diminish,  and  he  went  on  alowlv  improving  until 
April  !^d,  when  he  was  seised,  during  the  Jtl'tetnoon,  with  n  severe 
piiin  about  the  letl  clavicle  and'  upper  part  of  the  left  eido  ox 
tlie  cheat.  Great  swelUng  had  taken  place  since  noon,  so  as  to 
dmost  hury  the  clavicle.  It  also  extended  up  the  neck.  The 
intog^umcnts  over  the  clavicle  were  red  and  (edematous.  He  hod 
^cat  ditHculty  of  breathing,  and  the  prc^anrc  on  the  triLchea 
dmost  produced  flutfocation*  I  humediatcly  made  a  di^dcction 
down  to  tlie  clavicle,  but  no  pus  could  be  discovered.  The  bone 
itaeif  vrad  evidently  enlarged,  end  my  impi^caalon  from  tlie  eynip- 
lome  wtt3  that  pus  was  forming  in  ita  interior.  The  pain  wns 
le^  on  the  fallowing  day. 

Oa  the  21st  of  April,  the  swelling  about  the  cUvicle  had 
nearly  dianppcnred,  but  the  inner  third  of  the  bone  was  felt  to 
be  cnhirgcd^  From  this  period  be  slowly  recovered f  mid  left 
the  Hospital  free  of  eomplaint, 

M^marks.  —  The  opcrntjon  in  thia  cose  wna  ropidly  done,  with 
no  viiilenec  to  the  hkddcr,  a^  ahown  by  the  symptoms  nt  the 
time  and  atlcrwarda*  none  of  which  had  reference  to  that  organ. 
The  stone  woa  ^mall.  Not  being  aware  of  the  imrdneds  of  it, 
]  thought  it  would  yield  to  a  timall  ini^truinent.  The  power 
o\^  ihifl  not  proving  euttident,  it  woa  withdrawn,  and  another 
introduced ;  wbii^h,  however,  was  so  constructed  as  not  to  clear 
itself  of  the  dctritua  or  eand  made  by  the  crujthing  proceed. 
From  thifl  rea^n,  the  instrument  which  passed  the  obstruction 
caused  by  the  stricture  with  caae,  on  its  introduction,  was  ar- 
rested there  on  its  withdrawal,  from  the  jaws  being  imperfectly 
dosed;  and  some  tbrec  was  rctjuired,  though  not  amounting  to 
violence  i 


ffU 


OESnO-CKDEAKT    OMCASft. 


Ii  wiB  be  |Kmt*ieJ  thai  dK  fri^Boto  «f  tfone  aH 
swKj  wtfUa  s  wcvk  of  the  opcf^dav.     %m  4n»  iIat*  s&fr  itt 
pam  m  the  dbovUen  bcc>^  ah^  w^iA  aD 
iBslflBt  ahMtpckia  woe 
pofev  far  «a  or  arveQ  dsj*  after  ibe  17ib, 
tcry  nfMdr  rma^ag  fro^  190  to  312.     There  evened  t4>  be  j 
um^mj  in  r br  forMaiionrf  paa  MdMumt  pom  of  tbeboA^ 
kwaafaoDrl  abosi  ibe  metHHml  bane  in  tbe  Ant,  and  TO 
—itfj  to  exut  m  ibe  davicie ;   frvm  the  lAtier  it  vm  [nUblj 
ibaofbed  widMOt  anlriag  any  appearance  ootwanfiv. 

T^m  eaaa  will  evidenttr  cocoe  tuMkr  the  category  «r 
placed  by  Velpeao  and  Civtale  a4  ***^""**  of  paniknl 
tkat.  now  called  pvfeoua,  BOfDetimea  caused  hv  tbe  «tiu|tle   ld-; 
trodoetloti  i>r  a  OEheter,  but  laore  frequenilv  in  lithotritr  Uy  Umt 
irritBii'Jti  of  fragmenta  lodged  in  die  nnedini,  mnd  ab^it  the  neck 
of  Cbe  Uadder. 

The  itone  vu  analrT^  hv  Dr.  Baron,  wbo  gavie  xne  the  foW^ 
lowif^  nou  <rr  }t»  <KD9tituents  :  "It  conAietd  chiedj  of  uuda 
of  lime;  it  aUo  contains  oonnderable  unc  aoid,  and  a 
quantity  of  carbonate  of  Iim«.  Tbe  cDuc«ntno  layers  u*e  very 
numeroiu.  In  aome  fragments  under  the  ini'?ru£Ooper  I  eoimied 
from  ten  to  twenty,  or  even  more  lasers,  la  the  »ptice  of 
fifiiedt  of  as  inch.  The  radiated  ^ouctare  is  also  g«en  underi 
the  name  rircumat^ncc^,  the  radii  bdng  @till  finer  than  tlie  Uyeraj 
which  cro«4  diem  at  right  angles." 


Case    CXVIL  —  Cifstic    Oxidt    Calcufue.      Lithotrity, 
Cure, — A  man,  aged  43,  o  resident  of  New  York,  aj>plJ<Hl  tO; 
TOG  in  July,  lH'iS,     ^vcn  years  before,  he  wtu  seized  with 
virilent  pain  in  hU  vide,  wbioh  was  attributed  to  the  pauage 
a  caleulua  throu^^h  the  ureter.     Shortly  afterwards,  a  calculi 
of  the  0ize  of  a  pen  was  votdEtd  with  h\a  urine*     lie  had  a  num-' 
her  of  liiuo«  since  pu<^@cd  calouli, 

Ifi  April,  while  en^'a^i.Hl  in  ploufrhitig,  he  felt  a  pam  in  hi* 
iiliuliler,  the  cominencement  of  the  tiuffermgM  from  which  he 
applied  to  he  relieved- 

I  xo^udod  him  with  a.  ^mall  lithotnte.  and  deteete<l  a  oal- 
culu*,  which  inea«ure<t  an  inch  and  a  half-      Slij^ht   irritation  of 


STONE   IS   THE    DT-.\I>DER, 


213 


the  blailtlcr  followed  this  nxamjQation  ;  ami  it  was  nf^e^tiary  to 
kee^]  him  quieL  for  a  few  dnys,  and  usu  itJiiedit^f,  before  nu/ 
operaljoQ  could  be  |ierfunned. 

On  July  13di,  the  bladder  being  injected  with  half  a  'lint  uf 
wnnn  wnter,  (.]je  atone  yv&&  immediately  ^i/,etl  witli  the  en  shing- 
lEfltniment*  and  broken*  by  meana  of  the  screw,  wilhout  much 
dil^cult^' 

1/ith.  He  haxl  suffered  no  inennvenieoce  from  the  o^ier  ition, 
imd  ill  ffti^t  felt  rtlievtrl.  A  quantity  of  ejirid  find  fni^riii  -nts  af 
9Ume  ItJid  pfuH^ed  with  tbe  urine. 

Tb(»  ctperatiun  wm  rejieated  on  tlie  18th,  2Hil«  2lith,  29lh.  wml 
Any,  2d.  Afler  ent:h  iiperntion  he  jnwaeil  n  mmilier  of  fra;^- 
ments  ;  and  once  or  twice  it  wa^  necessary  to  remove,  by  the  for- 
ce|W-  porrkma  which  had  become  lodgeil  in  the  fossa  nav;cnbim> 
Oil  Aug.  3*1,  !i  fnc^uent  whirh  hiul  been  eni^^aged  in  tine  wity, 
and  wliicb  it  wmh  fomid  iin^Kir^ible  to  extract  entire,  was  geized 
by  n  pcupverfnl  jiair  of  dressing  forceps,  crushed,  and  thus  ex- 
tracteiJ  piecemeal. 

On  the  f>th  he  returned  home  well ',  and  on  the  25lh  I  received 
from  him  a  letter,  in  which  he  informed  me  thnt  he  had  expe- 
rienced no  dirticuhy  in  pusaing  his  water,  and  was  otherwise  in 
gooci  health- 

T)t.  Bacon  kindly  made  an  analyeia  of  the  stone,  which  is 
contained  in  the  following  note  :  — 

'*  The  cftlcuJna,  of  which  you  sent  rao  fra^^rmcnie  yestertlay  for 
analyst,  proves  to  be  of  n  rare  and  interesting  kind.  It  is  com- 
posed of  cifttint  or  ct/Jttic  oxide.  The  yellow  jxntions  coneiat 
of  cyaiine  in  n  stale  of  pnrlty,  with  the  exception  of  a  trace  of 
pbosplicile  of  linie.  In  the  wintc  friable  parts,  whifh  appear  to 
be  interspersed  in  the  y<?Ili*w  masses  without  forming  regular 
layers,  the  cystine  u  mixed  with  much  phosphate  f.if  lime  and  a 
little  triple  phosphate.  Your  speeimj?u^  H;;ree  pretty  closely  in 
physical  ebaraeterfl  with  the  description  given  by  aniliort  of 
this   very  imcommon   form  of  ealcuhis/' 

Tliiji  case  of  cystic  oxide  calculus  U  interesting  fr<im  llie  ex- 
treme rarity  of  thi*  kind  of  stone.  M,  Civiale,  whose  ^jreat 
experience  \n  well  known,  states  in  his  work  on  the  stim^  and 
gravel,  puhlish&l  in  1840,  that  he  has  met  with  fair   four  cases 


314 


GEKITO-irRlNARy   OHOANB. 


of  it.  In  the  Jldntcrian  Mu^^dum,  out  of  eix  huiidrcd  and  forty- 
nine  cnlculi,  k  appciirtr  by  the  tn.taIo<fiic  there  arc  but  tliroc  uf 
the  cy6tic  <vxi(le. 

It,  hns  bcpd  tftftted  that  an  lifTdlitsiry  dieposition  existed  in 
runny  of  these  cases  ;  two  of  those  und<;r  the  cure  of  M.  CiviaJe 
were  brothefa.  In  Ihc  present  case  this  diseaac  wn*  not  inhcr* 
ilcd,  accoi'ding  to  the  account  of  the  pftliert. 


Cash  CXVUl,  —  A  vtry  large   Cystic  Oxtdc   Calculus- 

/Sac  in  Biaddcr*  Juitftotrity,  Deaths  three  irGckff  ajler- 
lOfirtla,  front  In^ttiHTiintlon  of  tht  Bladder,  and  Ih/(FJiiia, 
Diseased  Kidney.  —  May,  ItiliS.  Tlie  following  CQPe  \s  the 
£rat  iu^tnncc  of  dcnth,  after  the  opcmtion  for  stone,  which  boB 
oecurrcd  to  mc  in  a  pnictiee  of  ovtr  thJity  ycitrrt.  Tho  pttH- 
moftcni  ajipenrmioca  showed  Umt  this  tcnuin^ttiou  wiuj  Almost 
inevitable* 

The  patient  was  a  ehoomnkcr^  of  spare  habit,  and  rather  poor 
Gondtitution ;  and  had  been  confined  wiUi  a  severe  attack  of 
pleurisy  on  the  left  aide  about  a  year  before,  eoon  after  which 
his  troubJcs  commenced.  The  first  symptoms  were  n  pain  id 
the  urethra,  and  smarting  on  micturition ;  the  atream  being 
suddenly  checked,  and  restored  again  on  a  cbangc  of  poailion- 
All  these  symptoms  were  ag^avatcti,  and  h^d  become  insup- 
portable whi^n  I  fir^t  saw  hitn, 

1  introduced  gently  a  sound,  and,  detecting  the  etone,  ecnt 
him  to  the  HimpitaK 

Being  etherized,  a  email  lithotritc  waa  introduced,  May  5, 
and  the  stone  sought  for.  It  was  not  at  onc^  j^clzed,  how- 
ever, though  apparently  of  very  large  size.  Finding  ef>me- 
thing  uncomcnon  in  the  eaee,  I  withdrew  the  ini^trument,  which 
cont^^ined  some  iloeeidi  of  mucous  membrane,  and  Boinc  colea* 
reoui  fragments.  The  bladder  was  now  injected  with  water 
more  fully»  a  liirge  inatnimeut  introduced,  and  the  stone,  meas- 
uring between  two  and  three  inches,  seized,  Thia  wna  tarried 
to  the  middle  of  the  bliidder,  and  crut^hed  witli  some  little  Ibrcc. 
The  small  fragments  were  then  caught  five  or'six  times,  and 
broken.      The  whole   opcrotion  lasted  less  than  Svc   minutea. 

There  was  some  fever  on   the  following  day,  but  tlie  water 


8TOHE  IK  TIIE  SLADDEK. 


215 


WHS  piwscd  more  freely  than  before.  On  the  third  day,  there 
woa  tenderncaa  over  die  bladder*  During  the  next  two  necka, 
many  of  the  fragmcDts  were  [insfcdi  though  with  diitioiilty.  I 
had  decided  that  he  could  not  undergo  the  rcpC4Xtcd  opcratiena 
for  destroying  so  larj^c  a  stone,  and  thot,  nd  soon  as  he  wan  in 
a  proper  condition,  i  would  reniovc  the  remaining  portions  bj 
lithotomy. 

At  the  end  of  tJiroe  weeks,  when  Kg  hnd  pas&ed  a  doy  more 
eonatbrtably  than  common,  hod  taken  solid  Kood,  and  ecemed  to 
be  improving,  he  wa^  suddenly  taken,  in  the  night,  with  a  foint- 
nci59,  and  died. 

The  following  appearanf^e^  wero  prcecntod  on  examination. 
The  bladder  was  greaiJy  thickened.  On  il^  poeterior  and  upper 
part  wraa  a  sac  communicating  with  it,  which  was  quite  thin 
towards  the  pei-itoncum,  and  in  a  etatc  of  high  inHaDimotion. 
There  woa  al^^o  peritonitis,  but  no  rupture  could  be  detected.  The 
right  kidney  was  about  one-quarter  its  Datum]  sixai  its  pclvia 
and  infundibuinm  were  greatly  dilutedi  and  iiJlcd  with  purulent 
laatler  and  ealenrcous  deposit ;  the  cortical  subatancc,  in  a  great 
measure,  having  diflappearcd.  The  ureter  wna  thickened-  The 
loft  kidney  wne  about  one-third  Inrgcr  than  natural.  Half  of  a 
cystic  oxide  enlculus  ^'n^  iound  in  the  bladder,  and  weighed 
480  grains;  also  a  frugmcnt  weighing  *22  grains.  AU  the  reat 
of  the  ftone  had  been  crushed,  and  \ui*l  passed  off  by  the  urine. 
The  ^vllole  Btonc  must  have  wcigheil  IHJO  grains.  The  right 
lung  waa  adherent  at  its  apex.  The  loft  lung  had  very  eiten- 
sirc  pleuritic  odhcsione  ;  and,  on  cutting  into  its  substance,  pu9 
escape<l  from  various  ixiiuts,  showing  purulent  abaorplion. 

It  is  probable,  on  the  lirst  explurntion  with  the  small  lithu- 
trite,  that  tlie  stone  woe  started  from  its  bed  in  the  eae,  which 
inHnracU,  and  gave  rine  to  the  aubecquent  symptoms. 

In  addition  to  the  preceding  caaca  of  cyetie  oxide  cfllc»lus>  1 
have  had  u,  thiid,  in  a.  mwi  under  my  care  for  frneture  of  the 
thigh-  During  his  confinement  to  bed,  he  waa  ecized  with 
violent  symptoms  referred  to  the  kidneys,  which  subsided  nfter 
tlic  expulsion,  p^r  ufethfrmi^  of  sevcmJ  minute  calculi,  which 
prevctl  on  examinatton  to  be  composed  of  pure  cystine.  Tho 
urine  also  contaJned  n  deposit  of  cyetinOf  in  largo  microsoopio 
crygtola- 


216 


GExrTi>um\Atty  oiioans. 


Case  CXIX. — OxithttG  "f  Lime  CaJc^tJu^,     LkholriUf. 

Ovre.  — An  Irish  boy,  15  years  of  oge,  wiis  brought  to  me 
in  October,  1848,  with  eymptom*  of  greai  irrifjibility  of  the 
bkdder»  such  as  usually  ari^omnflny  the  existence  of  a  forei^ 
body  in  that  organ.  At  tiiat  time  he  declined  all  ex  ami  nation, 
Hltbouifli  I  warned  him  of  the  proLtble  nature  of  the  dlacaae. 

In  November,  nearly  &  month  afterwards,  finding  that  no 
remedies  bad  any  eflecc  in  relieviog  bis  sufferin^H,  he  finbmitted 
to  the  operation  of  souuding,  and  (^uite  a  large  calculus  was 
discovered. 

Hia  mother  gnre  the  following  history  of  Ida  onse :  He  hud 
been  troubled  in  the  urinary  orgftna  from  infancy,  "When  three 
years  old,  he  had  a  violent  attnck  of  pain  in  the  region  of  the 
right  kidney,  for  which  ho  was  leeched  and  blistered.  He  re- 
covered for  the  time,  but  aftenvurds  was  seized  with  a  paia  lower 
down  on  the  same  side,  attended  with  difficulty  in  passing  water, 
and  with  bloody  urine-  From  that  time,  he  wao  slmoHt  con- 
stantly troubled.  He  was  obliged  to  pass  his  water  every  half 
hour,  and  it  escaped  invL>luntnrily  during  sleep.  He  could  not 
walk  fast  wjihont  pain,  and  passed  blood  oecaslonally. 

On  HL-eount  of  the  size  nnd  hardness  of  the  stone,  and  the  age 
of  the  patient,  I  advii^ed  the  operation  of  lithotomy;  but  tlie 
parents  would  not  listen  to  a  cutting  operation,  where  any  other 
method  waa  av:vilable,  1  therefore  delermint^  to  etherize  the 
patient,  make  an  attempt  with  the  erLiabing  instruments,  and,  if 
the  atone  was  fount]  to  resist  farther  than  waa  thought  safe,  to 
relinquish  this  operation  and  advise  lithotomy,  which  his  frienda 
would  probably  consent  to  when  the  former  was  found  to  be  im-* 
praciicjible. 

On  Nov-  16th,  the  first  operation  was  done  ^  the  bladder  waa 
injected  ^  the  crushing  instrumpnt  passed  in,  and  the  stone  seized. 
It  meat^nred  ore  and  a  half  inches.  Attempts  were  madB  to 
crush  it  by  means  of  the  screw;  but  this  waa  found  impossible 
on  account  of  it^  hardness.  The  hold  was  Therefore  rtdaxed, 
the  stone  seized  in  a  new  position,  more  on  one  side,  and  wh4 
then  broken  down  without  any  great  violence.  The  fragraerle 
were  cnishe*!  a  sr<^oiid  and  a  third  time. 

He  suffered  somewhat  in  the  bladder  after  the  operation,     A 


BTONf:  IN  THE   QLADDER. 


217 


number  of  Jragmcnta  of  the  caJcuIua  were  passed,  wliichj  on 
bcins  anftljicd,  were  found  to  consist  of  llic  os^Ulc  uf  lime, 
combined  with  the  triple  pLusphntc,  which  showed  iteclf  in 
glittering  tranfipai'ent  cryatnle.  The  Jntter  acemed  to  have  been 
deposited  on  the  aurfocc,  and  were  exceedingly  ehorp  and  irri- 
laling  to  the  toiith. 

20th.  The  operation  wa^  repeated;  the  Btooe*  when  tirst 
seized,  seeming  to  resist  the  action  both  of  (ho  €ei^w  iind 
Uaromcr  i  but,  atlcr  u  little  pcracvci-ancc,  It  wfla  finally  cni±»hcd 
by  pcrcueeion. 

The  following;  mornings  a  number  of  pieces  were  pBeeed,  and, 
among  others,  Jtppnrently  the  on<^mil  cakuluu  from  the  kidney  : 
it  WHS  of  a  li^^Ltidh-brown  color,  about  the  stiic  of  a  emidl  bean. 

The  operation  waa  repeated  aix  tiraca  at  intervals  of  a  wcek- 
The  time  devoted  to  the  acizin^  of  the  sti>ne  was  generally  about 
five  minuteS'  l^roin  the  groat  bardacss  of  ita  conipoaitioD,  it 
eoiild  not  be  crushed  into  Band,  as  is  the  cnse  with  the  pho.^phatic 
and  urir>aGid  ealeuli.  The  iragnienti^  were  largo,  and  required 
to  be  eeixed  and  enured  separately. 

Twice  in  the  courec  of  this  i>criod,  portions  became  engaged 
in  the  orifice  of  the  urethra  ;  and  it  woa  ncccaeary  to  adminiatcr 
other,  zind  extract  them,  as  the  L'anal  was  so  senf<itive  that  noth- 
ing could  be  done  without  the  aLa^istoncc  of  this  agent.  Finally, 
the  last  frngment  of  the  strme,  wJiieh  for  some  days  had  hcen 
lodged  in  the  neck  of  the  bladder,  and  which  I  liad  once  pushed 
bock,  beeamo  suildcnly  fixed  at  the  membranous  part  of  the 
uretiira,  so  aa  to  entirely  obstruct  the  course  of  the  urine,  To 
disengage  thia.  Hunter  s  forcepe  were  introduced  :  the  stone  was 
at  length  caught,  and  drawn  to  the  fosaa  navieularls.  From 
this  fipot  it  was  found  impimeible  to  extract  it  without  laceration 
of  the  urethra :  the  hoEd  on  it  was  therefore  relinquished,  and, 
by  the  use  of  forceps,  ^KJiti<ms  were  gradually  broken  away  un- 
til the  whole  was  removed. 

The  patient,  afler  thisi  fully  recovered  5  no  eymptoms  remain- 
ing to  denote  the  existence  of  an  irritation  of  thirteen  yeara^ 
standing  H         * 


S18 


GKNlTO-Ultty.LKY   ORGANS. 


CaBE  CXX.  — Vcfficttl  Ctdcftliin.     /jithf>triti/.     Itecovery. 

- — A  gentltfjuaa,  SO  yoBre  of  age,  eoosultcU  me  in  November, 
1853.  He  Und  the  fir«t  «ympti>iua  uF  the  dUesee  m  1843.  He 
had  previously,  (Uier  a  nephritic  nttackf  parted  a  staoh  c^culus 
from  tEie  urethm.  The  eymptomfl,  at  the  tituo  of  tho  upenLlicin, 
were  greut  pain,  a  fre«]ueiit  desire  to  piies  water,  Uoody  urine, 
and  injtliility  to  bear  tlie  jolting  of  any  vehicle-  The  water  wai 
paaeed  tTerv  halt-hour,  both  day  aud  iii-j^ht.  The  meiLSure  of 
the  cal(^u]uj^,  when  firf^t  seized  by  the  hthotritCf  was  tourtccil 
lines  in  diameter.  It  was  easily  crushed,  with  scarcely  any 
pain ;  fropnienta  pasflcd  off,  without  difficulty^  in  the  course  of 
tweniy-four  hour**.  The  operation  waa  re[jeated  three  time*  in 
a  fortnight,  without  the  ueo  of  other,  giving  scarcely  any  more 
uaeasinesd  ihnn  an  ordinarj-  case  of  cathctcriem  ;  and  the  patient 
was  perfectly  relieved  in  about  Ihrec  weehe. 


Case  CXXI.  —  Vt^cal  Cahuluf,.  A  Pebhh  foT  NncUn*. 
Bilateral  Lithotomy.  Heeovcnj.  — On  Nov.  7,  1847,  I  saw 
in  consultation  a  child  four  years  ofa^e,  aflected  with  eymp torn! 
of  some  foreign  substance  in  the  bladder.  The  child  was  thtiii 
ddicatCi  aud  tall  for  hij^  age.  The  history  of  tiis  di^eaee  was  9M 
follows ;  — 

Two  yeare  and  a  half  previously,  as  the  chiJd  was  making 
water  in  tho  street,  a  boy,  in  attempting  to  wrcfit  a  knife  from 
hinuT  pLille<I  him  over,  and  dragged  him  through  a  heap  of 
gravel-  Wlkcn  taken  up  by  hla  motlier,  a  quantity  of  this  sub- 
stance was  found  adherent  to  tho  glans  penis.  For  twonty-foor 
hour^i  he  haJ  an  almost  complete  stoppage  of  water.  At  the 
end  of  that  lime,  an  examination  being  niadot  diaclosod  a  small 
bit  of  gravel  lodged  just  within  the  orifice  of  the  urethra, 
was  removed  by  a  knitting-needle,  and  immediate  relief  obtained- 

Some  months  after  the  preceding  occurrouce»  the  child  began 
to  complain  of  difficulty  in  passing  his  water,  attended  with  fre- 
quent desire  to  evaemitc  the  bladtier.  Thcao  symptoms,  with 
intcTTalfl  of  case,  continued  till  within  a  few  months  of  the  time 
when  1  saw  him>  Then  they  became  much  aggravidcd,  bo  as 
to  make  it  imperative  to  have  active  nicufurcs  taken  for  his  re- 
lief ;  tho  sufferings  both  by  day  and  night  being  almost  copstont. 


STONE    [N    THK    RLAHJJEH- 


219 


and  tlie  cnlls  for  eviteufttin^  the  blnddor  inreasant.  All  nttecipts 
ac  an  iniroduction  of  n  aounJ  lieing  resisied,  he  was  etberized, 
and  I  dwcoi'ered  a  calculus. 

On  Nov-  l(i,  nn  npcrntion  having  heen  determined  an,  the 
child  W15  frdly  etherized,  find  a  sound  plaeed  in  ihe  blndder- 
Lithotomy  wuh  jjerforiTiod  by  the  bilriteral  melh-xl;  ihe  incision 
of  the  profltn-te  being  tnade  ^vith  a  straight,  prohe-poioted  bis- 
tonrv.  The*  atonp  wJis  removed  by  ti  large  polyjxie  forcieps. 
Ni>  bud  aynipiomB  followed  the  operation. 

On  the  lollowmg-  day,  the  water  paa^ed  by  the  urethra  :  on 
the  third,  by  tho  wound;  and  continued  to  do  so  tbr  a  week, 
when  It  resumed  its  natural  course. 

On  page  95  of  the  "Appendix  to  Etherization,  with  Surgical 
Remarks,"  will  be  found  a  deacription  of  tlie  stone,  with  aome 
CDiaments  upon  its  presumed  method  of  introduction,  by  Dr. 
J.  C.  Warren,  in  these  words:  — 

"The  Btonc  waa  ahont  half  an  inch  Jong,  the  fnuith  of  an 
inch  thick,  and  in  form  of  a  flattened  oval.  It  was  sawn  by 
Dr.  J.  B.  S.  Jackaon.  The  exterior  layer  conflisted  of  a  whit- 
ish deposit,  the  ebctecnth  of  an  inch  in  thJekuesa,  and  composed 
apparently  of  triple  phosphate.  The  layers  within  this  were  of 
a  brownish  color,  like  that  of  the  phosphate  of  lime,  and  were 
about  half  a  line  in  thickness-  In  the  midst  of  these  was  a 
harder  suhgtance,  about  a  line  in  diameter,  which  appeared  to 
be  silicious.  Its  outline  could  not  exactly  be  distin^isbed  from 
the  surrounding  biyere  of  brown  deposit. 

"  Tlie  reti'ogrado  paisage  of  the  apparent  Buclens  into  the 
bladder  may  eicite  Burpriae,  unless  we  take  into  consideration 
the  inverted  action  of  die  urethra,  by  which  bodies  received  into 
it  are  ao  often  conveyed  from  without  into  this  Drgan»  where 
they  serve  as  the  nuclei  of  stones.  The  introduction  of  this 
nucleus  may  receive  an  additional  explanation  from  the  fact,  that 
the  gravel-stone,  removed  by  the  mother,  prevented  the  paasnge 
of  urine  forced  into  the  urethra  by  the  strong  contractions  of  the 
bladder ;  and  this,  not  escaping^  was  driven  hack  by  the  contrac- 
tions  of  the  urethra,  carrying  along  the  inner  stone,  which 
formed  the  nucleus." 

The  first  of  the  following  cases  illustrates  the  ordinary  bi- 


220 


GBNlTOUUJNABr  OKOAKS- 


Inlernl  rjprrafion  of  Diipiivtren ^  hihI  may  serve  to  compnre  this 
method  with  ihal  ailopiei]  in  the  ne_xt  c;ibi%  wh(»re  the  i>ritna[y 
incifiione  wera  nuvel,  but  the  fiaii]  oneB  identttral  with  tliose  of 
Dii|juytren :  — 

Case  CXXIL  —  Vesicitl  Cfrlcuhis.  Siltiterttl  Ltlhotontff. 
Recovery-  ^A.  boy,  12  jcars  okl,  had  been  tTQubled  for  two 
or  three  years  with  a  want  of  power  to  retain  his  urine  ;  the 
Hiifferirg  h«il  Ijeen  excessive,  both  by  <Tny  and  night.  He  wiia 
in  a  very  miserable  and  emacin.Ie<l  (Mrdilion,  but  had  recently, 
however,  for  n.  few  weeks,  hfen  rmioh  more  conifGrtable ;  n 
fiiet  wbieh  was  afterwards  eiplaineil  by  finding  the  atonu  fixed 
in  the  upper  part  of  the  bladder.  The  preimce  wda  very  long, 
owing  to  the  habit  of  conRtJintly  pidlinjr  at  it.  On  sounding 
bim,  under  ether,  the  stone  was  felt  in  the  upper  pari  of  the 
bladder.  It  was  decided  to  perform  lithotomy,  wliich  waa  done 
by  tbe  bilaieral  method  of  Dopuytren.  A  eound  of  good  size 
was  introdneefi,  making  a  great  curve  outward,  so  as  to  project 
well  in  the  perinaium.  A  semilunar  ineiaion  wna  then  iniide 
ab<ive  the  nnua,  and  tlie  etaff  reached  at  the  membranous  por^ 
tion  of  tbe  iiretbra.  Dupuytren's  double  lithotome  Wtts  now 
piihW  into  tbe  bhidder,  with  its  eoneavity  upwnrdu ;  and,  tbe 
Bound  being  removed,  the  inatriiment  was  revenged,  its  bladea 
opened  to  the  extent  of  seven-eiijhths  of  an  ineh,  and  with- 
drawn. Tbe  forreps  were  now  intnxluced ;  the  finger  having 
previously  Ireen  used  to  explore  the  stjjne,  wliich  was  found 
firmly  adherent  to  the  upper  purt  of  the  bladder-  The  stone 
was  seiie*1  with  aome  <liflieulty,  nwing  to  the  firm  aiJhesiona 
whith  it  hiul  contraete*!  with  the  folds  of  tbe  muouuB  metnbrune ; 
but  it  was  finuUy  extracted  without  injury  to  the  organ.  It 
proved  to  be  a  mulberry  enleulus,  very  roiigli  nnd  irregular  In 
outline,  iind  weighing  180  grains.  A  piece  of  elaptio  catheter 
was  kept  In  the  wuund  for  twenty-four  huurs,  after  which  it  wbb 
diapeEBcd  with.  On  the  third  day,  a  little  water  waa  pnsaed  by 
the  urethra  ;  and,  on  the  tentli  day,  it  had  entirely  resumed  ita 
DHtunil  channel.  All  the  distressing  syniploms  of  stone  were 
imnLcdiiitely  relieved  by  the  o^iemtion  ;  and,  at  the  end  of  three 
weeks,  the  patient  waa  discharged  well. 


STOKE    tfi    THE    BLADDEfi. 


221 


Cask  CXXIII. — Vesical  Cnlnthis,  3fedjan  Li't/iotomy. 
Hecoi^ery.  —  A  boy,  13  yenra  ok],  entered  the  Hrjspitnl  in 
March,  1863,  on  account  af  great  BufTcring  in  the  regitm  of  tbe 
bladder,  jitvninjMinied  by  iTte<iiitmerce  of  urine.  Two  ycHrs 
boJbre,  he  noiicetl  an  cKrcasionnl  ditticidty  in  pausing  wnter^  at 
times  a  aiidden  stoppage  of  thr>  etream  occiirrpil,  and  the  urine 
waa  now  and  then  a  little  hluody.  The  symptoms  htniame  more 
urgent,  nnd  the  pain  eonfttant.  so  118  to  confine  him  to  hie  bed. 
The  urine  dribWetl  nwny,  ond  irritutcd  the  skin  of  tJie  penia, 
srrotnm,  nnd  thighs.  The  prepuce>  as  in  tbe  Inst  case,  waa 
much   elongated. 

On  intr<alui'ing  a  sound,  the  inslniment  encountered  much 
reeiaiant^e  at  the  neck  of  the  bladder,  but  Snally  pureed  ia  and 
wime  in  contact  with  a  stone.  The  bladder  was  quite  empty 
of  urine;  nud  tbe  cidrulun  mecling  die  r^cjund  at  diflereiiC 
points,  while  enveloi«?d  in  the  mucoiis  folds,  gave  the  impres- 
eion  of  the  exisfenrc  of  two  or  more  stones. 

It  was  decided  to  perforin  lithotomy,  after  relieving  tlie 
external  irritation  by  cleatiline^s  and  8uititble  dres^ingB. 

The  operation  which  was  perfonned  eombined  some  of  llie 
more  importaut  Aalurer^  both  of  tiie  riediim  und  bilateral 
uietbodH,  and  eeenis  to  ufler  eomc  ndvantagea  over  either.  A 
Bound  of  medium  site  was  pa^fled  into  the  bladder ;  tbe  meatua 
iiririftriue,  ivlueh  hud  become  \ery  much  conlnicted,  being  first 
piiglitly  enlarged  by  the  Ituife-  Tbe  ekin  was  then  divider!  in 
ihe  ufcedlan  raphf-,  and  the  disfleeliiiiii  continued  in  tlie  same  line 
until  the  membranouM  part  of  the  urethra  was  exposed.  Thiti 
wai^  next  opened,  and  tlie  attempt  made  to  introduce  the  double 
iithotome  ctic/ie  of  Dupuvtren,  Owirg  Ijj  the  uny  ltd  ding 
comlitum  of  the  neck  of  the  bladder,  the  litbolome  could  not 
rewdily  bo  passed  in  ;  a  prohe-pointed  histunry  was  tlierefcfrc 
eubatituted  for  it,  aud  the  proetate  divideil  on  bulb  tides.  Tbe 
finger  now  entcrcil  with  ease,  nnd  n  large  stone  wae  felt  very 
high  up  in  the  bladder.  Atlenipta  were  iiinde  tn  extract  it 
with  a  long  pmr  of  polypus  forceps,  and  then  with  the  onli- 
nary  lithotomy  forTCjw,  but  without  Huceeas,  owmg  to  ite  great 
bieb;  the  cut  in  the  jtrontale  was  therefore  enlarged,  and 
the  attempts  at  extraction   renewetl,   but  still  unBiicceeefully- 


2S3 


OENITO-ORrNABT  ORQAKB. 


Ab  \t  waa  not  deemed  safe  to  cnlftrgc  the  incisioii  in  the  proatatc 
further  with  the  knife,  the  two  forctingera  were  mtrodurcd,  back 
to  back,  nrd  the  aiibalance  of  the  glnnd  slightly  torn.  A  larger 
pnir  of  forceps  waa  then  passed  in  i  and,  by  ombrnting  the  whole 
Btone  within  its  jowa,  it  wue  extracted  without  further  difliculty- 
A  piece  of  catheter  was  placed  in  tlie  wound,  and  the  patient 
sent  bnck  to  bed. 

Un  the  ninth  dny,  the  urine  began  to  paea  through  the  urethra; 
[ind»  from  the  twelfth  davi  none  escaped  by  the  wound.  At  the 
end  of  three  weeks,  the  patient  wne  discharged,  with  the  external 
wound  nearly  healed,  and  free  trom  all  fyaiptoma  of  etonc. 

The  ealcuJuG,  w4iieh  appeared  to  be  composed  of  the  triple 
phosphate  of  magnesia  and  ammonia,  was  largo  and  very  rough  : 
it  measured  3J  inchcB  in  ita  longest  circumference,  and  2|^  in 
the  ehorteat;  its  weight  waa   210  grains. 

I  was  led  to  perform  the  operation  in  the  manner  related ; 
viz.,  by  making  an  incision  through  the  skin  in  the  caedian 
taph^T  instead  of  the  cross  cut  employed  by  Dupuytrcn,  ad 
illuetmtcci  in  the  first  case,  from  having  observed  how  easily 
theac  piirtd  could  be  dilated  in  the  inciaions  praetiBod  iu  perineal 
aection  for  the  diYiaion  of  strictnrea,  Irequently  im|iaeBablG  by 
the  Bmalleat  sound.  In  these  co^es,  after  cutting  through  a 
deep  pcrin;cum  filled  with  inflammatory  exudation,  it  ia  oftcu 
found  necessary  to  citercise  much  pntienco,  and  to  sjiend  much 
time  in  tracing  the  urethra  beyond  the  stricture.  Having  had 
oceaeion,  during  tho  past  few  ycare,  to  do  a  number  of  theae 
operatioufi,  most  of  them  entirely  without  any  guide,  I  wjia  led 
to  the  reHcction,  that  it  would  be  rery  eaay  ia  this  way  to  per- 
form the  operation  of  lithotomy  when  tJie  operator  i»  guided  by 
the  prcsoneo  of  a  lar;ijc  sUitf  in  the  urctlira.  When  the  mcdiaa 
flection  ia  pertbrmed  deliberately,  the  operator  hua  tlie  parta 
divided  freely  open  to  the  view;  which  is  not  the  case  in 
Diipuytren's  o)>eration,  which  has  to  ba  performed  mainly  by 
the  fiense  of  touch-  By  tins  method,  also,  the  vessels  are 
much  lesa  likely  to  be  wounded  than  in  the  common  operation. 
Although  different  kinds  of  operations  must  of  necessity  be 
praetiacd  to  suit  different  caece,  the  present  method  would  seem 
to  be  the  moat  direct  and  naturid  one  for  arriving  at  the  bhid- 


STO^TE    IW  THE   BLADDER. 


223 


dcr.  Since  performing  it,  1  hnvc  found  tlia.1  a  similnr  opera- 
tion  hfid  boon  sujii^'oatctl  by  Mr,  Eriehecn,  who  huJ  not  at  thnt 
lime,  however,  periurmcd  it  upon  Iho  living  subject,  Mr- 
Allurton'a  and  Mr.  Beaumont's  opcrationH,  altbou^b  done  in 
tbc  mcdiun  Ime,   arc  csscntiallj  clitlbniziti 


I  have  in  my  pu&ace^ion  a  large  calculus,  removed  from  tbe 
body  of  a  gentleman  after  tieath,  which  had  been  lodgeil  behind 
ihc  proaCatc.  He  bad  suftered  with  it  for  many  years;  and, 
finally,  it  wofl  the  cauec  of  his  death.  He  had  been  sounded 
by  a  number  of  distinguished  surgeons,  and  by  Bomo  dccliirod 
to  have  a  etone,  by  other*  not.  From  tide  tcQBon,  he  had 
deferred,  for  many  years,  submitting  to  an  operation.  By 
sounding  under  ether,  and  turning  tbc  beak  of  tbc  inetrumcnt 
backwards,  I  dctecced  a  stone ;  but  an  operation  was  tliougbt 
inexpedient,  on  account  of  the  great  disease  oxieting  in  ail 
tbe  urinary  organs-  After  death,  the  kidneys  were  found 
cxtennivoly  ult'crnted,  the  nrctcra  erlnrgod,  and  the  blud'icr 
greatly  thickened  and  aaeculated,  with  a  cavity  or  Joprostiion 
behind  the  enlarged  prostate,  in  which  the  calculus  woa  lodged 
and  partially  concealed. 

Case  CXXIV* — -  V^^sicai  Galcuhis  of  Oxalate  of  Lime  in 
a  Child  three  years  old*  ^ilatct'al  Oper<tiion.  Hecovoy^  — 
March.  l^'oT-  The  eymptoma  appeared  a  ycnr  and  a  half 
bciore.  The  Buffcringe  were  iateneei  preventing  sleep,  and 
producing  all  the  uBual  Bym[itonia  of  atone  in  tbc  most  aggrn- 
vatcd  iorm^  The  patient  had  been  twice  bounded,  while  under 
tlio  iniliiciice  of  etlicr,  by  experienced  ^iurgcons ;  but  no  dtono 
wiia  detected.  After  etherizing  him,  I  introduced  a  common 
sound,  hul,  with  tlie  most  careful  cxaaiinalion*  asaistcJ  by  the 
finger  intnuiaecd  into  the  rectum,  failed  to  find  nny  calculus. 
Tlic  instrument  was  therefore  withdrawn,  and  a  sound  with  a 
flight  curve  at  its  end,  eoracwhat  similar  to  the  one  describai 
by  Mcrcicr  for  exploring  the  priiatato  glnnd,  was  used.  Thi;?, 
being  passed  in,  and  taking  up  Ices  room  than  the  conimuti 
sound,  at  onee  struck  a  atone,  which  lay  very  high  up  in  tlie 
bladder. 


i94 


GENITO-UItlXARV   ORGAKS. 


I  ut  firfit  pro|kc»»et]  to  dej^troy  the  atone  in  this  Case  b^  the 
crur^fiiii^  process,  Imt  soon  found  tlizLt  tlie  bLtdder  waa  too  much 
contracted  to  conuiiii  tufficJent  wnter  to  ullow  the  inatnmicnt  to 
be  irionfcuvred  safelv-  The  bilnteral  operation  wjis  jierformcd, 
and  a  Ini^e  stoiie  ruuioved-  The  coiita  of  llie  bladder  were 
much  thickened,  and  its  cay'ity  greatly  cloug^itcd.  so  ihaX  quite 
B  long  [iciir  of  forceps  wjia  requifL-d  to  reach  and  dislodge  tlie 
stone.  The  patient  slept  soundly  the  night  after  the  operation, 
Lein^  the  first  ;rood  night's  sleep  be  had  enjoyed  for  more  than 
a  jear.  At  the  end  of  a  week,  the  urine  [mased  by  the  ure- 
thra;  iuid,  in  another  neek,  the  child  went  hctine  well, 


Case  CXXV.  —  Ve/itcal  Calcylusofeitjhlcenmonihit^siaud' 

till/*  Mt:dian  Lttfrrjtomtf,  litcoven/.  —  A  boy,  4J  years 
old,  had  always  enjoyed  good  hejiJ:h,  with  the  exception  of  the 
frllowhig  symptoras,  which  hid  hiated  about  eighteen  months. 
At  first,  he  was  obliged  to  pass  his  wjiter  more  frequently 
tlian  usual,  —  as  ofleu  as  twelve  thnes  during  the  twenty^-four 
hoiir&.  lie  sooD  had  great  difhculty  in  inducing  the  flow  of 
urine,  making  hearing-down  Li^orta,  and  exhibiting  Bigna  of 
pain.  A  correct  diognosia  was  not  made-  Owing  to  conatftnt 
pulling,  to  relicye  the  pain  at  the  end  of  his  penis,  the  prepuce 
wne  greatly  culArged.  H]8  health  was  much  reduced  ;  his  sleep 
was  iaterru[)ted  by  [jata»  and  desire  to  pass  urine,  which  dribbled 
away» 

On  entering  the  Ilospitn],  he  was  etherized  and  sounded,  when 
a  calculus,  about  the  size  af  a  filbert,  cuuld  he  caaily  felt.  The 
urethra  was  found  unusually  capacious- 
Four  days  flfierw^irds,  the  patient  was  again  etherized;  tlie 
bladder  was  filled  Avith  warn:  water;  an  ordioary  grooved  staff 
introduced;  and  an  incision,  about  one  and  a  quailer  inches 
in  lengtli,  made  in  the  median  hue  of  the  perina.'uoi.  Tlie 
Blaff  being  re^iched,  a  probe-pointed  knife  was  paaacd  along  the 
groove,  and  a  lateral  incision  wiia  made  through  the  prostate. 
This  incision  waa  made  bilateral  by  the  Uthotomc  cackS.  The 
calculus  was  extracted  with  some  difficulty*  The  dust  from 
ihc  calculus  coneistcd  of  oxalate  of  bnic,  carbonate  of  lime,  triple 
phosphate  of  ammonLt  and  magnesia^  and  urate  of  ammonuii 


BTOVE    TN    TRE    Bl^ADUEK. 


225 


ta 


On  the  third  day  nftor  the  oporution,  he  pussed  n  little  Trater 
by  the  urothni;  it  then  stopped,  and  for  fuur  dajs  passed  by  the 
wound ;  after  which,  it  passed  entirely  by  the  urethra, 

Ahmit  a  fortnight  aftpr  the  operation^  the  patient.  eThihiting 
AOme  ayniploms  indienting  the  presence  of  ei\lculiis«  a  sound 
waa  introduced  into  tfie  blndder;  but  nothing  was  dispovered, 

A  month  later,  the  child  waa  seen  again,  after  a  visit  of  ten 
dny»  in  the  nnuntry.  He  was  in  a  state  of  perfnni  henUh,  his 
whole  condition  Laving  been  entirely  ehanged  by  the  reniovtd  of 
the  stone  > 

Case  CXXVT. —  Vesicrtl  Oftladrie,  3fedmn  Lithotomy^ 
Recovery.  —  June  17,  1865.  A  boy,  aged  3j  yeora.  The 
symptoms  were  first  noticed  when  the  child  wag  but  little  more 
than  a  yenr  old,  and  were  ns  follows:  water  pasi^ed  otl;en, 
attended  with  diJliculty  and  pnin,  at  times  dribbling  away  in 
drops;   sleep   nnit^h  disturbed;  phimoats. 

For  over  a  year,  he  continued  to  grow  worse.  In  the  autumn 
of  1864,  according  to  medical  advice,  took  cod^liver  oil,  which 
improTed  hfs  general  henJth.  During  the  winter,  micturition 
waji  invohintnry.  Tlis  sippetilc  was  good,  and  he  slept  well 
when  not  disturbed  by  paJn- 

On  entering  the  Hotipital,  an  exAmination  was  made  while 
the  patient  was  under  the  induence  of  ether.  The  prepuce  was 
found  to  he  idmoBt  impcrviou'^»  admitting  only  a  umall  probe 
through  itH  Aperture,  It  was  slit  up  along  the  dorsum  of  the 
glana,  and  the  raw  edges  were  brought  together  by  a  few  sut- 
ures. A  sound  was  pnssed  into  the  bladder,  when  the  calculus 
was  easily  detected.  Analysts  of  urine  showed  it  to  l>e  cloudy, 
li^il^oolored,  w^ith  eonsidenible  preoipitatc  of  a  ropy  character. 
It  was  albuminous,  corresponding  to  the  dej>osic  of  pus  corpus- 
cles ;  very  faintly  nlkidtrie.  Under  (lie  mierosco|i€,  a  large 
number  of  crystals  of  the  triple  phoHphates,  interspersed  with 
puB  and  mucus  corpuscles  were  ob*;erve<L 

A  few  ihiyrt  afterwards,  the  median  operation  was  performed, 
US  detailed  in  the  previous  ease,  and  a  very  large  calculufl  re- 
moved with  much  difficulty,  notwithstanding  the  proatale  was  • 
notched  on  both  sides  after  the  first  section.      The  effect  of  tlie 

3? 


S26 


GENlTO-maNART    ORGANS, 


Operation  was  nt  (mt-e  to  entirely  relieve  the  pntient  from  pain. 
Tlie  tlilrtl  day  Hfter»  lie  pawsuJ  a  few  tlrojia  of  Tirine  by  the 
urethra ;  nt  the  end  of  a  week,  the  water  passed  freely  by  the 
DSLtiir&l  po^ange ;  at  tlie  end  uf  two  weeks,  he  went  home  quite 
well. 


8TBICTUBE   OF  THE  UBKTTniA,  WTTB   RETENTIOX  OF 
tnUXE. 

T  do  not  propose  to  enter  into  tlie  treiilioeiit  genenilly  pur- 
sued for  strictures  of  the  urethra,  hut  think  it  of  great  impor- 
tance to  allude  to  tliose  cartes  where,  frotn  aoine  nccidental 
cause,  a  sudden  retention  takes  phice,  attended  with  alarming 
eyuiptoms.  The  surgeon's  first  impulse  ie  tc»  relieve  the  jiaticnt 
by  the  u«c  of  an  inetniiQent-  This  is  frequeuily  found  ijnpo&* 
eible,  ami  it  is  ah[ui<ioned,  leaving  the  patient  in  a  wor»^  (xtudi* 
tion  than  before:  in  fact,  a  pai^sage  already  eKcesairely  smaU 
has  become  almost  nbliterat.ed  by  Hweliin^,  and,  of  course,  no 
instniment  ean  lie  made  to  penetrate  it.  Notlung,  indeed, 
needri  greater  forl>earaTiee  on  the  part  of  the  surgeon  than  to 
Terrain  hlnifldf  froiu  inKirumental  interference,  when  the  pulient 
is  (trying  out  in  agony  to  be  relieved  from  Jiis  suffering.  Tlie 
oaur«e  which  I  have  gejkerally  fonnd  suecestifiiJ  in  suth  cases  10 
as  follows  :  First,  where  it  is  pojHwible  to  temporize,  to  give  aa 
opiate  eiitina.  Second,  to  cover  the  ptrinffiutn  and  lower  part 
of  the  abdomen  with  ariodyne  fonieutatiuns.  By  tlieec  means^' 
nleep  is  gencndly  produced,  attended  with  profuse  pert^piration ; 
and,  when  tlie  patient  awakes,  he  can  empty  the  bladder. 
SomelimeM,  even  during  [sleep,  tlie  urine  gmditally  trickles 
away*  After  this,  by  pursuing  an  nutiplilugistie  course  for  a 
day  or  two,  n  small  iKiugie  mny  be  pas^eil,  and  the  stricture 
treikted  iu  the  ordmiu'y  way  by  dilatation.  Tliird,  if  the;  sufiei- 
mg  id  excesHLVet  and  the  distention  so  great  as  ordinarily  to 
indicate  puncture  oftlje  bladder  by  the  rectum,  the  patient  may 
be  etherized,  when,  by  passitig  down  a  fijifurm  buu^e,  auJ 
msertlng  it  parlialJy  into  the  stricture  hy  a  twirling  motion,  I 
have  often  aeen  the  urine  at  once  begin  to  flow  hy  ita  side  ;  and 
in  one  or   two  in«tanccaT   ou  withJrawiug    It,   a  vmall    atitnin 


BTHICTUEE   OF  THE   imETHRA, 


227 


followed,  which  continued  to  flow  until  the  bladder  wm  com- 
pletely emptied. 

In  n  patient  who  applied  to  me,  not  long  eince,  for  the  trent- 
ment  of  a  stn^tiire  of  long  Mfinilin^*  I  found  tbnt  it  wlls  impos* 
siblc  to  pit&a  El  filiform  bougie.  IIo  wns,  thcreforcT  put  undor 
trc&tmentf  jind  inetrunienta  abstained  from-  A  fe^  days  afler- 
wurda,  he  wils  seized  with  a  chill,  and  sent  for  me  to  vifiit  hini- 
Not  beiog  able  to  attend,  I  requested  a  friend  to  ecu  him.  He 
found  n  large,  hard  tumor  over  tlie  puhea,  and  a  retention  of 
■urine.  The  patient,  however,  complained  of  no  pain,  althouja^ 
the  CiLfie  Bcemcd  almost  to  indit^aie  tlic  ue<}eHstty  for  some  surgi- 
cal interference.  The  condition  of  tlung«  being  reported  to  mo, 
I  advised  the  treatment  by  opiates  and  fomentation^T  o^  above 
suggested.  It  was  followed,  in  the  course  of  the  night,  by 
rcliof  to  the  bladder.  On  the  succeeding  da}-,  the  tumor  fltill 
existed,  though  not  quite  sa  large  aa  on  the  preceding  day;  and 
the  patient  atated  that  he  had  noticed  it  for  the  previous  eigLt 
months,  tlioufrh  amaUcT*  than  in  this  attack.  I  saw  him  some 
weeks  siLbaequcutly,  with  the  tumor  undiminished  in  aize,  al- 
though a  good-aized  bougie  could  bo  passed  through  the  strict- 
ure, where,  at  first,  none  would  penetrate-  The  tumor  was 
doubtle^B  the  bladder  in  a  thickened  condition,  partially  filled 
with  water^  and  was  the  result  of  longKiontinued  ohatruetion  to 
itfl  delivery. 


Case  CXXVII,  —  lietentian  of  Urine  reli&ved  hy  Iniro^ 
dueiion    of  CtipillaTy    Bougie    atid    Opiate    Enema.  — A 

young  man,  28  yeai-a  of  age,  on  retiring  at  night,  found  that 
he  was  nnable  to  urinate,  and,  in  the  morning  folloudng,  also 
^ed  to  do  fio.  Five  years  before,  he  had  gonorrhtra  r  this 
vfttB  followed,  two  years  fnibHcquently,  with  complete  stoppage 
of  urine,  which  was  relieved  by  the  use  of  a  catheter,  and  «ince 
he  hod  never  made  a  full  stream.  He  couatilted  a  physician, 
who  tried  to  introduce  an  instrument,  but  was  unable  to  accom- 
plish it.  He  was  thea  directed  to  me  in  a  very  suffering  &tate, 
with  the  bladder  much  distoudcd-  I  at  once  introduced  a  oa|nl- 
lary  bougie  of  the  smallest  aiae,  which  passed  into,  but  not 
through,  the  stricture.  On  withdrawing  it,  the  urine  began  to 
dribble  away. 


228 


GENlTO-IIKraART    OROAKS- 


He  waa  then  tlirpeled  to  go  to  the  Hofijiital,  wlnjrt  lie  liad  a 
wunn  biidi  given  him,  nnd  an  eneiiift  of  fitrly  dmiis  uf  tini^ture 
of  opium  in  b.  wineglass  af  Bta.rch.  In  about  four  houra  tkher 
this,  lie  wjis  able  to  eni|it3"  hin  liladder,  milking  ijinte  a  fair 
Htream,  He  rt^mmned  in  the  Hospiml  a.  number  of  duys,  until 
ho  could  be  safety  discharged,  declining  any  ayeleniatic  treat* 
ment  for  his  Htriccore. 


Case  CXJ^VUl.— Stricture   of  Urethra.     Betnitton  of 
Urtne^     Relieved  by  Capillary  Boutfie.  —  A  man,  33  years  of 
ngp,  was  brouglit  lo  me  tm   a  Sunday  morning  in  November, 
iHfil,  suffering  greatly  fn.im  inal^ility  to  pass  bi.H  wnt<fr,      bfijne 
years  before  he  HulI  gonorrhoEa^  the  effect  of  wliicb  lasted  for  the 
better  part  of  a  year.      He  indulge*!   freely  in  ardent   spirilfl- 
On  Satiirtlny,  after  getting  wet   m  a  storm,  he  was  tnken  witli 
a  stoppage  of  water.      Krery  means  were  tried  by  Ilia  [jhjMician 
to  relieve  bim.      On  Sunday,  finding  all    ap[»li cations   tail,   he 
sent    bim  to  me  for  advice-      I   fount)    the  bladder  distended. 
]Vly  Rrst  disposition  was  to  send  bim  to  the  Hospitid,  mid  tiy 
the  effect   of   antiphlogistic   and    narcotic  remedves,   before  ut- 
tempting  the  u^e  of  any  instrument,  as  tbe  catheter  had  beun 
already    tried    withcmt    effet-t,    only    producing    a  diKcliatge   of 
blood.      Hij^  pain,  however,  was  eo  excessive,  that  I  decided  to 
uttempt  tlie  use  of  n  means  which,  tbree  times  before,  I  had| 
found  effectual   in  wises  of  retention  attended  witb   very  close, 
etrlcture.      Taking  one  of  Chiirri^re'M  smallest  bougie»,  almost^ 
capillary^  T  grfulually  passed  it  down  the  passage,  aufl  carefully, 
without  pressure,  worked  it  inut  tbe  stricture,  wbieh  took  a  firm 
hold  upon   it>      Tbe    jmtient  being  cmttioned  not  to  strain,  it 
waa  now  slowly  withdrawn,  when  a  small  and  irregular  ntream. 
of  water  followed.      He  was  retpieated  to  stand  up  ;  nod  slowly, 
by  jets,  some  blood  now  und    then    pasBing  out,  the  bladder; 
was   freed,  aud   almost  entire    relief  from    the   excessive    tor^j 
ment    obtained.       Tbe    patient    wa^    sent    to    the    Hospital,    a 
warm    bath    given^   and    an  eaemji  of   forty  drops  of  tinciuTft 
of  opium  ailer  it. 

He  bad  a  good  niglit;  and  cii  the  following  morning  passed 
bis  water  easily.  He  was  kejit  on  a  lii^uid  diet,  and  on  the 
13th  left  quite  well. 


axKicrruKK  of  tiie  urethua. 


229 


Cask  CXXTX.  —  Gnlta-prrclut  lionifit;  broken  off  iti  the 
Urttkni,  Fr(if}mtnU  ejei^ted  xpontant^ouelif .  ^  185iJ.  A 
young  man  applied  tu  me  ^IjileeuflGrLDg  uadt;r  an  obstruction  in 
parsing  vviittr.  for  which  he  hiwl  Lretii  subjected  to  much  treftt- 
nieut,  withinjt  relief.  He  luul  co^iti-acted  a  gimijrrkcpa  nine 
uii>Dthj4  helbrCf  aiid  had  a  gleet  ^ince.  The  symptoiufi  Indiaitiug 
fitricture,  he  was  advij^ed  to  liave  the  urethra  iixplorcd.  A 
Anirill  wax  bougie  was  Rmt  selected  irom  a  bundle,  but  rejected 
from  being  a  litlle  injuivd.  The  uext  tliat  ofTei-etl  w^ia  one  of 
gutta  percha ;  nml,  being  of  the  requisite  sir-e,  it  w&a  softened  in 
the  band,  and  pa^aed  up  readily  tn  the  pruBtatlc  purtlun  of  the 
urcibra*  Meeting  bere  with  some  ohsUuetloD,  it  wiu  wltli- 
drawn^  tlie  point  a  little  Hofliened  and  bent,  and  it  then  went 
caaily  Lntu  the  bladder,  without  ihe  use  of  any  force.  On  tak- 
ing hold  of  the  iuatiiinient  to  nithilraw  it,  at^cr  it  had  remjuned 
a  uiiuute  or  two  iii  gitu,  it  br(»ke  oH'  abort  at  the  orifice  of  the 
urethra;  or,  rather,  dropped  ofT,  as  not  the  leattt  violence  was 
applied  to  iL.  \  reijuestetl  the  jiatient  lo  Bland  perfeetly  atill, 
not  having  any  (|ue8tiou  at  the  time  but  limt,  with  a  forcepa,  it 
could  be  seized,  and  readjiy  withdrawn.  This  was  found  im- 
practiunble.  It  Heenied  to  retract,  and  bury  iLi^elf  in  the  anterior 
wall  fif  ibc  urethra;  and  any  attempt  at  seizing  it  only  resulted 
in  laceration  of  the  lining  membrane.  Various  instriinieikta 
were  tried,  whirh  T  had  generally  employed  in  wididmwing 
ibreign  cuhAtancca^  but,  fmia  the  pecuharly  aofl  nature  of  the 
muteriol  iu  the  present  iiL^tuncc,  and  \i&  umall  aize,  it  i:ould  not 
be  detected  or  «eized.  KffiJTis  were  made,  by  p^issing  the  finger 
into  the  rectum  and  by  manipulationi4  on  tlie  exterual  [»art  of  tlie 
uretbrn,  to  force  the  fragment  forwards;  hut*  from  the  reasons 
mentioDed  above,  viz.,  its  softness,  «mall  si^e,  and  ite  not  die- 
tending  the  canal  ao  as  to  make  itj^elf  [)crcex'tihle»  nothing  ci>tdd 
be  efl'ected  iu  this  way-  The  patient  was  ^eut  to  the  Jlospital; 
ftnd  as  it  wad  found  practicable  to  piisa  a  catheter  by  the  ifide  of 
the  bougie,  and  free  ihe  bladder,  it  was  concluded  not  to  cut 
down  for  the  purpose  of  removing  it*  hut  for  the  present  to  leave 
the  caae,  to  long  aa  the  aymptoms  were  not  urgent^  and  see 
what  nature  would  effect-  He  was  ordered  %  warm  bath,  and 
confined  to  his  bed  on  a  liijuid  diet.     The  day  foUowing,  he  was 


»30 


QENTTO- URINARY    OROANa, 


free  from  pain,  niul  lm<l  pasaetl  water  wliile  in  Hie  bath.  On 
tlie  tliinl  day-j  lie  abserveJ  a.  hani  Htibstiiruie  through  tlif  wnlU  uf 
the  urctlira,  making  its  waj  towanla  the  unficu :  thi^  he  oasisted 
&  little,  ]U](]  extracted  a  bit  uf  boug^le  jm  inch  m  length,  very 
brittle,  and  shrivelled  up-  On  the  Rfl]k  ilay  a  «tl1]  hirger  piooe 
was  plumed,  and  on  the  ^(ixth  the  reniaiiuler  of  the  instrument, 
niJiking  in  all  ahout  pcven  inchfis.  Tie  BTiHere*!  very  little  from 
its  presence  in  the  urctlini,  hia  prlncipul  coiupluint  being  the 
BorenL'Bh  of  tlie  urtilhra  near  the  menlns,  caused  by  ihe  atlempls 
made  to  extract  it;  which,  however,  had  been  conducted  witb 
the  utmiitit  care»  and  soon  dlacuntlnuetl,  as  they  were  fuund  to 
be  useless.  Tlie  pntic&t  quiekly  recovered,  and  waa  couipletely 
relieved  from  his  previous  troublesome  disease- 

I  have  often  use<l  the  gutta-percha  bougiea  for  taking  Impres- 
Bionf*  of  Htrictures,  and,  until  tlie  present  case,  had  never  expe- 
rienced any  iiccideiit  from  them.  lu  order  to  be  employed  vritb 
Btifety,  tbey  ehoidd  he  made  fresh  ^vhen  ref|uired  for  use,  aa 
tbey  become  exLremely  brittle  on  espoaurc  for  any  length  of 
tlum  to  the  air. 

PERDfEAL  SECTION. 


Mr*  Syme,  of  Edinburgh,  was  the  first  to  call  the  attention 
of  tlie  jirofeHfion  to  this  operation  for  the  relief  of  stricture. 

In  the  "  American  Journal  of  Medical  Sciences  for  ISGl ,"  1 
puLli^hed  a  paper  upou  this  subject,  in  which  I  advocated  the 
exten^inn  of  the  operation  to  a  ciat*s  of  cases  not  included  bj 
Mr.  Syme;  viz.,  to  those  strictures  in  which  iiiatruments  are 
iiupracti cable,  arising  eitlier  from  injury  or  disease,  Mr,  Bryant 
recommended  for  them,  in  Guy'a  Xloapital  licporta,  puncture  of 
the  hladJcr  through  the  rectum.  In  a  number  of  inAtaucett^  I 
have  iutrudjced  a  suiF  as  fu.r  as  the  stricture  ;  and  tlien,  cutting 
down  upoa  it,  searched  for  the  continuation  of  the  urethm, 
and,  wfien  found,  divided  It  by  careful  touches  of  the  knife. 
If  the  urethra  is  found  with  difficulty,  the  patient  may  be 
allowed  to  recover  from  the  in^ucncc  of  the  ether  eu£Bciently 
to  make  an  elfort  to  puss  water,  and  then  die  bulging  portion 
of  the  urethra  near  the  bladder  can  be  pierced,  and  the  Btricture 


PERI»KAL  SECTION. 


231 


[TT^ed  from  bohtnd  forward  till  the  end  of  the  stuff  is  reached ; 
Dr,  withuut  ihie  affietance,  the  uretlira  amy  be  iounediately  cut 
Jown  upon  near  tlie  bladder- 

A  few  cft^eft  are  scleciedj  which  show  the  advantages  of  peri- 
neal section,  even  in  the  mo£t  desperate  cases. 


Case  CSXX,  —  Organic  Stricture  of  the  Urethra  of  ton 
years'  standing.  The  Urttie  finfiU^  pa^Jied  ia  Drops.  Re- 
tsntion,  P^nenl  Section.  Jjiviffion  ofihe  Strittttre.  Com- 
plete Hecovertj,  —  A  man,  about  30  years  of  age,  entered  the 

Hospital  on  April  30,  ldf>0,  with  a  stricture  of  the  urethra 
of  ten  years'  dtiratioa.  The  water,  when  he  entered^  passed 
in  a  very  small  etream  ;  and  it  wae  constantly  dribbling  during 
the  night,  accompanied  witli  a  purulent  discharge.  He  com- 
plained of  pain  in  the  renal  rcpon^  thou;rh  not  of  a  severe 
character.  After  very  careftil  attempta  to  paas  a  bougie  of  the 
amalleet  de^ription.  It  was  finally  decided  to  incise  the  stric- 
ture from  within,  wliicb  was  done  oa  May  15th  with  temporary 
relief. 

On  May  2*Itb,  the  urine  became  leea  free;  there  was  conaider- 
able  Julnces  in  the  pubic  re^on ;  and  the  patient  complained  of 
pajn  about  the  bltidderf  with  gt^crol  uncu^inCEs. 

On  the  next  day,  I  found  he  had  a  complete  retention  of 
urine,  and  proceeded  at  once  to  perform  perineal  section.  He 
waa  plflcod  on  a  tabic  on  his  back  ;  and  after  being  thoroughly 
etherized,  so  that  hia  joints  were  ftilly  relaxed,  he  was  tied,  as 
in  the  operation  for  lithotomy,  I  have  found  it  much  bettor  to 
contitie  the  limbs  in  this  way,  than  to  intrust  them  to  the  care  of 
aseij^iantflf  who  are  apt  to  be  worn  out  during  an  operation  bo 
likely  to  he  long  and  tedious.  A  small  staA'  was  introduced; 
and  it  seemed  to  penetrate  the  first  Etriciurc.  which  was  incised 
about  a  couple  of  weeks  before,  and  brought  up  against  a  second, 
apparently  ju^t  behind  the  root  of  the  scrotum-  The  fore- 
finger of  the  left  hand  was  then  introduced  into  the  rectum, 
and  the  situation  of  the  prostate  ascertained.  The  pcriua^um 
was  then  divided,  and  a  careful  dissection  made  to  nj^ccrtain  (he 
site  of  the  urethra.  This  wa*  rendered  very  tedious  by  tlio  hem- 
orrhage from  the  Ijulh  at  the  bottom  of  the  deep  wound  ^  which 


232 


QENITO-ITRINARY    OROAXP. 


in  this  case  waa  ini>re  tlum  urdmarily  trouUesome.  The  urethra, 
however,  was  fiiLtllj'  mieiied  ilirtttly  in  tVoni;  of  the  proslale, 
BJid  a  large  giirn-eCa.'^tJC  c^thelcr  paefied  through  the  wuunti  Ltito 
tbe  bliidder,  giving  exit  to  a  very  krge  quantity  of  urine.  The 
csnal  WHS  now  opened  forwardfl,  and  the  eallositips  freely  diiided, 
until  the  fiticffwMP  reiichtKl.  A  sef*ond  gum-elaslic  estheier  whs 
now  jmssed  downwards,  thruui^h  the  [>eni!4,  until  iC  Jippenred  in 
the  wound ;  the  i^oiy  end  of  tlie  fin<t  having  been  cut  off,  tlie 
point  of  the  wcord  was  insinuated  into  it,  and  firmly  fixed-  In 
this  manner  it  was  dragged  up  through  the  whole  extent  of  tJie 
nretlira^  Tn  similar  rases,  whore  it  la  difficult  to  find  tlie  iire- 
thrii,  and  where  other  meant:  have  failed,  the  oourse  might  be 
pursued  which  w»h  adopted  in  tlte  jireaeut  cajie.  I  nllowed  tlie 
patient  partially  to  recover  from  the  elhor;  stinmlatrd  him  to 
make  nn  efTort  to  urinate;  and  when  the  urethra,  behind  [he 
atrieture,  became  dila-ted,  a  minute  strenm  of  unne  lasued^  indi- 
cating tlie  s[Kit  for  the  introduciiuu  of  a  probe,  and  llie  urethra 
was  found. 

No  unpleasant  symptoms  followed  the  operation  :  the  p&tient 
was  eomfortflble,  and  relieved  from  the  sense  *if  fuloesa  caused 
by  the  distended  bladdnr  and  ureters.  At  the  end  of  a  week, 
the  first  catheter,  being  removed,  wiia  found  to  have  been  pur- 
tiidly  acted  upon  by  the  urine,  ntid  its  calibre  somewhat 
obstructed  ;    it  was  replaced  by  nnnther. 

At  the  end  of  a  month,  he  was  ahle  to  introduce  the  instni* 
ment  himself;  and,  at  the  end  of  two  months,  [he  wound  in  the 
perimeum  having  healed^  he  ke|Tt  it  in  at  nighty  leaving  it  out 
during  tho  day. 

He  shortly  after  left  the  Hospital  entirely  well- 

Cabe  CXXXI.  —  Stricture  of  th^.  Urethrn  of  ivetity^Jtv* 
years^  duration,  yumerous  Urinary  I^iHiflie  in  thB  Serotmn 
and  Perint^\tm.  Perineal  Secfton.  Curt,  —  A  man  entered 
the  Massnrhn setts  freneral  Hosjiital  on  April  24,  1860,  and 
gave  the  following  history  of  himself.  He  had  siiffered  from 
gonorrhea  twenty-five  years  previously  :  he  then  had  a  slight 
stricture,  which,  after  fifteen  or  sixteen  years,  became  so  tight 
fls  to  give  liim   a  great  deal   of   inconvenience,    for   which  he 


I'EEtlWEAl,    SKf.TlON. 


S33 


entered  the  Hnsjjifal  iimler  my  nnre,  nnd  waa  lrecit<]d  by  irlornHl 
iniiisior.  Thi.'i  relievwl  hiui  tor  a  time.  In  185^,  a  fistulous 
ojteaing  appeared  in  tlie  periiusum,  followed  by  two  in  tlie 
BcruhiTo  :  throiigii  these  opt^nings,  purulent  miktter,  with  iirinej 
was  fredy  discharged.  The  wliole  of  the  scrotum  wiis  tense, 
indurated,  and  biiirowed  by  sinuses.  Two  monlhe  previous  Ut 
his  admission,  n  No-  1  bougie  was  passed  into  the  bladder  after 
much  efthrt,  by  whirh  his  syniplonis  were  aggravated. 

I  pulsed  a  No.  1  bougio  down  to  the  Btricture,  and  kept  it 
applied  for  two  or  three  houra  diiily,  eieriing  a  gentle  pressure 
against  the  stricture.  After  treatment  for  iihout  a  week  in  this 
way,  i\\Q  stricture  gave  way,  and  the  instniment  passed  into  the 
bbulder. 

No  I  with  standing  the  passage  of  the  bougie,  the  disease  of  the 
Bcrotum  increased  ;  and  towards  the  Ist  of  June,  the  atriciure 
having  Again  closed,  so  that  it  was  quite  impcsalble  to  patis  any 
itistruraent,  perineal  section  was  done  at  his  rcqueut,  on  June 
4th. 

He  was  etherized,  and  confined  in  the  position  for  Utliotomy. 
Syme'e  floiind  was  passed  through  one  stricture,  and  encountered 
&  second.  An  incision  was  niado  in  the  median  line  of  the  peri- 
na>iim,  untd  the  point  of  the  ^taff  wa^  reached.  The  dleseelion 
was  tediouB,  front  the  hardening  of  the  tissues  by  in61trationi 
and  on  account  of  the  hemorrhage,  which  was  very  free:  tho 
porina^um  also  was  uncommonly  deep.  In  order  to  see  more 
clearly  the  continuation  of  the  urethra  beyond  the  stricture,  the 
endof  thestalTwaB  turned  out  through  tho  incision,  and  served  to 
hook  up,  and  thus  brin^  tho  deeper  parts  mure  fully  into  view. 
The  wound  being  freely  sponged  with  iced  water,  a  puncture  was 
made  into  the  urethra,  in  the  neighborhood  of  the  neck  of  the 
bladder^  into  whiclj  a  probe  was  passed,  an<l  the  uriTie  allowed 
to  eecnpc.  A  large  gum-clastic  catheter  was  substituted  for  the 
pi^be.  A  ebarp-pointwl  knife  was  passed  up  by  the  aide  of  a 
Ginall  Syme's  gound  ;  and  tho  Erst  stricture,  which  lay  behind 
the  middle  of  the  scrotum,  was  freely  divided.  The  catheter 
was  drawn  up  through  the  urethra,  ue  in  the  last  cu&e> 

The  first  catheter  was  left  in  place  a  week;  then,  bcooming 
obatructcd,  it  was  replaced  by  another,  and  this  waa  done  weekly 


234 


GENTTO-URDiAlir    OKGAlffi. 


through  the  nmrHe  of  iIk-  trentrnGiil.  The  wnnnd  in  the  pen- 
napum^  on  accotiiit  of  the  (lisujusnl  »iate  of  the  liriauos,  wan  very 
■low  En  henling;  and  the  patient  remained  in  the  Hospital  for 
two  unmllin  Hflerwanla. 

A  communication  was  received  from  him  in  Ntiveniher,  I860, 
in  which  he  HtateiJ  t}iat  he  was  entirely  well. 


CA8fc  CXXXn.  —  Trajonatic  Sirictttre  of  thf.    Urethra 

of  Jive  years*  duration.  V^et^co-rectal  PiRtulo.  —  A  teiimster, 
36  years  of  age,  came  into  the  Hospital  under  my  care  in  the 
early  piirt  of  the  »[irini^  of  IKGO-  He  piaid  th^t,  five  yeara 
hefore,  hts  had  heen  jammed  against  ft  wall  hy  the  huffier  c»f 
a  freight-car,  vritli  such  force  oa  to  produce  a  rupture  of  the 
urethra.  He  remained  in  a  mtical  fiitiiatiDn  for  a  time«  and  had 
never  since  been  able  to  pasa  his  water  except  in  a  very  Bmall 
fltream. 

On  examination  by  the  rectum,  T  found  that  tlie  bladder, 
intestine,  and  surrounding  parts,  were  glued  together,  and 
involveil  in  an  indurated  mass,  and  the  calibre  of  the  intestine 
was  very  much  diminished.  Fistuhc  had  formed  by  the  side  of 
the  rectum,  and  there  was  communication  between  the  bladder 
and  ihe  recium.  A  probe  being  introduced  inlo  the  fij^tida  by 
the  side  of  the  rectum,  pnssed  up  by  the  side  of  the  intestiiie, 
througli  the  induruted  tiasues,  and  appntently  entered  the  inte- 
rior of  the  bladder.  No  ordinary  menna  afforded  relief;  and  I 
advised  him,  unless  willing  to  have  perineal  aeetion  performed, 
to  desist  from  any  further  efforts,  for  fear  of  producing  imtation 
and  complete  retention,  especially  aa  he  did  not  sufler  much 
from  his  disease- 
In  June,  baring  heard  of  the  success  of  perineal  aection  in 
other  casefl^  he  came  hack  to  the  Hoapital  for  the  purpose  of 
having  it  performed  upon  himself- 

The  operation  was  performed,  and  a  catheter  introduced,  riB 
in  the  Urst  caae. 

Not  the  slightest  unfavorable  symptom  followed  ;  but  at  the 
end  of  the  week,  when  it  was  neceeaary  to  replace  tJie  catheter, 
the  end  of  the  instrument  escaped  into  the  rectum.  This  was 
prevented  by  hooking  the  beak  of  the  instrument  against  the 


PEltrNEAL  aEonoN- 


235 


pubea  ;  and  then,  inateaJ  of  trying  to  force  it  forwards,  the  han- 
dle WHS  suddeaiy  <\e\ir(;ssed,  und  it  clipped  uito  the  blndder- 
Carried  foi-warde  in  the  ordmary  way,  it  always  wont  into  the 
rectum. 

Before  the  end  of  the  month,  tho  urine  was  paeeed  by  the 
oatheter,  althou^^^h  there  vras  purulent  discharge  through  the  fis- 
tuloua  opeDing  near  the  rectum,  and  occaatoTiaJly  from  the 
rectum  itself.  The  patient  remained  in  the  Hoapltid  rather  more 
tbao  two  monthS)  when  he  Ictl,  and  haa  since  been  bceu  well. 


Cam  CXSXm.  —  Urethral  Fistula  from  BuUet^t^otmff, 
PerxTieal  Sectimi.  Hecovert/.  —  A  yoimg  man,  20  years  of 
fljfe,  entered  the  HoBpitalr  June  3,  1865,  h&vin<^  hoen  wuiinded 
in  the  attack  on  Fort  Stendraan  in  the  preceding  March-  Tlie 
ball  grazed  the  fiide  of  the  penij^,  taking  out  a  piece  of  the  pre- 
puce, and,  pttssinijp  through  the  eerotum,  carried  away  tlie  right 
testicle-  It  ihea  penetrated  the  deep  muHclee  of  the  periniDum, 
fbllowinir  the  course  of  the  urethra,  nnd  cume  out  just  below 
the  margin  of  the  onus.  When  wounded,  he  was  in  an  orctt 
posture  ;  he  fell  iusensihlc,  and  was  at  once  carried  to  the  rear. 

On  entering  the  HoHpital,  the  entire  wound  was  found  to 
have  healed,  with  tbe  exception  of  the  fistulous  opening  below 
the  anus-  He  was  obliged  to  urinate  once  in  two  or  tliree 
hours,  anrl  the  greater  portion  of  the  wnter  eacapod  through  the 
wound  near  the  nniis.  lie  had  previously  been  repeatedly 
informed  that  nolhinj?  could  be  done  to  relieve  him.  On  on* 
anunation,  a  stricture  was  found  near  tho  prostatic  portion  of  the 
urethra ;  and  a  bou^ic^  intr<xlurcd  into  ihc  meatus,  emerged  at 
the  anni  opening  of  the  wound.  I  directed  that  a  bouj^ie  jihouid 
be  inserted  daily  down  to  the  ai:ricturc-  On  June  Si!^th,  the  usua! 
operation  for  perineal  section  was  performed.  The  end  of  the 
Bound  being  reached,  the  posterior  portion  of  tiie  urethra  was 
found  involved  in  a  nmss  of  cicati'iciaJ  tissue;  and  great  difli- 
eolty  was  eipericnccd,  after  the  wound  was  enlarged,  in  tinding 
the  orifice  of  the  urethra  which  led  to  tlic  bladder. 

This,  being  found,  was  freely  divided,  and  a  large  gum-olaetic 
catheter  introduced  tlu'ough  the  whole  course  of  the  uretbm. 
On  the  followiug  day,  he  was  qiiite  comfortable.     On  the  Sth 


g36 


GEMTO-UmSARY   OR0AN8. 


of  July,  the  t^Eitheter  wna  reinoveil,  and  the  wound  in  the  peri- 
□a^uni  wan  ln^iiliiig  ra^iidlv*  No  urine  ei^iijicd  froLii  the  old 
"nound,  near  the  anus,  after  the  operation.  A  few  daja  after 
this,  he  passed  a  fijll  etreani,  a  few  dn>p3  onlj  eacapbg  through 
the  periiijpum,  wliich  was  rapidly  graimlating. 

He  shortly  aftenviirda  left  tlie  Htjspita!,  hut  returned  from 
time  to  time,  during  tlie  fullowiug  Sve  or  ai.x  niontlis,  to  have 
an  inetruiueut  pufiited>  Ilis  recovery,  eo  fax  as  I  know,  waa 
compIeLe. 


Case    CXXXTV.  —  Traumatic     Stricture    of     Urethra. 
Perineal  Section,     Recovery,  — July,  113G3»     A  tall,  thin, 
delicate  boy,  Ifl  years  of  age,  tripped,  while  walking  on  the  top 
of   a   fence,   and  cjuiie   Juwo   astride   uf   it,   striking   the  pcri- 
nreuui,  and  produulag  a  rupture  of  the  ui\:thra.      At  firet,  there 
was  a  bloody  dlschjtrge  fxoiu  tlie  urethra,  and  retention  of  urine, 
\vhicli  was  relieved,  al  tlie  time,  by  the  use  of  a  catheter.     The 
nfit  four  months  were   passed  in  great  i-ullering,  and  with  fr^ 
qucnt   uttacka   of  retention   cf  urine.      lu   January,   1$C4,  six 
months  after  the  occurrence  of  the  accidcut,  the  retention  b»-; 
cDiiie    coiapleLe ;     and   an    operutiLjEi    waa    found    necessary    to 
relieve  him-      A  distinguished   practitioner  was  sent  for  from   a 
diBtance,  who  cut  down  upon   the   urctlira    in    the  pcriiiu^unia 
having  first    introduced  a   tatheter    into    the   penis    as    far   fu 
po^siltle.       Tlie   urethra   wax   reached  at   die   point   ivlicre   thfi 
o]>striietiou  eommeneed,  hut  could  not  he  traced  farther;    and^J 
although    an   elastic  catheter  was   introduced    into  a  passagaj 
which  Becnied  to   couimunicate  with  the   bladder,  it  wiia  after-l 
wards  found  not  to  reach  that  orgaii.      From  diut   tiuie   until^' 
1  saw  binif  sis  weeka  niler,  he   had  periodical  returns  of  reten- 
tion about  once   a  week,  which  were  relieved  by  the  escape  of 
ft  email   portion   of   solid   matter,    followed   by    a  jet  of  urine- 
Improvenicnt  for  about   a  week   fi»llowed  i   but,  at  the  end  of 
tliat  tiine,  tlic  retention  again  oLJCurred.      The   urjne  Fihowed  a 
constant  tendency  to  eacjipo  hy  the  perineum,  unleas  prevented 
by  chming  tlie  oHBce  by  the  iiiij^r. 

After  watching   the  case   for   a  week,  during  which   lime  he 
hfld    an  attack  of   ccniplcte  retention  fcr  eight  or  ten   liours. 


FERTNE.iL   SECTION. 


237 


wmen  wiis  only  relieved  by  opium  und  ctlicr,  I  finnlly  o]>eratcd 
on  him  on  the  ^th  of  March,  18C4. 

He  was  placed  in  a  etroug  light,  and  fully  etherized  ;  ft  capil- 
lary bougie  W0S  pneacnl  into  the  urethral  and  the  end  of  it 
appeared  at  once  through  the  opening  in  the  perinipunip  The 
direction  was  dow  made  upwards  towards  tlio  spot  nl  which 
the  bou^e  cecapcd  from  the  urethra,  in  hopes  of  finding  a  con- 
tiniifttion  of  the  pasBa^c  in  its  vicinity.  On  diede(?ting  to  thia 
spot,  which  was  underneath  the  sorotum,  near  ita  root,  no  trace 
of  the  inferior  portion  of  the  urethra  could  be  (^seovercd. 
After  exploring  lor  a  time  with  n  hooked  prulic,  a  small  opening 
wafl  detected  at  the  tiidc  of  the  other,  but  not  in  a  direct  line 
with  it.  Into  thia,  a  accond-capillary  bougie  whs  pasecd,  which 
evidently  penetrated  to  the  bladder.  The  whole  length  of  thia 
paesagc  was  now  gradually  laid  open,  hcirg  through  a  Bolid  ad- 
ventitious deposit.  Tlicre  was  no  possibility  of  passing  a 
prcbe,  even  at  the  side  of  the  bougie,  until  arriving  nearly  at 
the  ncek  of  the  bladdery  the  urethra  being,  in  fact,  constricted 
throughout  the  whole  perineal  portion.  A  probe  waa  now 
passed  into  the  bladder ;  and  a  catheter  of  medium  size,  being 
firet  passed  into  the  meatus,  waa  carried  by  the  eide  of  the 
prcbe  into  the  bliiddcr.  On  witljdrawiug  the  probe,  a  quantity 
of  caleareoTifi  matter  escaped-  In  the  c^mrsc  i»f  the  night,  a 
stoppage  took  place,  which  could  not  be  relieved  cither  by  using 
the  Btylet  of  the  catheter  or  l>y  injections;  and  the  urine  began 
again  to  escape  by  the  opening  in  iho  pcriiiwjum.  On  pneeing  the 
finger  into  the  rectum,  the  bladder  was  found  to  be  half  full  of 
semi-solid  matter,  feeling  like  a  bag  of  putty.  This  proved  to 
be  a  phuHjiJialic  deposit,  which  hrui  probably  been  for  a  long 
time  collooting,  owing  to  the  extreme  narroH'uoaa  of  the  paaeage 
through  which  tlie  water  trickled.  The  elastic  inetrumcnt  wne 
therefurc  removed,  being  dragged  away  with  some  slight  difli- 
eulty,  owing  to  the  cjiJeareons  substance  wliich  adhcreil  In  il- 
This  WU3  replaced,  foTlumitcly  without  much  difficulty,  by  an 
S-ehapod  eilvcr  catheter.  The  bladder  M'aa  ayringcd  out  t^ice 
a  day  with  water,  and  some  of  the  pboaplmtic  eubatance 
brought  away  at  each  injection.  This  catlictcr  became  eloppcd 
on  the  following  day,  and  hatl  to  be  taken  out  and  rcphiccd, 


238 


(jENlTO-tTRINAKr    ORGANfl- 


ivlikli  wa»  efT&'leil  under  ether.  lie  iiltiniiilel^  reoovereil,  re- 
qiiinng  tlie  ^jocu.Hjiina]  u^g  of  tLe  instrument  ti>  iiiiuntiun  the 
free  pAdsage  nf  tlie  canal. 

Case  CXXXV.  —  Slricfure  of  Urethra  of  ticenf-if  yearn' 
aliiiding.  Flslnioi  in  Pcriii^o.  I^eiLnenl  Section. — A  man, 
5li  years  of  uge,  ihin,  ]>ali!.  wnd  of  miaemblG  jiw[>ect,  entered  tlie 
Huspitiil  in  Maivh,  18fi.1,  with  stricturef^  Liflhe  uredini  of  Iwen* 
ty  yearfl*  Htjiiiding.  Tlie  urim*  trieklwl  nwny  in  drupa  or  n  fine 
btream,  and  no  Infilrument  could  be  parsed  uito  tJie  bladder. 
Some  years  bcForCf  be  Jiad  a  pcriuual  £i^tid^,  wlik'b,  af^r 
Ireiitmeiit,  r.luhfd  ;  the  urine  resuming  \ts  natural  cbuiind-  His 
strictures  bad,  however,  oontinued  to  grow  worse.  After  a 
triiil  of  [ii^vera]  weeks,  a.  CHplllary  bougie  waa  pasHcd  without 
violeucu  du"ougb  the  first  atriclure,  which  was  jutit  lu  froat  of 
thu  BcrotuDi*  It  wa»  left  Jbr  half  an  hour  every  daj  in  the 
alrictnre,  gradually  dilating  it.  A  second  fltriciuw  was  soon  dis- 
covert^ o^poaile  the  middle  of  the  pcn.ua.'uiu,  whL^re  a  cidluMty 
could  be  felt  of  tlie  size  of  a  marble,  Tlie  bougie  was  llnally 
p]u:fed  tltrougli  this  obstruction  alao  iijtu  the  bladder.  Despair' 
ing  of  getting  iu  any  larger  instrument  as  a  guide,  as  the  inlro- 
djction  of  this  amall  oue  had  already  occupied  aeveral  weeka,  I 
determined  to  operate,  A  free  iuci&ion  was  made^  iu  the  usual 
manner,  in  the  periuteoui ;  aud  a  long  and  patient  dissection 
performed  before  the  urethra  could  bo  discovered,  the  bougie, 
from  its  smallncse  and  flejclbility,  acjircely  serving  as  a  guide  Co 
the  touch.  The  urethra  waa  found  to  have  been  pushed  to  one 
side  \jC  the  median  line  by  iuHamuiatory  cxudatioa.  It  was 
opened  at  the  sttictured  pEu^t  for  the  length  of  about  half  an 
inch,  after  wLleh  it  admitted  a  No.  8  elastic  catheter  from  iLe 
wound  into  the  bhidder*  To  divide  the  other  stricture  behind 
the  bcrotum,  a  director  was  carried  up  from  the  wound  to  the 
stricture,  and  on  it  a  eonceale<l  knife  wod  passed,  and  the  con- 
striction with  flome  difficulty  divided  ;  tliere  being  a  disposition 
to  push  the  stricture  in  front  of  tlic  knife,  owing  Ut  Jt^  CAtreme 
toughness.  A  No,  G  elastic  catheter  was  now  introduced  intu 
the  meatus,  and  passed  into  the  bladder,  though  with  difficnlty ; 
for  the  external  stricture  grasped   it  with  some  force.      The 


PERINEAL  SECTION. 


239 


f>aticnt  was  placed  in  bed,  and  an  el^cic  tul>e  ftttacbwl  to  t!ie 
catheter  to  convey  the  urine  into  a  receptacle  placed  for  it  be- 
ncatli  the  bed.  For  the  first  time  for  miuiy  years,  tlie  wntef 
flowed  freely  frora  the  bladder.  On  the  folJowing  day,  the 
itricture  had  nlready,  frf>m  absorption,  bo  far  relajted  lU  hold 
upon  the  instniment.  as  to  admit  of  ita  ensy  withdrawal,  nod 
the  introduction  of  a  larger  one;  a  proceeding  rendered  necea* 
aary  nleo  from  the  obatruolion  of  the  eyea  of  the  firet  one  by  tlie 
ffiucua  of  the  bladder.  For  the  samo  reason*  it  was  ullinaately 
necessary  to  gubstitnte  an.  S-shapod  silver  catheter  for  the  eiia" 
tic  one ;  af^er  which  the  obstruetion  did  not  recur,  and  the  man 
made  a  good  recovery. 

Case  CXXXVI.  —  Traitmattc  Striciitre.  Perinsrjl  Sec- 
iicn.  Recovejy. — June,  1*^65,  a  man,  aged  49,  entered  the 
Hoapital.  Three  years  previously,  he  fell  a  distance  of  eight 
feet,  coming  down  astride  of  a  beam.  This  was  soon  followed 
by  abscessed,  which  resulted  in  orinary  ftstulfC'  On  eutrance^ 
the  scrotum  and  Integuiucnt  of  penia  were*  greatly  s^vollen  and 
cedematous*  At  the  middle  portion  of  ureUira,  thrcu<^h  the 
scrotum,  a  hard  tun^or,  the  size  of  a  goose's  e^p;,  could  be 
detected.  The  urine  paaacd  only  in  drops,  A  capillary  bougie 
could  be  made  to  enter  with  diflieulty  into  the  bladder. 

Perineal  section  and  the  operation  for  j>hymoai8  were  per- 
formed about  two  weei^  atler  coming  to  tho  Hospital ;  nnd,  in 
a  little  mure  than  throe  weeks  ofler  the  operation,  the  patient 
woe  discharged  well^  the  ecrotum  and  peuia  having  re^nmed 
their  natural  dimensions,  and  the  urethra  being  thoroughly  per- 
yious. 


Case  CXSXVTI-  —  Tmnmatie  Slrietnre^  Penneal  Sec- 
tion. Hecofcrif.  — April,  18li5,  A  laborer,  two  years  before, 
TCceived  an  injury  to  the  perinacumi  which  was  enceeeded  by  a 
elriciure  of  the  urethra.  Subeequontly^  fistulous  openings  ap- 
peared in  the  perinieum,  which  communicated  with  the  urethra  r 
tliese,  however,  healed.  On  entering  the  Hospital,  it  was  found 
that  the  urine  escaped  from  the  meatus  in  drops,  while  the 
greater  portion  made  its  way  through  fistulm  ou  the  under  aspevt 


240 


OENiTO-lJRINART"    ORGANS. 


of  the  pi?nU,  nnd  tlint  there  were  several  strichires  i  oni?  near 
the  meatus,  am\  the  others  in  the  tnctuhmnoiia  portion  of  the 
urethra.     The  penis  wns  flwlemntoua. 

Perinesil  sei^.tion  aiid  the  operation  for  phj-moflb  were  per- 
formed, aud  the  patient  discharged,  neruly  well,  one  month 
after  the  operation,  and  two  tuontli**  after  being  admitted. 

Case  CXXXVm.  —  Traumatic  StTicture.  Perine.trl 
Section.  Recovery.  —  March  13,  1861.  A  laborer,  aged  53, 
received,  shout  three  raootlis  before,  a  blow  in  the  periiucuiii, 
where  an  ah>;cesa  formed,  and,  twentv-fonr  hours  niYer  mjdry, 
broke,  discharging  hlood  and  urine  j  lejiviug  a  fistulouH  ojien- 
ing,  t]irougb  which  i>aLjent  voided  )iih  water  for  two  months 
prior  tu  hia  coming  to  the  HospitnJ. 

On  examination,  iin  iinpcrnieable  stricture  wa^  faund  about 
one  inch  anterior  to  ihe  trianguliir  ligaineui.  TIte  fi^tuloufi  open- 
ing in  the  perinicum  admitted  a  probe  for  the  didtJtnre  of  an  inch, 

March  23d.  Perineal  flection  was  performed,  and  the  Htriolure 
divided.  In  mx  weekiif  the  urine  was  pjtH^etl  through  meatus, 
the  wound  henled,  and  the  patient  discharged  well.  The  oon- 
valescenee  in  this  cuse  was  prutracted,  tlie  patient  having  re- 
peated attacio*  of  erywjpelatouj*  inflammation  and  hemorrhage. 


DrSEASES  or  TITE  rHOETATE   GLANB. 

The  affections  of  tJie  prostate  gland  are  of  great  importance, 
and  require  ijuite  as  much  delieney  in  their  treatment  U8  do  Htrii> 
tnreB  of  the  urethra.  Stealing  on  gradually  in  peraona  about 
sixty  years  of  age,  they  do  not  often  ret^uire  the  a^ij^istanoe 
of  a  fcurjTGon  until  almof^t  euraplete  Bte]>[in^  of  water  baa  taken 
pinee-  Ii  will  then  be  found,  that  the  patient,  for  some  time 
previously,  has  passed  hin  wat^rvery  frerjuently^  and  that  finally 
it  has  begun  to  dribble  away  from  him  in^neibly :  on  pitising 
tlie  catlieter,  a  large  qnanlity  of  fetid  urine  ib  evacuated  ;  and  it 
w^ill  at  once  be  fieen,  that,  for  a  long  time,  the  Uatlder  bad  lieen 
but  partially  emptied.  In  most  instances,  the  ])rostatic  catheter 
can^  with  great  care,  be  made  to  enter  the  bladder:  in  otliers, 
however,  the  passage   has   been    renilered   tortuous   by  Uie  eu- 


WOUVD  OF  THB   BLADOKK, 


241 


Inr^ment  of  tlie  tliinl  IiiIm*  of  the  pnwtntB,  n.n(l  grpnt  wire  is 
rijcjiiii-eil,  or  mitichief  will  he  ilnne  with  the  iii^lrument.  In 
tbeM!  CRS^es,  I  Imve  niutiaired  beat  with  a  French  [mtn-el]L»ttc 
cailipter,  tenninnttHi  wiili  nn  iilmonf.  ciipillury  point,  mid  Imvhig 
the  eye,  ur  aperlHre  in  it,  ut  iibtiut  two  inrheB  Jistsince  from 
the  terminntion.  TfiiB  mjty  be  introduwd  ta*  Car  as  the  olifilnic- 
tion,  wkli  a  stylet  within  it :  by  a  sudden  motion,  it  may  then 
be  shot  off  froMi  tlio  atylet,  and  carried  into  iJic  bbidder-  Tf 
carefully  witbdniwn,  after  rcmainin^r  in  phme  fur  tn)inti  honrfl, 
it  will  generally  retaiti  the  eurvjiture  of  the  lorttioiiB  passage. 
Where  tliore  is  much  [lain  or  Jrrifjilion  frmn  tlie  uitnKluctiun 
of  the  instrument,  it  luul  better  be  left  in  the  hUdiler  for  ilie 
greater  part  of  the  twenty-four  hours.  If  these  causea  do  not 
exist,  the  water  may  be  drawn  off  iwo  or  tliree  tinica  a  dny. 
j\r™»t  pjilientj*,  after  having  a  poro^tyi^ni  like  the  above,  arc 
relieved,  and  things  go  on  for  a  time  as  tibuqI  :  In  others, 
where  the  patn  and  suffertTLg  ban  been  very  great,  secondary 
syniptonm  come  on ;  and,  juBt  ha  ihc  patient  schema  to  have  got 
through  his  dcffieulties,  a  cerebral  affeftion  *in[>ervenes,  and 
he  dies  with  alt  tlie  aymptonttt  iif  unemia.  Where  bloixl  Is 
thrown  out  into  the  bladder,  and  no  urine  |j)w»eB  on  the  intro- 
duction of  ihe  c;ijhe1er,  nri  injeclion  of  water  may  be  made ;  and, 
sfler  a  day  or  two,  the  congula  beoome  dissolved,  and  paj^s  off 
witbonl  ditfieulty.  Cases,  which  at  firnt  louk  very  formidable, 
ofien  tarn  out  favombly,  even  in  persona  of  quite  an  advanced 


WOUND  OF  rxiB  nLADDEn. 

Case  CXXXIX.  —  R^-marhnhh  Case  of  a  Wound  of  the 
BladdpT.  — A  young,  vigorous,  and  brave  officer  was  btrtick 
by  a  liall,  which  passed  directly  llirikugh  the  pelvis,  just  be- 
hind the  hip  joint,  penetrating  the  bladder,  ilie  mine  escaping 
&om  both  openings  of  the  wound.  An  examination  by  the 
rectum,  h»s  reported  by  the  [latienti  revealed  the  fact  that  the 
left  lol^e  of  the  proJttnle  hnd  been  carried  away.  A  catheter 
was  introduced  and  kept  in  the  bladder,  and  the  urine  allowed 
to  pnsH  tliroii^rh  it  during  the  treatment.  InHammntion  took 
place  in  the  ooursc  of  the  uretlira ;   and  an  abscess  fnrniefl   in 

31 


54S 


GE\lTO-IJKL\AKr    ORGANS- 


front  (if  the  scrotum,  breiilcing  there,  lenving  the  nrothm  open 
fi>r  a  ttpnce  of  nearly  two  jnches.  At  the  time  of  The  recepuon 
of  the  wouTLil,  there  wilb  a  eenaa  oF  numbneaa  prniliirod  in  bolfa 
lower  extremitiea.  After  n  long  anJ  lediona  ff^nfinement,  he 
regninwl  fair  health,  having  an  a|x^rtiire  In  front  of  the  flcrotum, 
through  which  the  iirina  passed  when  the  bla*Mer  was  evaca- 
ated  ;  the  recovery  being  in  other  respects  g^od,  conaidering 
the  g^ravily  of  the  lEJurj.  He  returned  to  his  poal,  and  took 
part  in  an  engagement,  five  or  sisr  monihs  nfterwarJs.  Shortly 
after  this,  he  conaultei]  me;  being  nerroua  on  account  of  ft 
ivant  of  power  which  he  felt  in  the  lower  rstremi tics ,  and  which 
he  feared  might  leail  to  pandysTs.  These  symploma  I  atiribnted. 
to  bin  riding  on  horseback.  On  cxiuninatiun  of  the  wound 
made  hy  the  hall,  I  found  the  sear^  on  either  side  of  the  pdvia 
in  R  healthy  condition;  and,  on  cinmining  the  neck  of  tha 
blEuldcr,  a  bridle  c^niU  Le  felt  in  the  reL-tuiu  agninet  the  lefb  lobe 
of  the  prostate,  where  the  injitry  hml  apparently  been.  The 
aperture  in  front  of  the  Heroluni  wrjs  largo,  and  a  great  part  of 
the  urine  escaped  through  it  during  micturition  ;  but  there  was 
perfect  control  over  the  neck  of  the  bladder. 

Thia  case  ia  a  very  intcrcBting  one,  from  the  fact  of  there 
being  so  serious  au  injury  of  the  pelvic  nnd  bladder,  urine  paas- 
ing  out  from  both  opeiunga  of  the  wound,  followed  by  good 
recovery. 


TESrCO-RBCTAL  FISTULA, 

Cabe  CXL.  —  Commujiieaiion  i/elv^een  the  Bladder  and 
Reatitrn,  resnltinff  probably  from  Ulceration.  —  Dec,  12, 
1864,  a  mon  ahoul  35  years  of  age  conaulioJ  me  oti  account  of 
the  following  diseased  condition  of  the  bladder,  which  I  put  on 
recoi^l  on  account  of  its  rarily.  lie  said,  that,  for  a  month,  he 
had  passed  no  urine,  but  only  a  white,  milky  fluid,  per  nnuni, 
in  quantity  of  about  a  tablc-spooniul,  when  he  etmined  at  9tooL 
On  farther  questioning,  however,  I  found  that,  throe  times  & 
day,  he  was  in  the  habit  of  going  to  the  water-closet^  and  dis- 
charijiug  from  tlie  rectum  a  large  ctuantity  of  tiuid,  followed  by 
ft  eolid  operation.  He  said  that  he  had  suffered  for  the  past  two 
years  from  inflammation  of  the  bladder,  caused,  as  he  supposed, 


CANCER  OF   RECTUM, 


243 


bj  assisting  at  tTie  o.onftiiomeiit  uf  I119  wifi^,  nburii  he  held  dur- 
lag  tbe  whulu  ijij;lit,  wlill4;  she  \fiis  struggling  whh  the  pains  of 
labor.  This  Jie  did  much  agaiast  hib  incliuutJoiL.  Ever  alnce 
tliAt  time,  he  had  difRciLlty  Id  poashig  Wis  "^vnter.  which  vas  dls- 
charged  ijuite  fi'eijiieiiLly,  und  niiKcd  with  mucus. 

I  ]>a[4«ed  an  elBstit:  cftdietcr  Into  the  hluddcr,  and  drew  uff 
about  hitlf  nu  ounce  of  tbtid  urlnt^f  mixed  with  piia  :  Eome  hlood 
folJuwed  llie  wltlidnLwu]  uf  the  iii^ti^uijiciit.  A  rocul  exaiulnu- 
tlon  dIstlowMl  nothing  iLbnortiml ;  hut  the  finger  cdjiIiI  not  rtjieh 
liigli  enuiigli  to  deteot  the  oppning  Into  the  bliutder.  Tt  was  very 
evident,  however,  that  tlie  case  was  one  of  lon^-iTintimiwI  in- 
flammation, with  ulceration  of  the  bladder,  ending  In  |>erf^iratiaii 
into  tho  rectum.  I  forbear  glving^  the  trentmentf  as  there  w«s 
evidpndy  hut  lilllc  to  be  done, 

Tltc  patient  was  eieesdively  pale  and  emaciated,  aiid  liad  the 
aspect  of  a  map  whose  case  would  be  likely  to  terniitiate  un- 
favorably . 


Cancrk  or  Rectum.  —  Ca.sk  CXLT.  —  Scirrfious  Tnwor 
of  ike  Reciuta  mid  BUuhler,  —  A  gentlemau,  5G  years  old, 
confiulleil  »ic,  in  1849,  on  aeirount  of  retention  of  urine.  He 
was  ojicraled  ujxin  for  the  jiilea  nineteen  yenrs  befure  ;  and,  at 
ihnt  time,  a  small  hard  tumor  wna  diseovered  n^nr  the  aoua, 
which  he  declined  having  interfereil  with.  Al^erwanls,  he  oeco- 
ALonally  had  nttacks  of  |)uln  iu  the  buwels,  and  ladige^ion,  but 
never  any  ecnona  Hymptoma  in  the  rectum^  He  always  bnd 
diarrhea  a. 

An  examination  was  attempted  per  imum  ;  and  it  was  found 
that  the  reetuin  wn»  obstructed  by  a  «cirriiauti  tnasr^,  which  pre- 
vented the  intrtHiuction  even  of  the  little  finger,  Tlie  retention 
was  gradually  overcome  by  the  use  of  the  catheter,  nnl  the  pa- 
tient had  moderately  good  health  during  the  annimer.  The 
next  fall,  I  was  called  to  htm  on  account  of  a  second  retention, 
which  gave  way  to  remedies,  without  the  use  of  the  catheter. 
It  was,  however,  ahordy  followed  by  general  anasarca  ;  and  he 
gradually  Hank,  exhiiusted- 

At  the  autopsy,  the  Inat  four  inches  of  the  rectum  were  found 
pervaded  by  a  ficirrhoud  mais9,  leaving  in  the  centre  u  narrow 


244 


GEMTO-UlrlNAKT   OltG.^S- 


j>iill»rtay  fur  tlie  fe«3a.  Tljc  iliwiwe  liinl  eTtenJed  to  the  blad- 
der nnJ  urethra,  iind  apps-rently  impticiited  the  midiUe  lobe  of 
lh(^  |iroNt]ite  gland,  which  projected  intu  the  bludder,  and  occu- 
pied ahmit  \i  third  of  iti-^  cuvily. 

Owing  to  the  loose  state  of  thft  howelfl,  the  patient  had  heen 
able  to  live  nineieen  vonr^  wirh  this  tiinior,  am]  had  euffer^l  but 
little  inconvenience  from  It ;  and,  in  i'jict,  was  not  made  aware 
of  its  exiatenee  bv  aay  pain  vt  other  sensation,  except  aii  ncca* 
eional  irrilatian  of  the  skiu  id  tJie  ncighborliood,  the  result  of 
the  iinperfet't  manner  in  which  the  evat-uatiuns  were  contrijlled. 

The  left  kidney  was  in  a  bi^^h  Htale  of  indamiiiatiun,  uiid  there 
was  some  purulent  deposit  in  liti  pelvis :  the  ureter  was  not 
extraordiiuirrly  disteiide*!. 

It  might  be  titated,  that,  during  the  lust  week  of  bis  life,  he 
refused  food  entirely,  on  aeeuunt  of  the  difficulty  and  iMiiii  in 
swallowing,  caused  by  an  iaflnnimation  in  llie  faucea.  Very 
flevere  hiccough  tnsned,  wbicb  wjls  mitigated*  and  the  Ijtst  part 
uf  his  life  made  easy,  by  the  oecoaiunal  inhalation  of  ether. 


Case  (TXLIT.  —  EiwrTJiouit  Canc^rovm  Dinpnire  of  Ester^ 
ntil  Genilal  Ort^ans^  Memoval.  ^  A  laborer,  aged  36  years, 
entered  the  Hospital  in  May,  1865.  Three  years  previously  be 
had  an  ulcer  en  the  penis,  which  was  soon  followed  by  inflnm- 
mation  of  the  left  testicle.  He  received  no  treatment  until 
October,  1864,  when  the  diseaseJ  testiele  having  attained  great 
eize,  w&a  removed  by  aume  surgeon  in  the  sonthem  portion  of 
the  country. 

In  about  a  month  after  this  operation,  a  hard,  gray-colored 
tumor  formed  within  the  lips  of  the  wound.  This  was  cauter- 
i:iwl,  bnl  oj;ntimied  to  inereaji^e  in  size  rapidly.  It  presented  the 
appearanee  of  an  irregular  injisa^  about  the  size  of  a  very  large 
tomato,  being  at  least  teu  inches  in  circumference,  having  & 
granular,  fungous  appearance.  It  envelope'^  the  loft  side  of  the 
(icrotuni  and  the  puhes,  and  implicat^^d  the  penis.  There  was 
a  fetid  discharge,  and  ocea?«ionally  hemorrhage,  hut  never  mucli 
pain.  His  mother  hud,  at  the  time  of  her  death,  a  "rotio 
cancer."  He  desireil  an  operation,  although  Informed  that  it 
would   be  only   palliative. 


IVDDEATEn    TUMOK    OF    PRNIS. 


545 


Miiy  10, 19C5,  he  was  etherized.  A  ligature  was  first  pfi-53o<l 
throiij^h  ihnt  portioD  of  the  ttimor  Eitunted  above  the  pubea,  und 
drawn  up  firmly^  The  remainder  of  the  tiimor  waa  then  die- 
eocted  ami  torn  from  ita  ndhesioTia,  nnd  caustic  potash  ap|)lied 
to  the  hanG.  SevcrsJ  hli^^iQg  vessels  were  tied,  and  the  cdgoa 
of  the  wound  were  brought  together  with  suturea. 

This  was  a  most  desperate  case  of  disease,  in  which  hardly  nny 
operation  seemed  fivnilflhle :  the  disenw*]  maae  was  ahnost  n  foot 
in  circum  fere  nee,  nnd  the  intej^'unionts  of  two-thirds  of  tlio  penia 
implicnleii.  The  snuas  m  the  grojn,  in  the  course  of  the  spcr- 
iniirie  cord,  descended  so  deeply  that  the  only  fidr  way  of  con- 
trolling the  hemorrhage  seemed  to  be  to  enclose  the  whole  base 
of  the  growth  in  a  ligature-  The  patient  left  the  Hospital  in 
nhout  four  weeks  after  the  operation  with  a  wound  of  the  size 
of  u  dollar,  and  able  to  move  a.boui  freely  ^nd  to  pursue  his  or- 
dinary avocations.  The  relief  from  the  dreadful  stench  of  the 
ulcerated  miiJ*s,  even  if  but  temporary,  was  enough  to  repay  hhn 
for  the  operftiion.  Before  it  he  was  completely  di*abW.  The 
diueaae  returned  subae<iuently  internally,  and  destroyed  hiia. 


INTUBATED  TUMOR   OF   TENIS. 

hid«T-ated  Tttmor  of  J^enis.  — I  have  four  or  five  times 
met  with  n  very  [>ecultar  disease  of  ihe  cavernotis  foKtiire  of  the 
|>enifi,  which  I  have  not  seen  dei^crihod  in  any  book  until  re- 
oentJy.  It  has  genemllv  nppenreil  in  the  up[)er  part  of  tlie 
fihron^  covering  of  the  corpora  cavernosa  at  the  root  of  the 
penia,  and  so  perfectly  defined,  flat,  and  firm,  na  to  seem  like 
H  foreign  body  implanted  in  the  substance  of  the  organ.  Its 
edges  were  quite  regidnr,  with  Hbarply  defined  corners,  like  a 
bit  of  broken  crockery.  The  disease  haw  usually  appeared 
slowly^  increased  gradually  till  the  induration  baa  arrived  at 
aboQti  the  size  of  a  ten^^ent  piece  or  somewhat  Inrger,  and 
then  remained  stitionary.  It  ha^  not  been  pnxluctive  of  much 
pidn  ;  and  the  pnneipal  efTVct  bain  been  to  produce  an  increased 
carve  of  the  penis  towanls  tlie  puhea,  with  a  degree  of  tension 
and  uuensiuess  during  erection.  In  one  insbince,  —  ihnL  of  n 
gentleman  about  to rty  years  of  age,  —  the  iEduration  wbs  Inn- 


u% 


Gi::4lTO-URINjUtY  OKQAKe. 


iteil  to  (ine  side,  ami  caused  a  deTmtioQ  of  tlie  organ  in  that 
direction,  u  greater  source  o("  mconvemcQCe  than  in  tlie  position 
fitated  above. 

The  tumor  ia  entirelj  free  from  acute  inHiuumatory  nctioQf 
and  ia  uiillke  tLe  induration  caused  hy  Hiq  nipturc  of  tlia 
Cilvernous  tiasue,  which  occurs  in  the  course  of  venereal  dlwjise. 
This  ia  particitlorlj  the  case  in  the  lufiammatiDn  from  gonoirho^a, 
wlucJi  is  lijiiited  to  the  under  part  or  one  of  the  sides  of  tho 
[icnis,  and  douictimcs  tenuinates  in  eu]j|airation. 

The  treatutent  adopted  cousisted  pnncipallj  in  management 
of  the  diet,  alittinence  from  nil  excitement  of  tho  sciu-J  i>rg;nna, 
&nd  in  the  local  application  of  mercurial  ointment  by  inunction  ; 
■loo  in  tke  use  of  an  olntraent  of  the  iodide  of  poLish,  imd 
occasionally  of  leeches.  These  remedies.  es[)ecially  the  mei^ 
curial  ointment,  have  ficcmed  to  have  the  eflect  of  arrcflting  tlie 
disease,  or  producing  a  slight  diminutioa  of  it,  but  in  only  one 
instance  causing  the  entire  diaappearnncc  of  the  tumor  i  so  that 
1  have  almost  been  led  to  the  conclusion  that  there  may  be  a 
sliglkt  dcjHjsit  of  calcareous  matter  in  it.  In  none  of  the  cosea 
met  witli  has  an  oi>eration  seemed  to  be  neoessaiy. 

Having  made  a  statement  of  the  above  facts  to  the  BoBton 
Society  for  Medical  ImprovenicDl,  about  ten  or  fifteen  years 
since,  for  tlie  purpose  of  eliciting  information,  my  attention  was 
dran-n^  by  a  medical  gentleman,  to  a  i;iaper  published  in  the 
"  London  Lancet,"  nbont  that  time,  giving  a  number  of  casee^ 
but  attributing  the  origin  of  the  disease  to  former  venereal  affec- 
tions ;  at  least,  in  most  of  the  ca^cs  adduceil.  tlie  patients  had 
been  more  Or  less  addicted,  m  the  course  of  thctr  lives,  to  sexual 
irrcfi^arities. 

This  disease  is  ulao  noticed  by  Dr.  Groas  in  hifl  "Surgery," 
published  ill  1S53,  Avhere  he  refiirs  to  a  case  of  indurated  tumor, 
in  the  pcctinifurm  septuiUj  removed  by  an  operation. 


Case  CXLIII,  —  Indurated  Ttimor  of  Pcntg.  — A  gentle- 
man 5^  years  of  age,  well-formed  and  in  good  healtli,  with  the 
exception  of  a  prolapsus  of  tlie  anus,  applied  to  me  on  accotmt 
of  a  trouble  in  the  penis.  He  said  that*  during  ereciion,  the 
glans  crooked  backwards  on  the  doreum;  alao,  that  the  sexual 


nroUKATED  TUMOR   OF   FESIS. 


247 


powers  were  much  iJiminialied.  On  exauiliiuLlon,  I  founcl  at  the 
back  flnd  rui>t  of  llie  jiemB,  partly  liiJilcn  hy  tlie  t\dn^  &d  indu- 
ration aituatt^d  in  the  corpora  cnvemo&ft,  e^ten^ling  quite  ricroas, 
ant]  of  a  de[itEi  uf  about  an  inch.  It  fbit  aimoEt  like  a  bit  of 
wood  under  lUe  £broLis  ahc:at}i  of  the  peni».  He  nmd  (iiat  it 
had  ejciatcd  about  two  j^ears,  gradually  extending  from  behind 
torwardfi.  There  wae  no  pain  in  it*  nor  sensation  on  handling 
il-  I  could  not  dlflcorcr  any  symptom  of  trouble  in  the  ure- 
thra, p]-08tfltc,  bladder,  or  kidncya. 

1  advised  him  to  uae  a  cold  enema  daily  for  the  prolapsua,  to 
rub  the  tumni'  with  an  ointment  of  the  eubmunalc  of  mercury 
and  tlje  iodide  of  potnasium,  to  avoid  excitement  of  the  organs, 
to  uae  no  stimulant,  and  re&trict  himaelf  principally  to  a  vege- 
table diet ;  also  to  take  internally  the  iodide  of  potassiunii  three 
graiua,  twice  a  day.  Under  this  treatment,  the  tunior  alowly 
decreased  in  ai2e,  but  did  not  disappear  entirely. 

Case  CXLTV- — fmlaraled  Tiuiioi-  in  iJtt  Peni^,  —  In  the 
previous  cose,  the  induration  was  situated  on  the  doraura  of  the 
pCDis,  near  ita  root,  and  in  the  immediate  vicinity  of  the  puW. 
lu  the  present  instance,  it  was  aituntcd  near  the  extremity  of 
the  organ,  aitd  in  close  proximity  to  the  ghtns.  The  gcntleuiaa 
wa£  advanced  in  life,  fiomewlmt  gouty  or  rheumatic  of  habit, 
had  been  troubled  with  acialica,  and  fit  one  time  dysjjeptic. 
He  had  nCYcr  suHered  (rom  any  form  of  venereal  diacase. 
When  1  flaw  him»  he  was  in  a  very  good  atate  of  health* 
His  attentiou  waa  Erst  drawn  to  thia  itfTection*  from  hh  penis 
becoming  distorted  during  erection,  being  turned  a  litile  to 
one  side-  This  was  attended  with  a  slight  degree  of  uacnsi- 
neds,  and  with  an  unnatural  hardness  of  the  organ  at  the  point 
indicated-  Ou  exitEiiiEiation,  1  found  on  the  back  of  the  penis, 
near  the  glans,  and  somewhat  to  the  left  tide,  a  distinctly 
marked  induration,  which  felt  almost  like  a  foroigu  body, 
flituatcd  beneath  the  skin,  in  the  Gl^rous  tissue  of  the  coqma 
cavemoBUm.  It  was  quite  angular;  and»  when  seized  with  the 
filers,  wa«  found  to  be  partially  movable  In  the  surrounding 
partJ9.  Tlierc  was  no  appearauce  of  inflammation,  nor  any 
tenderueas  on  pressure-     I  advised  him  to  apply,  twice  a  day. 


»8 


CE?mO-CKlKAST  OSOASd, 


wtuiki  MiDtiwgirt  omr  ihe  indnndon,  fir^  Whtng  Uk  pnrt 
w^  wvmvaler.  TIbs  ODitf«eme  fblknred  for  about  a  month, 
wWs  tht  DBC  of  tbc  oinbneni  wȣ  GUSfiCiided  on  anxnuit  of  a 
■S^lit  imUtioB  qT  the  skm.  This  soon  Mifaeided,  and  an  omt^ 
BOA  oC  kxlide  of  poCaesum  vas  subetkotcd  fiv  the  mercuruil 
oACiBeitt.  He  «B»  al$o  adTiscd  to  take  do  wine,  ami  noC  to 
ait  oa  horacback,  bulli  of  wltkh  be  n&s  in  tbc  hahil  of  doing. 
Il  m»j  ht  stateil  tlial  lliere  was  im>  dis<mf«  of  die  unnaiy  or- 
gaBf.  Tbe  pabcal  fulloned  thi»  course  far  about  a  vvsr*  sm^ 
pcB^Bg,  frDm  time  lo  time,  Uie  use  of  remedies,  for  eiglit  or 
Icn  Aa^  loguker.  He  nMd,  f<>r  tbe  most  pait*  the  olntmeat 
of  Bodidc  of  potKaniD,  ntrdr  tbc  mcfraraL  The  diMftse 
giadaallr  Tvlded  Ed  a  certain  extent,  tbe  ^Larp  oatUite  of  the 
indaniioM  diiappeani^,  leaving  ouIt  an  arale£ned  lunlneas, 
irU^  wu  imtLer  diffiroJt  U>  detect.  At  this  period.  I  adviaod 
Inm  to  eospend  trratniait,  but  to  fellow  oat  tbe  precuitiooA 
vrlucfa  I  had  planted  out.  Tbe  unpJeasttiLt  eriLptoma  whkli  ml 
firet  atleaded  tbe  di^iease  had  difapprared. 

The  hu-ioTT  of  this  ca^  if  Ttrj  smilar  to  that  of  otber^,  — - 
tbe  mitigalioa  of  tbe  mnpCoiiu  under  treatment ;  but  m  neailj 
bD  tboK  WMS  still  a  per^iftesce  of  »xae  iDdoxatkin.  in  ^pite  of 
leaKdwsi.  I  have  never  f^:^u  it  atA^ume  a  m^iiiauit  fi.>mi, 
the  fear  of  wluch  patkirts  gmeraUr  have  in  their  miode,  nor 
coqU  anj  ai  tbe  c^Sf»  be  Irac^l  to  a  venereal  ori^n. 

&aot  wTiti^  the  above,  the  patioit  cousulled  me  for  ■■*^*"* 
and  I  found  that  the  induratiOD  bad  cuoipleteJT  di»- 


: 


Traovs  w  Sfekmatic  Cord. — C^k  CXLV.  —  Adijnac 
Twmmn  of  £k  Spermtattc  CWif.  Annorai.  fliffcorery. — 
Nawafacva  1843.  A  Bamed  maut  M  jtar*  %M^  iwentv  jv^m 
bdne  iBodw.pJ  an  i^oiiHl  henna  oa  tlv  r^bt  ^nle,  bv  a  ftrmiu. 
It  wt^  of  the  aze  of  cbe&tnui,  and  ^ifilv  irdonbie.  He  bad 
^vajs  faecB  IbUc  lo  the  renirm>ce  of  the  hernia  fitoce,  and 
wore  a  tran* 

la  1037,  be  |ietcei*vd  a  foaW  swelling,  or  tumor,  at  tbe  lower 
part  of  the  sooCinn.  of  a  globular  fum,  haid.  movable,  not 
riiiii       IW  tatkle,   be  ihou^t,  ctJuM  be   ^t  bdow-     lUs 


TUVOBA  OF  SPenMA^nC  COKD. 


249 


tuTQar  increased  until  it  had  acfoined  the  sizG  of  an  orang^e. 
and  ttien  ceased  to  enUr<^. 

Nine  years  after  the  appearanoe  of  the  first  tumor,  a  ^ecood 
one  was  detected  above  It;  and  three  others  have  since  been 
di^overed.  He  had  bc«n  examined  by  &  number  of  surgeons, 
and  the  tumor  vanoaelr  pronounced  to  be  a  hydrocele,  disease 
of  the  testicle,  ouientid  hernia,  &c. 

On  ejLiminalionf  it  presented  the  following  appenrances  ?  The 
scrotum  was  the  size  of  a  child's  head  at  birth,  the  increase 
being  evidently  on  the  nghl  side.  It  contained^  apparently, 
Beveral  tumors,  more  or  less  connwti?d-  One,  at  the  lower 
part,  of  the  size  of  the  testicle,  and  in  which  pressure  caused 
the  peculiar  pain  pTodiieed  by  injury  lo  that  organ  ;  above  this, 
a  tumor  of  the  size  of  an  orange,  qutie  hard  and  in^iensihle; 
BtiJl  lusher,  two  large  and  two  small  tumors,  the  latter  I>eing  in 
the  vicinity  of  the  inguinal  ring.  An  Ludistlnct  feoling  of  fluc- 
tuation pervaded  the  whole  of  the  mass,  which  was  pressed  up 
against  the  orifice  of  the  inguinal  canal,  and  c<»mpletely  cov- 
ereil  it. 

On  dragging  it  down,  and  cmbraCLng  the  inieguinents  b^s- 
tweeu  the  thumb  and  forefinger^  the  spermatic  eord  could  be 
distinctly  perceived  paasing  out  from  the  ring  ;  but,  on  the  most 
careful  examination,  no  prolongation  of  the  tumor  into  the  ab- 
domen was  diseoTored.  On  causing  the  patient  lo  cough,  a  por^ 
tion  of  intestine  waa  felt  to  force  itself  down  into  the  scrotum, 
and  immetlifltely  recede.  The  queslion  of  diagno»^is  seemed  to 
regard  :  1st,  An  omental  hernia ;  2d,  A  disease  of  the  testicle ; 
3d,  ^omo  tumor  of  rare  oocurrence. 

The  objection  to  the  former  wne»  that  there  seemed  to  be  no 
connection  between  the  tumor  and  the  aUlomen  ;  and,  although 
it  is  known,  thnt,  in  some  eases,  from  the  efTecfs  of  pressure,  tlie 
connection  in  old  omenlal  hernia  with  the  abdominid  cavity  JA  cut 
off,  this  u  not  of  very  frequent  occurrence.  To  tlie  supposition 
of  its  being  a  di.^eiiaed  testicle,  the  smnll  tiimor  at  the  lower 
pnrt  of  the  scrotum,  of  the  apparent  size  and  sensibility  of  that 
organ,  could  be  objected-  My  own  impressions  were  in  fiivor 
of  the  third  view  of  the  case,  and  tbercJore  1  advhei)  him  lo 
have  an  exploratory  incision  made ;  and,  if  it  was  found  that 

32 


250 


OENTTO-tmiNAET   0ROAN8. 


the  operation  could  not  be  terra innted  without  great  risk  tc  life, 
llial  the  wound  should  be  cloaL'J  without  procccdiog  further. 

Thifl  being  consented  to,  tlio  patient  wa£  etherkcd,  and  an 
incisioii  maJo  through  the  integiinicnts  of  the  eerotum,  exposing 
the  middle  lube  of  the  tumor;  but  the  diagno^ia  wae  not  cluci- 
dOitcd  by  euttin^r  into  this.  The  Jower  lobo  was  then  removed  ; 
the  teflttele  bniii;;  ineoqioroted  in  il,  apparentiv  heallhv,  though 
smfLlIer  than  natural.  In  the  diaacetion  of  the  rernaLuing  tu- 
mors, uearcr  the  inguintd  ring,  the  hernial  bao  was  unavoidnbljf 
cut  into^  hcm;2;  iutimutcly  connected  with  them,  Xo  intcatino 
appeared,  cnrefid  compression  being  niadoou  the  inguinal  canal 
duriag  this  latter  part  of  the  operation. 

The  lecoTcry  woa  perfect,  after  a  amarl  attack  of  consti- 
tutional irritation  ;  the  inguinal  ring  being  plugged  by  tbe  rc- 
mnius  of  tbe  inflnnied  and  thickened  gjic. 

Tbe  tumors,  on  careful  examination,  were  found  to  bnvd  a 
fntty  Btructure,  and  cmbrnced  the  spermatic  cord,  —  the  vaa 
deferens  being  trnced.  in  its  whole  Jcngth,  pai^sin^  throu^b  the 
centre  of  the  mass. 

One  or  two  mstanccg  of  similar  tumors  arc  given  by  authori- 
tieSf  but  none  apparently  of  so  large  a  size* 


PHIMOSIS. 

The  operation  for  phimosis  has  been  variously  performed. 
The  common  method  is  to  pull  forward  the  skin,  pre^s  back  tbe 
glana,  and  then  remove  a  circular  piece  Irom  the  end  of  the  pre- 
puce. On  letting  go  the  port,  tlie  skin  recedes,  leaving  tbe 
mucous  membrane  etill  conetriotcd,  and  often  with  a  ring  of  in- 
tcgunient  attached  to  it.  This  ia  slit  up  longitudinally  on  the 
upper  side,  and  the  edges  of  the  skin  and  mueou:)  membrane 
brought  together  by  a  aeries  of  eutures  pineed  around  the  whole 
ctrcumfcrenco  of  the  organ.  The  old  method  con&istcd  in  sim- 
ply slitting  up  the  prepuce  upon  its  dorsal  aspect,  and  allou'ing 
the  integument  to  roccde  on  either  side.  Tliia  operation,  iu 
many  coses,  onawera  the  purpose,  although  it  leaves  a  rather 
unseemly  Hap  of  loose  akin.  The  operation  first  describedi  in 
some  coses,  does  perfectly  well ;   but,  almost  always,  there  is 


aTDROCCLE. 


251 


an  cxccssirclr  »^rc  spot  At  the  point  where  the  fhtnam  u  divi- 
ded, taking  a  Ion;;  lime  to  heal,  aud  attended  by  muetk  imtAtioQ. 
All  the  benefits  of  the  operatioQ  may  be  isecured  by  the  foUovr- 
ing  procedure.  The  front  or  dorsaJ  part  of  the  prepuee  is 
fleizi;it  by  forccfi^t  placed  obliquely  upon  it,  5o  aa  ti>  take  up  a 
triangular  p*>rtion  of  the  tissues,  covering'  the  gtan^ ;  the  skin 
behind,  or  that  continuoud  with  the  trEenum,  being  lelt  im- 
grafipcd  by  the  jaw^  of  the  jn^tTument.  The  portion  protmdir^ 
beyond  tlie  torccps  i:^  cut  away  with  sciaaor^.  The  same  end 
may  be  attained  by  making  tbc  fikin  tense,  by  introducing  one 
blade  oF  the  forceps  iaaide  the  prepuce  and  the  other  outride, 
and  removing  nr  apron-ltkc  portion  in  front;  care  being  taken 
to  divide  tJic  mucous  membrane  well  down  towanla  the  baae  {>f 
the  gloos,  od  a  failure  in  thid  pArt  of  the  opcrution  is  one 
of  the  most  fertile  eourceiS  of  etmngulation.  The  edged  of  the 
wound  arc  then  nicely  adju^stcd  by  means  of  many  sutures 
taken  Tery  near  the  margin-  It  will  be  underetood,  that,  in 
thifl  latter  operation,  the  akin  behind  la  not  inlerferfd  with. 

The  ertcct  of  pbimo&ia  ia  to  act  a^  a  place  of  deposit  for  eon- 
tagious  Accretions,  In  many  cases  which  I  have  seen,  in  young 
persona,'  it  haa  ap|>eured  alao  to  have  retarded  tlie  growth  of 
the  organ.  In  eljJdrcn*  wc  often  find  the  prepuce  adlicrcnt  to 
the  gians,  aometiinca  so  firmly  aa  t(J  render  it  imposBiblc  to  de- 
Glroy  the  adheeiona  ;  in  which  coaCi  there  is  nothing  to  be  done 
but  to  cut  the  skin,  and  draw  it  boekwardsn  Generally,  how- 
ever, after  slitting  up  the  (ircpucc  in  front,  the  raueoua  flurface« 
can  be  caaily  separated  from  each  other  by  means  of  a  prube. 


HYDROCELE. 

I  shall  atludc  to  thia  common  Uiscnsc  very  brieHy,  The 
favorite  treatment  of  late  years  ha*  been  by  the  injection  of 
Tincture  of  iodine*  A  drachm  of  the  tincture,  or,  what  is  per- 
haps better,  the  eom^>ound  tineture,  of  ioduie,  tm  it  does  not 
predpitate,  diluted  with  three  parte  of  wator,  \a  throvm  into  the 
one,  and  left  there.  Tine  treatment  is,  however,  very  uncci'tain. 
I  have  tried  tbo  setou,  but  have  seen  much  inHummntion  pro- 
duced by  it;  and  in  one  case,  hemorrhage,  from  the  ulccraEion 


S53 


GENITO-LItlSIAitV    ORtiANS. 


cau&od  hv  it,  (rnttirg  off  a  good-si^ed  \ess«?l-  Tnc-iaion  is  apt  to 
be  foUowwi  by  eiippiirative  iTirtfimmntion  and  n  letiious  conva- 
lescCDGe-  Tn  one  or  two  iData.ncea  in  wliitrh  I  have  lately  pmi^ 
tiaed  it  after  other  nieuutf  had  isiileJ,  I  fouiKl,  :ittnoht*d  to  the 
tpstide,  numerous  cystic  ^ou-ths  containing  Bpcrmntozon,  which 
Mr.  Curling  destTilMzs  aa  hnving  found  tn  an  encysted  hydrcn^le 
attadied  to  the  ejiididymis.  Aa  u  general  rule,  I  have  fuiind 
that  the  wcaltliier  chissca  in  life  |irefcr  the  jmlliutive  openUion 
of  tapping-  The  laboring  classes,  who  are  more  ineonvenienced 
by  it  ID  Lheir  vocjitions,  prefer  the  radicrd  cure.  Before  operat- 
ing, it  i«  nlwaya  nt*.ejjsttry  hi  look  i\tr  the  trnnaljceucy  of  the 
tutnor,  (jy  suuliglit  if  posHihle.  The  <ipf*ration  of  tripping  ia 
best  done  witli  a  auiidl  trociu',  thrust  in  quioLly  ;  Lhe  point  being 
direcltd  oldiipicly  upwards,  b^  the  testicle  is  usually  at  tlic  back 
part  of  the  scrulum. 

H-jEMATOCELK- 


Case  CXLVT. — Hmmatocele.     Ext\i*pnfion  of  TfMicte, 
—  This   patient  hful   carried  a  tumor,   of  uuknovrn  origin,  for 
nineteen  yeahs.     Wlien  seen,  it  w:u  of  the  size  ttC  a  ciiaiu-iiuli 
finu,  widiout  fliKtUHtion,  and  presenting  an  indiimfd  t^pot  u|K>ai 
its  anterior  aspect.     Being  considered  a  tumor  of  the  testicle,  itaJ 
extirjjalum  was  a^lviseil  and  priictiaed.     The  sac,  whieb  waft  not^ 
puni;tiLred  dnriiig  the  opcratioa,   was   subaeipiently   laid   open, 
and  gave  ihsue  to  a  dirty-colored  fluid.     The  le/-ticlc,  after  tho 
removal^  was  found  finttenetl  and  waalcd  on  the  posterior  fat 
of  the   sac.      The  tunica   vaginalis  was   thiL'koned   to  nearly 
quarter  of  an   inch,  its   interior   lined   with   troagulatod   lyinphJ 
aud  iliflteudcd  so  much  aa  to  hold  a  pint.     The  rci^ovcry  w&s' 
perfect  in  two  weeks  ;   and^  ahhou^jli  there  waa  a  mistake  in  th» 
diagnosis,  the  oijeniiion  pei-fornied  was  tlic  best  ibr  the  paiient^ 
aa  the  process  of  granuhition,  in  so  duckened  a  sact  must  iiecea-| 
aarily  have  been  very  tardy,  and  tJie  teaticle  waa  do  longer 
any  cffieiency. 

The  diffindty  of  diagnoflis  was  inerea^cd  by  the  enlargemi 
of  tlie  other  testicle,  which  had  within  a  year  attaiaed  doubl 
its  natural   size,  was  much  datteued,  and   evidently  had   m 


H^::3IATOrELE, 


253 


wflter  pstemnl  to  it.  Bath  the  piitiont  nml  hjs  physipmn  in- 
siat^  thut  the  disense  of  the  other  le^iicle  commenced  iu  tlie 
same  mnnner ;  and  the  latter  Btateil  thnt  he  had  often  e:iamined 
it  with  the  view  of  deiec<ting  fluid  in  die  tunica  vaginalis,  but 
□ever  could  discGm  uny. 


Cask  CXLVTT. —  Case  of  U/p^mfitocelef  res^nthUnfj  Dlti- 
ea*H  of  tfiP.  T't'.nd/i.  H/itnoi-aL —^In  Miiy^  IflJij^  the  following 
case  of  difficult  dmgnosi^  came  under  my  cure  nt  the  IIo$|iiraL 

T^e  patient  wne  a  colored  man,  aUout  35  years  old,  of  large 
powerful  hiiilfl,  Mongintf  to  the  navy-  Seventeen  years  be- 
fore, he  lind  rR<jcived  a  bluw  upon  the  te^itide  from  the  fall 
of  n  powder  box.  The  testicle  swelled  until  it  wue  twice  wi  largo 
Ji9  naturaK  and  afterwanls  'lid  not  diinrnish  in  e\ze.  In  Mjirrfi, 
18^5,  he  had  an  attack  of  intermittent  fever,  attended  with 
great  swelling  of  the  testicle,  and  excessive  pidn  in  it.  The  jiain 
was  so  great  when  he  entered  the  Hospital,  tliat  lie  Lij[ietl  to 
have  the  testicle  removed  the  same  day-  For  the  farther  inves- 
tigation of  the  cafle,  howf^ver,  I  decided  to  place  htm  under  treat- 
ment for  ft  short  time-  He  was  put  in  bed,  on  a  light  diet,  and 
large  lauilannm  poultices  were  kept  coii<itantly  np]jlied  to  the 
scrotum  :  opialea  wctc  giv(*n  at  night,  Uoder  this  treatment, 
in  three  daya,  great  improvement  took  place ;  the  pain  was 
much  relievwl ;  and  it  wng  possible  tu  hanille  the  organ.  On 
examination  of  the  parts'  the  cord  was  found  cpate  healthy; 
the  tumor  of  the  scrotum  was  nearly  globular  in  form,  smooth 
and  elastic,  such  as  might  he  presented  by  a  greatly  enlarged 
testicle;  no  feeling  of  fluid  raiuld  he  detected.  The  skin  moved 
fireely  over  all  the  tumor,  eicept  ut  the  back  part»  where  there 
seemed  to  be  a  projection  from  the  main  imwH  of  a  different 
character ;  the  skin  h[>re  being  a^Iberent,  and  the  snbjncect  tissue 
giving  ft  pasty  sensation  to  ihc  finger. 

Being  in  doubt  as  to  the  nature  of  tbe  diaeafle,  I  informed 
him,  that,  after  exposing  the  Burface  of  the  tumor,  I  should  ex- 
plore it  bel'ore  [kroceeiliug  to  exlirpaiion-  He  was  therefore 
etherised,  and  an  incision  made  in  the  sci-otum,  over  the  front 
port  of  the  tumor.  A  second  incision,  nt  the  lower  p.irt  of  the 
scrolumj  exported  a  small  portion  of  the  healtliy  structiux;  of  the 


254 


GENITO-UaiNAHY  OBGAITS. 


tcaticlc*  An  incisum  was  then  mtwle  deep  iuto  the  tumor  oboje, 
hy  which  a  eoc,  ncnrly  three-quarters  of  an  inch  in  thkkucdSt 
was  openciii  giving  vent  to  s,  little  bloody  Hukl*  A  fibrinuuH 
inaas  waa  found  in  the  sac.  Ttic  aiae  waa  at  once  shown  lo  he 
one  of  old  htcrantotclc,  and  its  rcniovol  wiw  proceeded  with. 
The  projection  behind  waa  a  cyst  filled  with  fiuld,  wliich  had 
been  the  sent  of  Tcccnt  inftnmmulflrv  action.  The  akin  of  the 
fiurotum  was  here  eo  adhercnti  tJinC  it  was  removed  with  the 
tumori  The  testicle,  us  in  the  preceding  cosCi  waa  much  diniin- 
iehcd  in  blzCi  and  so  dL^placed  and  compressed  that  ltd  fuDcticnd 
miiat  have  been  entirely  snajKnded.  The  Ictt  scrotal  cavity 
was  the  Beat' of  a  hydrocele,  whit: h,  however,  was  of  recent 
dcvelo[>mcnt,  and  probably  dependent  upon  the  acute  attack  of 
the  other  side. 

T.UIICOCEIB. 


Many  methods  have  been  su^geeted  for  the  cure  of  rartcoccle, 
or  enlargement  of  the  spermatic  reins.  Brcechet'd  methodi 
with  the  screw-damp,  is  olmoat  inaupportably  painful;  while 
that  of  Kicord,  which  is  now  perhaps  the  faroritc  oae,  eoneiaU 
fiimply  in  cuttings  across  the  packet  of  veins  with  a  ligature.  I 
have  tried  both  these  plans,  as  well  as  that  by  reDsoTing  a  por^ 
tion  of  the  ecrotum :  or,  in  caeee  where  it  has  been  much  elon- 
gateil,  by  producing  adiieeiona  of  its  eidcs  by  mcana  of  auturca. 

The  folluwing  operation  for  the  relief  of  varicocfUf  which  I 
Lave  successfully  jicrformcd  in  from  sixty  to  seventy  caace,  and 
wliich  is  I  believe  pecullari  seems  to  me  to  be  the  eimplcst  and 
most  etfoetual-  Tiie  vas  deferens  is  firet  separated  Irom  the 
Tiaoular  part  of  the  curd,  imd  is  kept  out  of  the  way  by  an 
asBistant.  A  longitudinal  inciaion  of  about  two  inches  in 
Icn^h  is  neict  made  in  the  scrotum  down  upon  the  bundle  of 
Teins,  which  ia  then  ceizcd  with  the  ibrccpsi  drawn  out,  and,  by 
a  few  touches  of  the  knife,  aeparated  from  the  adhering  tissues* 
Two  strong  ligatures  arc  now  passed  above  and  below  the  ma^ 
cf  enlarged  veina,  and  ^rmly  tied,  eo  ua  to  include  between  them 
as  much  of  the  diseased  tieeue  as  poc^ible^  The  etrangulated 
Teins,  which  at  once  shrink  into  a  very  amall  compass,  are  now 


VAKICXKTELE, 


255 


alloTred  to  reocde  into  the  wound,  which,  W  the  corlra<^tion  of 
the  wfoEuni,  becomes  reduced  to  a  compnrnliveiy  enmll  «iz€. 
The  patient  ia  confined  to  his  b«l,  and  wntcr-drcf^itJfK  npplicd 
dunog:  the  separation  of  the  sJou^h,  which  takes  pl&e«  >□  from  ten 
tc  fourteen  ditvs.  In  several  co^ee,  where  the  acrotum  had  been 
clonpitwl  to  double  its  natural  length,  and  filial  with  large 
maffee  of  veina,  which  would  almost  seem  to  defy  any  modo  of 
treatment,  I  have  operated  by  this  method  with  perfect  sucecfla, 
and  have  aeen  llic  scrotum  eoniract  within  a  few  weeka,  or  at 
most  a  fe^  months,  to  its  normal  ^izc. 

1  hare  never  fieen  varieoccJc  cxeept  on  the  lett  side  of  the 
eerotum. 

Case  CXLVUI.  —  Varicoceh  of  Grirat  Stsc.     OperatiQn* 

Hetovet'if*  —  A  young  man,  22  years  of  age,  for  ten  yeare 
had  more  cr  lees  of  a  tumor  in  tho  eerotum.  Finally,  it 
became  bo  large  and  cumbersome,  and  attcndeil  with  eo  much 
pain  in  the  loins,  that  he  eont^ulted  me  for  relief.  The  scrotum, 
when  the  veins  were  fully  di^^tcndcd,  hun^  half  way  down  the 
thigh.  The  left  testicle  was  atrophied;  and  its  vaa  deferens, 
when  ecparated  ftom  the  re&t  of  the  Epermatic  coril,  woa  but 
half  the  size  of  the  other.  The  testicle  was  so  enveloped  in 
the  enlarged  and  thickened  veins,  that  1  feared  it  would  be  diffi- 
cult to  remove  the  latter,  without  the  former  being  dragged  out 
with  them.  1  therefore  informed  the  patient  tljat  tliie  might 
take  place,  aa  it  had  once  before  oceurrcd  to  mo  in  a  eimilar 
inetnnee,  which  mndc  it  necessary  to  remove  the  whole  mass. 
Ho  agreed  to  hove  done  what  woe  thought  expedient*  Being 
elherized,  and  the  vaa  deferens  held  out  of  the  way  by  an  oasidt- 
ant,  iiie  veins  were  exposed  a«  high  up  as  possible,  for  fear  of 
encroaching  on  the  tunica  vaginalis  ;  and  a  loop  of  them  being 
drawn  out,  assisted  by  a  few  strokes  of  the  bistoury,  a  double 
ligature  was  past^ed  under,  and  tied  above  and  below.  The 
ficrotum  being  loo  long,  a  large  piece  of  it  wns  e^tciacd.  The 
whole  wonnd,  with  the  esecption  of  where  the  ligatures  aud 
tumor  formed  by  tho  ticd-up  veins  protruded,  wae  closed  by 
fiuture»,  A  cold-water  compress  wa»  placed  over  tho  wound. 
A  considerable  amount  of  infiammation  Ibllowed  this  com- 


jd. 


plicated  Operation.  At  the  end  of  four  day?,  the  sutures  wefe 
wiEhiirawD,  and  titftst  of  the  plough  of  ths  vtjins  cue  oC 
Tlio  wound  waa  dressed  witJi  u  poultiee.  An  nb^e«fl  formed 
low  duwn  at  the  htu-k  i>f  iKl'  scrotum,  ord  re<|aired  the  bUtourv. 
After  this,  he  gratlimlly  recovered  ;  and  left  the  Hosptal  in  ihre^ 
weeks,  with  a  small,  hciUthy,  graauliting  wound*  The  scratum, 
from  tlio  ftize  of  an  orange,  wfw  redueed  to  tlial  of  an  egg- 

I  £HW  bim,  dome  riiontha  nflerw&rds,  entirely  free  from  dift- 
eaae,  &nd  relieved  of  pain. 

Case  CXLIX.  —  Varicocele  tind  I/i^drorelt,  Optrottm 
Her^overtj.  —  June^  IS^iO,  —  A  man  i5(J  yenre  of  age  bad,  for 
n  long  time,  been  nfflieted  with  a  varicocele  and  hydrocele  of 
the  left  side  of  the  scrotum-  II  causwl  him  pnin  in  hU  baek. 
from  the  dragging  on  the  oord.  Being  eiheriye*!,  an  inciuon 
was  mmlc  over  the  cord  ;  die  veina  were  drawn  out,  and  tied  in 
ihc  ui^ual  manner.  At  the  same  time,  a  alight  opening  wis 
miide  info  the  toniea  vaginalis,  and  the  serum  evacuated^  The 
parient  did  well  for  two  or  tliree  dayw,  when  he  was  attacked  hv 
gangrene,  which  then,  fi>r  the  first  time  since  the  organiiaiion 
of  the  Hospital,  jx-rvarled  tiie  hoiise^  on  acctinni  of  the  filling-up, 
with  bad  material,  of  tlio  ilata  in  the  neighhorhood.  A  large 
bit  of  the  RcrotLim  sloughed,  and  nJi  ahacess  formed  behind, 
whieh  re*]ijirc;d  evaluation.  A  yeaat  poultice  waa  appliM,  nnd 
the  patient  put  upon  rjninine  and  stimidanta-  At  the  end  of  a 
month,  he  waif  well  enough  to  leave  the  Hi>Apital ;  nnd,  &  month 
aftortt-ard*,  he  ca.]led  on  me  perfectly  well,  the  varicocele  and 
hydrocele  being  both  cured. 

Cash  CL-  — Varicocele,  Operation.  Recovefif.  — A  Bol- 
dier,  3(1  years  of  ago,  entered  the  Hospital,  Oet.  li>,  18(>4,  ri>r 
a  large  varicocelo  in  the  le^t  side  of  die  scrotum,  whieh  luiii 
troubled  hira  for  mEuiy  years,  but  had  been  nggravated  by  tiffi 
performance  of  military  duty,  during  fuur  months,  and  finally 
caused  his  di^chiirge  froni  the  jinny. 

On  the  12th  of  October,  tlie  veins  being  exposed  by  an  in- 
cision, in  the  manner  iJcwriljed  above,  a  longj  curved  nee<lle, 
armed  with  it  double  ligature,  wn:^  pah^  between  tlicm  aikd  the 


Ml 


RETAILED    TESTrCLK- 


257 


vatf  deferens,  TJie  loop  uf  tlie  ligiitiire  beini;  cut,  and  t)ie  veins 
[lulled  i>uL  mi  f;ir  m^  [Kr^H^ible.  llie  li^itiin^  were  tl<^cl  ubiive  :iiid 
below,  80  as  1«  iikclude  a  large  niasA  of  vewelrt.  The  wliaJe 
wnj4  ihen  puslied  liiu-k  into  the  seititiim,  ami  water-dreftsiiigB 
applies!.  On  the  27th  of  October,  purl  of  the  ligniurea  were 
removed  with  the  roreej>8 ;  and,  on  die  SSth^  iJie  rest  came  away, 
Oct,  31at,  he  lefl  the  Hospital  well. 


RETAINED    TESTICLE, 

Case  CLT.  —  TenCiele  r^taiut^l  in  the  (rroiii.  If^tnoval. 
Stt^^ueiit  D*tath  of  l/u;  Piifitnt  from  hiteniftl  Disease, 
appare^itlif  Mftll^mint.  — A  gentleman,  38  yeara  uf  age,  con- 
»iiilfe<f  me  in  Fehnmrj,  ]85fi,  on  account  of  his  right  testicle, 
whieL  had  never  descended  into  the  scn^tuiUt  but  Eiud  been 
retained  in  the  tn^inal  canaL  For  Tnan  v  veant^  ihitn  waa  no 
inconvenience  to  him;  but.  just  before  Le  saw  mci  it  liat]  been 
quite  tender,  giving  him  extreme  pain  on  tlie  slightest  pres- 
sure, eAieudtnii  npwiirdit  into  the  abdomen,  auil  down  tlic  thi^h- 
Aa  no  treatment  gave  relief,  I  pertbmied  the  operation  of  re- 
mo  vhI. 

lie  wju  in  poor  health,  and  quite  nervoua,  hut  with  nu  appar- 
ent malignant  dlseade.  He  wai4  etlierJzed  with  eldorie  etlier,  and 
the  dlBBectioii  wjndiictLil  with  the  utmost  caution,  ibr  fear  of  in- 
fiinging  on  the  alidomiQal  cavity-  The  tenticle  wa^  removed, 
with  tlie  tunica  vaginalis,  which  closely  embracetl,  and  in  aomc 
places  Htrongly  adhered  to  it. 

On  cutting  into  the  tcsucle,  the  flCrneture  wa«  found  to  be 
completely  dif^jrganized  :  the  up|)er  [wirt  of  114  Ux]y  prewenting 
tlie  iL^pect  of  an  uni^ijie  apple  ;  in  the  lower  waa  a  cf  tft  filled 
witli  a  jelly-like  nialerfal,  Uruler  the  micrn3CO|)e,  some  nucle- 
ated tx^Is  wexe  aeen. 

This  gentleman  recovered  from  the  opemtioQ ;  but  died 
Guddeuly  a  yeai^  aflcrwards,  having  aufTered  fur  some  time 
previuusly  witli  obscure  symptoma  (jf  internal  diiteaae. 

lu  two  other  cjisea  of  testicle  retauied  in  the  groin,  which 
X  hare  wltueescd,  the  organ  wa£  Invaded  by  encephaloid  ilis- 
eaae. 

S3 


U8 


FEMjOS  OENlTO-URQfArtT   OBQANS^ 


FEMALE  CENITO-TJaiNARY  ORGANS. 


iiUPTcmE  OF  rcBiy^uu. 


Case    CLLL. — liuptiti^    of  tk^  Perinmum*      Operation* 

Cure.  —  I  waa  requeated,  in  October,  185E),  to  see  a  latly,  35 
yeai-fl  of  age,  who,  five  vears  before,  had  received  a  severe 
laeemtion  of  the  pcrina^um,  implicating  the  rectum  about  an 
inch  and  a  \mW.  The  effect  was  complete  iocoatinence  of  ihe 
feces,  causing  confltant  annoyance  and  anfl'ering. 

The  pntient,  being  fuDy  cthcriicd,  waa  operated  upon  on 
Monday,  Oct,  I8tli,  in  the  following  manner,  the  position 
being  the  same  aa  for  Hthototny ;  The  lacerated  edges  of  the 
rectuin  were  firat  miwlo  raw,  and  a  quadrargular  bit  of  integu- 
ment removed  en  each  side  of  the  fie^^urc,  about  thrce-fburthd 
of  an  inch  wide^  and  an  inch  and  a  half  long.  The  edges  of 
the  rectum  ivcre  then  brought  together  by  three  sutures,  which 
were  cut  off  close*  Three  deep  auturCB  were  inHCrted,  with 
etrong  double  thread,  commencing  about  half  an  inch  from 
tlic  borders  of  the  wound,  and  travcraing  its  entire  depth- 
Theec  threads*  being  secure<i  over  bits  of  bougie,  were  made 
tight,  and  brought  the  edges  of  tlio  woiiad  well  up  togetlier. 
Five  auptrficiiU  stilchca  were  now  paascd,  to  adapt  more  per- 
fectly the  edges  of  the  eldn  ;  and  one  within  the  vagina,  to  bring 
together  the  deep  part  of  the  wound-  Thia  being  done,  the 
finger  was  introduced  into  tlic  rectum,  to  aaccrtain  what  reaial- 
ancc  was  likely  to  be  made  by  the  ephinctcr  ani.  Thie»  which 
before  the  operation  could  not  be  diatinguiehcd,  waa  now  quite 
prominent,  and  could  be  hooked  up  by  the  finger*  like  a  broad 
cord  or  ribbon.  An  ineiaion  was  therctbrc  made  through  the 
integument  at  the  margin  of  the  anoe,  the  mu^ele  c:tpoeed, 
and  freely  and  carefully  divided  on  the  finger,  by  the  BCiBBora, 
without  cutting  through  the  n)ucoue  membrane  of  the  rectunj. 
Tlic  anus,  which  before  thie  division  was  eloscd,  now  remained 
loose  and  <i[iou,  A  hit  of  lint  waa  placed  over  the  wound  of 
the  periniuum,  and  lixcd  in  place  by  collodioo,  ao  aa  to  serve  as 


RUPTUEE    OF    FEIUN-EUM. 


259 


fl  prote^^rion  from  the  eonlncl  oi'  the  urino.  The  patient  waa 
then  plnc^d  on  her  jiide,  »iid  a  kr^re  cathetor  with  n  Me]d  to  it 
introduced  into  the  uretlira,  the  end  of  which  fifterwards  wus 
attached  to  a  bit  of  ^utta-percba  tube,  which  conducted  the 
urine  into  a  niak  urinal  provided  for  tJie  purpose.  On  recov* 
orin^r  from  the  ether,  ehe  had  thirt}'  dropa  of  laudanum  admin- 
istered to  her,  chiefly  for  the  p»jrj)ose  of  checking  the  action  of 
the  hou'eld.  Tlie  opcrittion  lasted  no  hour  and  a  half,  not- 
with^^Nindiag  nil   expedition   vviia   employed. 

She  pasAed  a  quieC  night,  and  felt  no  pain  in  the  wound-  The 
catheter,  causing  some  irritation,  was  withdrawn,  and  nfterwardB 
was  introduced  twice  a  day,  with  the  gutta-perchn  tube  attached, 
to  prevent  any  coniaci  of  the  urine  with  the  edges  of  the  wound  ; 
and  eubeefjuently  an  ordinary  female  caUieter  of  much  smaller 
mze,  with  a  gutta-percha  tube  aitachetl,  was  employed.  Her 
nouriflhmeni  was  priucipally  a  hit  of  oraeker,  with  a  little 
brandy  and  water,  two  or  three  times  a  day,  which  she  preferred 
to  tlie  juice  of  meat. 

On  the  fifth  day  after  the  operation,  the  wound  becoming 
sore,  and  the  sutures  more  or  less  loose,  the  quill  stittirea  were 
removed,  leaving  the  superficial  ones.  She  had  had  no  evacua- 
tion, but  had  been  somewhat  troubled  with  flatus.  The  water 
was  drawn  off  twice  a  day  with  the  catheter,  and  the  wound  kept 
clean  by  constant  bathing  with  warm  water,  and  subHcquent 
protection  by  a  little  cerate,  rubbed  on  wJlh  the  finger. 

By  the  tenth  day,  all  the  autures  of  the  rectum,  skin,  and 
vagina  were  removed;  and  ihtre  seemed  to  be  a  good  solid 
union,  with  the  exception  of  a  very  small  aperture  between 
the  rectum  and  vagina,  which  fitUl  remained  o[ien,  hut  gnuiu- 
lating. 

On  the  twelfth  day  from  the  operation,  she  had  a  very  large 
evacuation  from  the  bowels,  aided  by  an  enema  of  warm  water, 
Thi*  was  efTcefed  without  doing  any  damage  to  the  union  of  tlie 
wound ;  and,  on  the  following  day,  she  began  to  paas  her  water 
without  the  use  of  the  catheter,  sat  up,  took  fooJ  more  freely, 
and  w»s  considered  convalescent. 

On  Not.  5ih,  I  made  a  final  examination  of  her  caee. 
The  aperture  in  the  rectum  was  cJosed,  so  far  aj*  ixjuld  be  de- 


260 


FEMALE  GEMTO-UBlNAKr   OKGANS. 


tpmiin&l  fnim  IniipeJ-tJon  nf  the  [mrt  hy  llie  «i3eciiliim  nni,  ami 
diflr!<isffll  no  HiimI  |iflj*ftirg  frurii  iln^  rpiiMiin  into  iIht  vngiiia. 
The  perinffium  wbs  t*trong,  thick,  anil  finii,  longer  th»n  is  uau- 
a!ly  perreiveil  in  ei  woniiui  whr*  h;is  Ixirne  children.  The  union 
wii.H  sft  gnod  thill  triu:ee  tif  the  DiJera^tic*!)  wero  !*cjircelj'  per- 
ceptihle-  The  patient  hiul  AJl  control  of  her  evacuations  for 
the  firpt  time  in  five  years:  and  her  atdmach,  though  a  little 
dyajjuptic,  wiis  in  better  condition  than  it  had  heen  ihr  a  good 
pmt  of  that  lime. 

The  division  of  the  sphincter  niii,  und  the  use  of  rollndicm  to 
protect  the  eitenial  wnund  from  tl»e  atrfjon  of  the  nrine,  uere. 
I  ihiak,  of  ^eat  advaiLUige  in  prodiidng  a  favitnible  ret^uh. 
The  removal  of  the  urine  twice  ilail/,  hy  the  cntheter,  witli 
a  p^Lim-elaatic  iidie  att.at'htil,  wa?i  also  of  ^eat  utiUtyn  A  little 
urine  only  imce  a^srideiitally  iranie  in  contact  with  the  wound, 
unJ  wad  immediately  followed  hy  much  irrit^ition.  This  can  be 
prevented,  when  the  catheter  is  removed,  hy  pinching'  up  the 
gum-elaeiit:,  retaining  the  urine  in  tlui  instnimcnt  until  ii  is 
carried  to   the  uteneiL 

I  have  gone  into  some  detail  in  this  caae,  as  T  have  felt  better 
dati^Bed  with  the  mimagement  uf  it  than  of  auy  that  had  come 
under  my  oljservalism.  The  u»t  of  a  small  ^das*  or  ivory  rod, 
in  place  of  a  hou^e,  woidd,  T  think,  be  of  advantJige,  a*  lew 
likely  to  retniit  irritntini^  matter.  In  using  the  quilled  suture, 
J  took  great  paiss  not  tu  dr^w  tbu  stltehcs  tighter  tliaii  wa8  ab- 
fiohilcly  nccctit^ary  to  bring  together  tlje  deep  part  of  the  wound, 
from  fear  of  prodncjng  partial  aErEmgulalton,  and  oonsequent 
unhealthy  inflammation  in  the  intermediate  Integument,  —  an 
accident  uf  nut  uncommou  occurrence,  as  appears  hy  rectirded 
cafleA.  The  jntroductiou  of  a  atltcb  witliin  the  vagiua  was  of 
much  uHe  in  faeilitating  the  union. 


CAflE  CLin. — -Ifupiure  of  the  PertntEum.  Operalion. 
Cart.  —  This  caae  iflcundenfced  from  die  Ilof^pital  I'ccords.  In  the 
spring  of  iy<i+»  a  young  u'omiin,  £0  years  of  age,  wfim  admitted 
to  the  Iloppilal,  on  account  of  rupture  of  the  perinieiiin-  8he 
stated  thiit,  four  years  before,  the  had  been  delivereil  of  a  male 
child,  by  u  miJwiie,  after  a  labor  of  forty-eight  hours.      When 


EUPTUfiE   OF    PERIN-^XM- 


361 


she  left  her  bed,  it  was  discovered  that  the  perinfl>iitn  wn«  rup* 
tured.  She  \vns  able  to  retain  her  feces,  exce])t  when  tliey  were 
very  liquid.     She  always  had  pain  nt  ev^icuntjons. 

She  was  etherized,  sind  phii'csl  m  ihe  position  for  litholomy- 
There  waa  found  to  he  Ji  partial  prokpee  of  the  uterus.  The 
rupture  cif  the  perin^oaoi  involved  only  &  part  of  the  sphincter 
aui,  lenvinn;  the  recto-vaginal  septum  entire-  A.  V-shnped  in- 
eisioti  WAS  made  through  the  mtegument  along  the  furrows  just 
outside  of  the  extermd  labia.  That  portion  of  skin  which  lay 
near  the  nnns  was  dissected  up.  and  tiie  dissection  carried  back- 
wards fijr  .1  distance  of  three-quarters  cf  un  inch  upon  the  up- 
per surface  of  the  sphincter.  The  dissertion  was  continued 
inward.s,  in  the  line  of  the  V'-sha^ied  incision,  so  as  to  olitaiu  a 
riw  surface.  Thus>  flnps  were  obtained,  ibe  edges  sind  raw 
surfa<<es  of  which  could  be  eiisily  ftpproxi muted.  Silk  fiutiires 
were  passed  tlirough  tJicse  flaps,  about  half  an  inch  from  the 
free  wiges,  and  Hepiiw?(l  over  pieces  of  bougie,  acenrntely  ad- 
justed on  each  side  of  the  wound.  The  pressure  thus  ejcerted 
was  in  a  line  with  the  pnnots  where  the  sutures  were  inlrothiced. 
The  edges  of  the  flups  were  held  together  by  means  of  inter- 
rupted silt  sutures.  The  laceration  was  thus  closed  without  any 
tendency  towards  outward  traction,  since  no  portion  of  the  in- 
tegument of  the  nates  was  involved  in  the  operation. 

Direction  was  given  to  pass  the  catheter  as  often  as  should  he 
necessary,  and  not  to  allow  any  urine  to  lUII  upon  the  wound. 
A  simple  cold-water  dressing  was  applied. 

On  the  sixth  day  after  the  operation,  an  examination  was 
mode,  and  it  was  found  that  there  was  the  usual  suppuration 
abotit  the  sutures.  All  the  sutures,  except  one  near  the  nuLLs, 
were  removed.  There  wna  firm  union  without  any  tension- 
Subaeqiienily,  cicatricial  ion  was  complete;  and,  on  the  eigli- 
teenth  day,  she  was  discharged  from  the  Hospital,  cured. 

Case  CTjTV. — I^r/phire  of  the  T^erintRum  nnd  J^**cto-vafji~ 
nai  Septum^  Opfrttfioji.  Recnvery.  —  A  lady  30  yeurs  old, 
of  ordinary  good  health,  who  applied  to  me,  was  confined,  two 
years  before,  with  her  first  child,  having  been  forty-eight  hours 
in   labor.      The   head   of  the   child   was   dropsical,   and   nearly 


2fi2 


FEIMAI^E    GEMITO-ITEINART    ORGANS. 


doublo  the  naCtinil  size-  As  it  pasaed  ibe  external  organs, 
the  rupture  owurrerl,  whk-b.  however,  wa&  not  detected  imcil 
the  next  da.y-  Her  phyginian,  suspecting  a  laceration,  mftde 
an  eiamination^  and  introduced  two  stiloliesT  wliicK  were  inef- 
feetunJ  in  producing  iiuion.  From  thai  time,  she  had  not  been 
able  to  retain  the  contents  of  the  bowels,  wliiob,  unlike  tlie 
previone  case,  were  constipated  insfend  of  being  relnsed.  About 
9ix  monlba  before  T  t-nw  her,  having  stood  a  lon^  time  in  a 
crowd,  occasionally  on  tiptoe,  she  was  tskt-n  with  a  sense  of 
difltresa  and  weight  in  tiie  pelvis ;  and  it  wa*  found  that  n  pro- 
lapBiw  of  tiie  iitenjs  lind  taken  place.  Thi*  was  aa  additional 
source  t>f  trouble  to  her,  obliging  her  to  wear  a  sponge  tor  sii|> 
port,  and  to  n»e  astringent  injcetiona. 

Tlie  operation  was  done  much  as  described  in  the  previous 
ease.  The  haJr  being  shaved,  a  surface  thrcoquarters  of  an 
inch  wide  was  exposed  on  eauh  side  of  the  laceration.  The 
sides  of  the  deep  lisftiire  in  the  recto-vaginal  septiiui  wtre  dis- 
sected up  (separating  the  rectum  from  the  vagina),  their  efiges 
freshened  and  brought  toijether  hy  Htitehce.  The  perini'Uin  was 
brought  togetlier  by  the  cjnilled  suture*  three  atitdiea  being 
ueecT,  nn<l  the  edges  of  the  skin  nppniximated  tiieely  by  melius 
of  four  Hutiii-cr*  with  fine  tbrejid.  The  sphincter  nni  was  di- 
vided on  tlie  left  side  as  follows :  The  finger  was  introdneed 
into  the  rectum,  and  the  mus<rle  hooted  up  upon  it.  A  Hmal] 
aperture  wil^  mside  oo  the  nmr^n  of  the  mucous  oiecnbrane, 
distinctly  exposing  the  muacular  fibres;  these  were  divided 
with  a  small  prtir  of  blunt-pointed  HcisBors,  down  to  the  mU'- 
coiia  meiulmiue  of  the  rectiiir,  held  oa  the  finger.  Tliu  uuub 
now  remuitied  perlectly  open  and  relaxed,  and  without  the 
slightest  traction  on  the  fititchea  holding  it  In  front-  Tlie 
operation  IzLsted  h:df  an  hour,  the  patient  bemg  fully  under 
ether.  She  was  placed  in  bed,  on  her  side,  and  the  nurse  di- 
rected to  draw  off  tlie  water  with  a  catheter  having  on  elafitic 
tube  attruOieil  to  it,  tliree  times  in  the  twenty-fonr  hours,  u.ud  on 
DO  account  to  allow  any  urine  to  touch  the  wound. 

Four  days  after  the  operation,  I  removed  the  back-stitch 
wiiich  held  the  quill,  as  auppurutlon  liad  tiiken  place  around  it, 
causing  some  pain  and   irritation   about   the   anus.      In    other 


VESICOVAGINAL  FKTDia. 


263 


tf^Bperb,  ev^ry  thiii^  il!J  wi:!!,  and  tlie  putient  experienced  no 
ttnwtituLiojiiLl  (lit^turbance.  The  atitches  iu  die  akin  were  aUn 
cat  And  w^ithdrawD,  and  the  union  appeared  goodi  She  took 
iiread.  lea,  iind  brotli  for  nouiiahment.  ller  recoTCiy  was  per- 
fect. 


YESICO-VAOINAL   riSTCLA. 

The  treniment  of  this  afTeotinn,  whicli  hud,  until  vcrv  rerert- 
\j,  been  almost  wbolly  confinefl  to  ihe  simplest  ca^eg,  lnu*  been 
Intel?  revived  m  this  country  with  remnrkable  SMCcese,  espennlly 
sinee  the  puWieaiion,  by  Dr.  Sims  of  Npw  York,  of  n  number 
of  very  flui^c&^sful  cases,  in  which  lie  itltributed  the  good  result 
to  the  cTDpioymant  of  sutures  of  (Silver  wire;  but  a  more  ex- 
tended trial  ba*  failed  to  demonstrate  tliat  sitperiority  wl»eh  wns 
datmc<l  for  them  over  silk  or  linen  threads,  and  tl»e  greiirer 
inofinvpnience  which  attends  their  employment  has  iilrendy  led 
to  their  abandoninent  by  some  r^nrgeons. 

In  <|uite  a  large  nrnnber  of  operational  which  I  have  per- 
fhrmed  for  vfciico  and  iirethro  vaipnnl  lifilulii,  1  have  always 
used  Bittures  of  coinmnn  surgeons  Bilk,  and  have  had  every 
reason  to  be  salisfiei]  with  the  rc#<iilts. 

The  reid  imprtneinent  in  ibis  o]>enitionj  and  that  which  has 
been  the  meana  of  bringing  it  into  so  general  ufie»  is  the  very 
free  dif<secrion  \tf  the  vai^nal  muroiifi  membrane  from  the  old 
cicatricLal  ti^ue^  and  frtim  the  wallji  of  the  bladder  i  bv  tWia 
plan,  the  »ti[i:hej^  are  i.*ffecliially  relieved  from  tension,  and  the 
re8ii]ls  are  generally  favorable. 

In  many  ca^^e-f  of  this  digeaHCf  we  Rnd  c1ic  as  uteri,  and  some- 
times tlie  upfter  pirt  of  tfie  vagina,  completely  obliterated  ; 
causing  retention  of  the  menstruul  Siiid.  I  have  watched  a 
numljcr  of  caae^  of  this  kind^  and  have  always  ob^ervejl  that 
relitjf  is  ultimately  obtained,  often  after  great  siift'ering,  bv  the 
formation  of  u  fisiuhtus  opening  eommunicaling  with  the 
vagina,  or,  very  rarely,  with  the  bladder. 

Few  surgical  diaejise^  are  mare  distressing  to  the  piUient  llum 
ve?(ie<i-VAgiTnd  Rstuln.  and  no  operation  better  rewards  the  skill 
uf  the  eurgeon-  It  reacne?*  die  uuflTerer  from  a  state  in  which 
eustpmre  has  become  a  burden,  and  restores  her  once  more  to 
llie  world  iLnd  to  the  enjoyments  of  aocioL  life* 


264 


FEMALE    QENlTO-URINAKr    OEGANS. 


Ca.sk  CLV.  — Vrsiro'i'i/ginal  Ftfihilit.  OpVTfUion.  lif- 
coverij,  —  A  wuiiuu  2^1  yfurn  lA'  ag<^.  mother  of  thr'ev-  diil- 
dren,  was  in  labor  four  days  with  her  liiHt  cliiid.  All  her 
rhililren  were  horn  dead.  She  did  not  pereeive  the  injnry  done 
to  die  hliLfliler  uU  ahe  b^^g^in  ti>  g^t  itp  from  her  CDiiUnement, 
twelve  days  aftcrwanU,  whoii)  on  examination,  it  was  di^- 
coiercii  that  neiirly  all  die  urine  escaped  throii^rh  a  laige  open- 
ing in  die  vagina,,  I  iirst  saw  her  iii  November,  Ifl^lO,  The 
aperture  iii  the  bladder  extended  fnuii  an  inth  bcldnd  ihe 
pnbea  to  the  oa  uteri,  which  was  ragged  and  irregular,  having 
been  Involved  in  die  injury.  She  had  nienstruatEjd  twice  since 
die  aitideut,  and  w^:^  ratht:r  ft^ble.  Tlie  akin  of  the  inside  of 
the  tliighs  was  irritated  by  the  conatant  jjOisaage  of  urine  over  it- 
The  ciper:ilioii  wad  jierfjrmed  in  Nuveinljer  i  die  ii^nry  wjia  rt?- 
Ceived  in  the  pretedinj^  February.  Slie  waa  plaLied  on  an 
elevated  [jJutfurm,  constructed  for  diiti  purpuc^e,  on  her  abdo- 
men; the  limbs  being  jilaced  at  right  anglea  with  die  trunk- 
The  mucous  inemlirane  having  been  freely  diaaecteil  in  the 
usual  way,  six  auturea  wert  intruduCE^,  and  the  whole  wound 
broiigiit  merely  together:  the  button-euture,  accordingto  Bo^e- 
matfri  Tuelhod,  was  not  o^eil  on  aecouiit  of  the  great  extent 
of  the  opening,  odierwiee  it  woulil  Imve  been  employed.  She 
WBJi  laid  on  her  aide^  and  a  catheter  with  a  gum-elaj^tie  tube 
ftttttclied  to  it  introduced  every  four  hdura.  to  draw  ofT  the 
water,  the  tube  being  added  to  prevent  any  contact  of  urine 
witli  the  external  organs.  Thia  pkn  J  have  found  preferable 
to  leaving  the  ealLeter  coimtontly  iu  place,  b;^  it  allows  much 
mure  freedi>m  to  the  patient.  Every  thing  went  oa  wcQ  imtil 
die  end  of  a  week,  when,  ou  account  of  the  attend:int'e  omit- 
ting to  dmw  off  the  water,  she  paeeed  the  whole  night  with 
the  bladder  distended.  This  waa  followed  by  a  lojikage  from 
tliL'  woujid  tlie  next  niorniug,  Iu  the  couLEe  of  the  following 
week,  all  the  euturea  were  removed ;  and,  about  the  iirat  of 
December,  ehc  left  the  Hoapiln]»  as  fihe  said,  well,  being  able  to 
retain  her  wuter  about  two  lioiird.  I  aaw  her  before  ahe  left 
town,  on  th«  14th  December,  She  had  not  menatruated  aince 
die  operntion  ;  and  I  found  it  dil£eiiU  to  decide  whether  the 
opening  i'rom  tiic  uterue  wm  into  the  bladder  or  vagina.     lier 


VESICO-VACDfAL    FISTCLA. 


2G5 


>jenUb,  hnwever,  wiid  goiJ,  ami  luis  remalnra!  ho  since-  Tn  a 
fljiiiiliir  inRtiini"e»  tlie  incn^tnuJ  fluid  jia^sed  into  tbe  bladder, 
and  escfiped  from  tlie  urethra  without  iDcoavenicnce. 


Case  CLVI,  —  Vesic*>^affinal  J^iatula,  Cauterization^ 
Relief.  Pho»phatic  CnlcytJtu.  Litk&trity.  Rdief. — A  wo- 
□OAD,  aged  32,  entered  the  Hospital  March  9,  184S,     Fourteen 

weetfl  before,  she  wna  delivereil,  hv  forceps,  oF  a  dead  child, 
after  a  kbor  of  four  days.  During  this  period,  she  was  for 
the  greater  part  of  ihe  time  insensible,  from  the  eflwts  of  nar- 
C'ulioe. 

Tw'j  days  after  delivery,  there  was  incontinence  of  urine, 
which  flowed  constantly  from  the  vagina,  never  pa*Bii:g  by  ihe 
urethra,  or  collecting  in  the  bladder. 

She  did  not  meoHtruate  after  lier  labor,  nor  did  she  have  any 
difficulty  at  the  period  when  the  raenstrriHl  secretion  should 
appear.  TJiere  was,  however,  much  milk  in  the  hreaats,  but 
varying  in  amount :  she  bad  not  noticed  any  relation  between 
tbe  (]UBn[lty  i^ecretL-d  and  the  catamenial  period. 

The  external  organs  were  found  excoriate*!  by  the  -urine, 
which  i^as  constintly  dribbling  away.  The  vagina  wae  eome- 
wlmt  contracted  throughout  its  entire  length,  hut  more  e.^pe- 
oioUy  at  aboat  three  inches  from  the  vulva,  where  there  was  a 
vcrv  marked  constriction.  Behind  this  was  a  loniritudinal  alit, 
with  ealloua  edges,  on  the  anterior  wall  of  the  vagina,  through 
whiclk  water  was  seen  issning  fi'otn  the  hlncider.  A  sinall  ii-regu- 
lar  opening  eiisted  irt  tho  posterior  part  of  the  vagina  near  the 
Bihmtion  or  in  the  place  of  the  oa  uteri,  which  had  entirely 
disappeared  in  the  cicatrix. 

She  wa«  thoroughly  etherize*!  with  chloric  ether,  aa  it  was 
found  almost  impossible  to  mnke  the  slightest  examination,  on 
account  of  the  extreiae  sensibility  of  the  parts.  The  epeculnm 
of  Ricord  was  naed  both  for  the  examination  and  the  ojjcration. 
Tlie  edges  of  the  fiiitida  were  cauterized,  so  ns  to  produce  a 
elougb,  with  ihe  potiisM  umn  cjiIcc,  and  ii  cndieter  introduced. 
Thia  instrument,  which  ha<l  been  made  fir  the  puqjose,  was 
half  an  inch  in  diimieter,  Ave  inube^  l^ng,  with  a  shield  an  inch 
from  its  exiernal  erifiee. 

u 


ws 


TEtiMjE   aEKlTO-UBINA£Y  ORGANS. 


The  patient  suffered  but  little  from  the  eauatic,  and  no  urine 
passed  through  lliG  liistula  for  several  <]aja>  It  vniB  touehod 
oDooflionally  with  creosote ;  and,  nino  days  atlcr  the  opcrntion, 
nn  urine  havinp  pitJ^sed  throiip;h  it  for  eomo  timo»  the  cnlheter 
wns  omitted,  and  she  wtm  allowed  to  walk  about. 

A  month  later,  ehe  reported  that  no  urino  pEta&cd  bj  tbe 
vttn;ina»  When  the  crtthctcp  wns  first  omitted,  tho  water 
dribbled  away  from  the  urethra,  whieh  from  long  disuse  had 
upparcntly  last  its  power  of  retention.  Thia  power,  howe\'er, 
was  by  dcrrrccs  restored, 

Ou  JMay  7th  nn  examination  woe  ii>adc  both  by  the  vagina 
with  a  epeeulum,  und  by  the  hlEidder  with  a  catheter.  The 
fifitulouB  opening  vas  hardly  perceptible.  In  the  bladder  was 
found  n  iralculuflt  QpparcTitly  ahoitt  tlie  aiae  of  a  eheetuul.  With 
d  lithoti-itc,  the  Btouc  was  easily  oaught  and  crushed.  On  the 
fallowing  day,  the  fragments  of  the  alone  eatne  away  with  the 
urine.  They  were  found  to  be  composed  of  the  phosphate  of 
lime. 

Thie  patient  remained  in  the  Hospital  until  the  latter  part  of 
May,  when  she  liad  full  command  over  the  urine.  During 
the  whole  of  this  time,  tliere  was  no  appearance  of  the  men- 
Btrunl  ijecretion  ?  but  at  Btoted  period^T  ^-t  an  interval  of  four 
weeks,  an  increaeed  tieeretion  <if  milk  took  place  in  tlie  breasta. 

A  year  later,  she  cidled  on  me,  and  euid  that  she  had  been 
well  ainee  lojivint^  the  Hospital,  About  three  nionthe  before, 
nearly  a  year  after  her  dehvety,  the  ealamcnial  function  was 
restored,  and  remained  regidar.  This  muat  have  had  ila  exit 
at  the  orifice  whiel]  took  the  place  of  the  oa  uteri,  and  which 
undoubtedly  when  I  first  saw  her  waa  partially  oeeli]d4>d. 

On  over  distention  of  the  bladder,  a  small  quantiCy  of  urine 
wae  found  to  escape  from  the  vagina.  An  examination  with 
the  apeetthnu  proved  tliat  the  old  Hstula  had  elosedf  and  tliat 
the  urine  must  eecape  from  the  same  fiasure  in  the  nterua  aa  the 
catamenia,  showing  tJiat  a  veBieo-uierine  fistula  existed, 

Li  quite  a  uumber  of  tbe  eases  of  indammation  and  toughing 
of  the  vLigina  al^r  tedious  labor,  which  have  occurred  in  my 
practiee,  the  ob  uteri  has  become  olJitemted.  The  menstrual 
fixnction,  however,  ha^  not  been  suspended :   having,  in  «ome 


VESICO-VAGIVAL   FISTULA- 


267 


uietnncee,  fonad  an  exit  through  tJie  bladder ;  in  otherB^  forcing 
its  way  into  the  vagimt. 


Case  CLVU,  —  Vesica  -va^ttml  7*V.fl/n/a-  Operation, 
Citj-e.  Jietention  of  Men&trnat  Fluid  for  Nine  Year*, 
Spontaneous  liupinre  into  Vifjina, — About  the  year  184fi, 
1  woe  cfdlel  to  sGG  a  wooi^Ln,  2o  years  old^  who  had  been  de- 
livered  of  a  dead  child,  some  weeks  before,  after  n  txjdioiis  liLbor. 
I  fouod  that  the  whole  va^niU  portion  of  the  bl;tdder  hod 
sloughed  away,  leaving  but  the  aiiporior,  and  a  suieJJ  portion  of 
the  htteral  walls-  There  were  bci^idea  large  abseessca  running 
into  each  groin  from  the  v.igina.  After  a  prepiratory  treatment 
to  restore  her  strength,  eho  was  operated  on-  Tlie  bladder 
was  dissected  away  from  tlie  vagina  as  for  aa  possible,  oad  the 
wJges  of  il,  being  pared^  were  brought  together  in  the  usual 
manner  with  Bilk  sutures.  The  organ  was  then  not  more  thnn 
one-half  of  its  original  size.  The  operation  was  followed  by 
complete  suecess- 

By  the  previous  iaflanimation,  the  os  uteri  bad  been  entirely 
obliterated;  and,  at  each  subsequent  menstrual  period,  she 
surtered  dreadfully  for  a.  number  of  years.  No  uterine  tumor 
could  be  detected,  either  by  the  abdomen  or  rectum-  Nine 
yeara  aftcrwarda,  during  one  of  these  monthlyattaelcs,  a  rupture 
look  place  in  the  vagioH,  foUowcd  by  the  discbarge  of  nearly 
two  qiiaita  of  menairual  fluid.  This  was  the  only  appcarjince 
of  this  aocretiou,  [  saw  her  in  1866,  eleven  years  after  the 
nipmre,  and  finiad  there  had  been  no  return  of  the  discharge. 
There  had  been,  however,  until  within  three  years,  the  usual 
preimmitory  flymptomfl  of  diecatamenial  flow,  but  nothiag  more. 
She  was  in  good  flesh  and  strength,  but  bad  suffered  fnim 
disturbance  in  the  stomncb  and  bead  nearly  all  the  time.  She 
CTmaulted  me,  when  I  Inst  saw  her,  on  account  of  profiine  vom- 
itin|r  of  a  colorless  fluid-  The  bladdex  bail  performed  its  iimc- 
lioiifl  normally  *iince  the  operation.  The  de^iruction  of  tissue 
was  more  extensive,  and  the  result  of  the  i>[>enttion  more  suc- 
cessful, than  in  any  other  case  of  this  kind  that  I  liave  had. 

In  ant^llior  case,  where  the  whole  lower  half  of  the  hlad- 
dor  Wfis  lost  by  slou^rliiug,  the  siune  symptoins  were  miinifested 


FEMALB  GENITO-UTUKABY   OROANS, 

at  the  cafcwneruai  pcrlocla.  At  one  of  theae  perioiU,  a  year 
ftcm  tbeir  tomuiencemcntT  tlie  paiaa  became  violent  Jintl  forcing, 
OS  in  labor.  A  rupture  of  some  part  of  tbe  utcrua  into  the 
vagin;i  took  place;  and  the  patient  was,  as  #lie  atatea»  at  once 
dt'iugeil  with  blooJ,  so  that  long-conrinucd  fainting  took  plncCi 
from  which  slie  was  with  difficully  recoTered,  The  rQenetniftl 
ftiDCtion  baa  since  gone  on  regularly. 


PROLAPSE   OP  THE   WALLS   OF   VAGtNA- 

Tbc  follow4njr  cAsei  illustrate  the  jiroinpsc,  or  hernia,  of  the 
bladder  into  the  vngma,  not  a  very  common  Jiffcction.  It  is 
UBUnU^  caused  by  a  ^training;  effort,  acting  upon  tlie  relaxed 
wallfl  of  the  vagina,  and  must  be  Jiatinguishcd  from  prolapse 
of  the  mucous  membrane  of  that  passage,  and  from  cyatic 
tumors  arising  in  ite  w^Ia*  When  the  tumor  formed  by  the 
bladder  is  of  large  size,  it  is  the  source  of  great  iocouvemencc 
in  walking,  and  interferes  with  mlcturitioD- 


CasE  CLVIII.  —  Prolapsus  of  the  Bladder  and  Antdit^r 
WaUs  of  the  YagiTiti,  simulatii\ff  tt  'fianor.  — In  September, 
18(!3,  a  young  woman,  25  yearfi  of  age,  consulted  me  lu  regard 
to  a  protruBioQ  from  die  external  organs,  which  interiered  with 
locciuotion.  She  hnd  been  married  at  seventeen,  and  waa  the 
mother  of  five  clUldrcQ.  The  tumor  was  not  noticed  until  alter 
the  birth  of  her  last  cliilJ,     Her  general  health  waa  good, 

A  large  fold  of  iLc  anterior  wall  of  the  vagina  was  found 
banging  down  just  within  the  labia.  The  os  uteri  was  slightly 
enlarged;  otherwise  the  uterua  was  normal.  Elevating  tliat 
organ  had  no  effect  upon  the  tumor.  A  catheter,  passed  into 
the  bladder,  could  be  made  to  enter  the  tumor,  by  reversing  its 
beak. 

I  introduced  a  horseshoe  pessary,  with  immediate  relief,  ao 
that  she  was  enabled  to  walk  home*  a  greater  distance  than  she 
had  previously  walked  since  her  confinement.  This  exertion, 
however,  caused  a  aligLt  hemorrhage,  ao  that  I  thought  it  best 
to  remove  the  pessary  after  tAvo  days.  Subsequently  she 
IcEimcd  to  introduce  it  herself,  aud  wore  it  with  relief. 


TUMOR   OF    moss    VENERIS- 


269 


Case  CLTS.  —  Prolapsus  of  the  Bl^dder^  shiinltitinif 
Otf»iic  Tumor.  I'^ormalion  of  a  I*'istula.  —  Iti  September, 
1861^  I  wna  reijiieatefl  to  see  a  lady,  about  50  years  cf  nge, 
who  wna  effected  with  a  tumor  in  iJie  xagina,  rGaonibling  cystic 
tumor.  It  wns  first  nollL-ed  several  years  before,  after  ^trainiDg 
while  lifUng ;  recentJy  it  bad  caused  uiccuirenieiice  by  ils  weight 
and  the  pain  felt  during  luicturition,  which  was  frequent  and 
tliffietdl,  I  perceived,  on  eviiniiniition,  a  Ini^e  tumi:>r,  i^ttuatcd 
m  front  of  the  oa  uteri,  wliidi  retranted  on  pressure,  waa 
flabby,  and  projected  bet^'een  the  labia.  Half  an  inch  below 
the  iirethrn.  was  an  ulceration,  tbrtiu^h  wbieli  n  frittbeter  waa 
[Missed  iiiio  tlie  eavicy  uf  tbo  tumor,  wliich  proved  lo  be  the 
bJadder,  A  sound  could  only  be  introduced  through  die  ure- 
thra into  the  bladder  when  die  latter  was  rodueed  to  the  normal 
postlion,  not  when  proJapaed.  Evidently,  the  obslruetioo  lo 
the  paeenge  of  tbe  urine  through  tbe  urethra  waa  the  cause  of 
the  formiition  of  a  fiaiidn.  She  was  advised  to  wear  a  ring 
pesaarv,  to  keep  tbe  bladder  in  position. 


Cask  CLX.  —  Uncommon  Tumor  of  thk  Mo\s  Vene- 
ris, RemuVaj„  Clke.  — A  Ijidy,  42  years  of  age,  nolice(l, 
*oon  aftor  coufineineni,  a  tumor  in  the  left  groin.  It  gr:ulu- 
■Jly  made  ita  way  into  the  labium  of  that  side  ;  and,  as  it  en- 
lnrgcd»  iiivolTed  the  niona  veneris,  dragjriDg  it  down,  togetlier 
with  the  iiiteyumenia  of  tbe  abdomen,  and  finally  formed  a 
large  pendulous  tumor,  hinging  between  the  limb^,  cox-ering 
the  external  organs  of  generation,  and  causing  much  pain  and 
inconvenience. 

It  waa  removed,  and  found  to  be  fibro-celliilar,  of  very  firm 
consistence  %  the  cellular  tissue  surroumling  St,  and  entering  into 
its  eoinpoeition.  being  infiltnited  with  serum.  Its  weight  was 
two  pounds  and  two  ounces, 

I  leame^I,  subseqiicnily,  that  she  na^  well,  and  bad  been  safe- 
ly delivered  of  a  hejdtliy  child. 


270 


FEMALE  GEfnTO-CRUTARY   ORGANS, 


VASCl3LAfi   AND  SENSmVE   TUMOU  OF  THE  FEMAJ-E 
UKETH  RA- 

A  vascular  tumor  la  not  infrequently  met  with,  junt  nt  tlic 
entrance  to  the  nreTbra,  in  the  female,  having  nrounrl  \ts  haw, 
uriimllyf  jt  hnght  ei^the mat 0119  hluah.  It  ia  comput^ed  of  en- 
Inrgwl  veinB)  nrd  is  trliiHsed  by  Paget  nmang  erec file  growths. 
Mr.  liutcluneon  eompftrea  it  to  lieroorrhoid*.  It  m  generally 
Teiy  eenflitive,  and  ia  the  sonrt^e  of  ^reat  irrifntion,  t^using 
piiin,  ilrlimg,  ami  smarting  dnring  micturition,  often  rkggra* 
Viilf^l  at  night:  Dt'eiwionully  it  is  the  seat  of  henntrrhf^e. 

Extirpation  ia  die  only  remedy ;  and  care  muat  he  tiiken 
to  excise  tho  whole  morbid  growth,  and  even  then  it  la  liable  lo 
recur.  A  vnhmhtc  monograph  has  been  written  on  this  subject 
by  Dr.  Alexander  E.  Husiick  of  New  York- 

The  followincr  eases  are  illustrative  of  tliis  aflecdon  ;  — 


Cask  CLXT.  —  Sen/ntive  Tumor  of  the  I^cmnlc  Urtihra, 
Excision-'— TVe  patient  wna  a  marrip*l  woman,  (i4  yearn  of 
age,  never  pregnant-  She  had  harl  good  health  iloriiig  early 
life,  with  the  exeeplion  of  dyainenorrhcm.  Her  cataiiienia 
ceased  suddttnly,  when  she  waa  ftfty-«x  years  old;  and  four 
years  9nb«c*qiiently  she  putFereJ  from  dypuria,  attendeil  with 
severe  tsenlding  :  at  night  there  waa  atinging  |>mn  in  the  region 
of  the  iiretbni,  and  priirituH  during  rhe  day^  The  external 
genital  organs,  especially  in  the  vicinity  of  the  uretlim,  were 
exeesaively  tender.  These  aymptora^  inereaj*ed  in  severity  up  to 
Jujic,  1^63,  when  I  first  saw  her, 

I  found  a  vascular  excrescence,  about  the  atze  of  a  pea,  pro- 
truding from  the  nrcthni-  On  ihc  1st  of  July,  the  tumor  wa« 
exciseil,  with  a  dreiilar  portion  of  the  mucous  metnbrane  around 
tlie  orifice  of  the  urethra,  and  the  wound  cauteri:£cd  widi  ni- 
trate of  silver,  A  flexible  catheter  was  then  introdiii^  Into  the 
bladtlcr,  and  allLJwed  to  reutain.  She  soon  recovereil,  and  was 
disoharged  well.  The  tumor,  however,  recurred  some  months 
after  tlie  operation,  but  gave  nmcli  leas  tmuble.  It  was  re- 
moved nh  before,  and  I  have  out  ^ince  heard  that  it  returned. 


TUMOR   OF  THE   FEMALE  mETHBA- 


271 


Case  CLXQ-  —  ScupUit-e  Tumor  of  Female  Ufethta. 
Ejc^isimi.  Complete  tleUef.  -^  A  youngs  womiin,  26  jears 
oIJ,  of  dark  hair  and  eomplexiun,  hai3  for  four  veara  been 
troubled  in  micturition.  The  affection,  however,  had  not 
ftsfiumed  a  very  aevere  form  u»tiJ  a  month  before  ber  first 
viait  lo  mc.  Kvcry  pfLtiaag^  of  water,  at  thie  time,  was 
attended  by  a  burring,  slinging  aensntian,  which  was  almor^t 
Ineupiiortiihlc.  anil  finnlly  became  so  severe  as  to  affect  her 
health.  With  the  neiial  delicacy  which  women  feel  in  com- 
plaintfi  of  lbi3  nature,  she  had  avoided  consulting  her  physi- 
cian ;  and  it  waa  only  t>y  the  advieo  of  her  sister,  wlio  had  been 
a  nurse,  that  ehe  waa  tnally  persuaded  to  apply  to  me.  At 
this  lime,  the  mere  contact  of  the  clothes  was  inBupportablc, 
and  alic  had  Imd  one  or  two  ottaeke  of  rather  profneo  bleeding 
from  the  neigliborhood  of  the  urethra.  On  examination,  a 
vnsonhir  tumor  waa  found,  of  the  size  of  a  very  email  pea, 
projecting  from  the  urethra ,  the  mueoua  membraQe  at  its 
ba^c  iKiinfjj  hi^jlily  injocfcd-  The  tumor,  and  the  surrounding 
pnrtB,  were  exquisitely  painful  to  tho  toudi.  The  patient  being 
fully  etherized,  tho  tumor  waa  seized  with  fbrcepe,  dragged  out, 
and  as  Jarge  a  ptirtion  na  poHpJblo  of  tho  mucoua  membrane 
excised-  The  operation  was  followed  by  eoropletc  relief;  being 
the  first  case  thiit  1  hnyc  mot  with  where  a  cure  has  roaulted 
from  a  atnglo  operation  ;  most  of  the  coaee  having  been  attjicked 
by  caustics  or  the  knife  before  coming  under  my  obacrvatioc. 


Case  CLXIII.  —  Sensitive  Tn^mor  <if  Feviaie  l/relAra, 
Extininn.  Heiief.  Hccnyf^nce  of  Tumor  at  the  Had  of  Ten 
Yt^tira^  Exfitfion.  Relief  — A  lady,  rJS  years  of  age,  had 
been  trimbled  for  nine  j-enra  with  great  dyeuria,  and  oxceasive 
Ben*iitivene3Ji  of  the  parta  in  the  ncighboihood  of  the  urethra,  so 
that  she  could  not  Ircar  even  tho  cc>ntacl  of  her  clothed.  Before 
C*maulting  me,  cauterization  had  been  employed ;  without  giving 
her  any  relief,  however, 

I  found  a  small  vascular  tumor  projecting  from  the  orifioc  of 
the  urethra,  bleeding  on  the  slightest  touch,  and  eo  painful  aa 
to  elicit  loud  outcriee  from  the  patient  on  the  moet  delicate 
examination.     She  was  etherized,  and  the  mucous  metubrane  of 


272 


FEMALP^   OENrrO-UBTVART    OBGAKS- 


ihe  urethra  everted  lo  ae  great  an  extent  as  [>osdb1e  with  die 
forocpa,  Tind  excised.  The  hemorrhage  inuring  the  operation 
w^  quite  profuse. 

Relief  followc<!  for  nearly  ten  years,  when  the  tumor  re- 
apfieured,  but  with  less  violent  eympiom^  than  J>efure.  It  was 
trt^ifed  in  the  same  icanner  us  at  tirst,  and  with  as  goixl  result. 

1  have  not  heard  of  ita  recurrence. 


OAIfCER   OF   VTXYA. 


I  have  been  much  struck  with 


lave  Deen  mucii  struck  with  the  great  relief  afforded  lo 
patients  wilh  extensive  and  painful  cancerous  affectioaa  of  the 
vulva  by  a  surgical  operation.  Femalea  are  very  apt  to  con- 
ecal  the  disease  until  lis  ravages  have  made  great  progrces, 
when,  frora  the  amount  of  discharge,  the  difficulty  of  locomo* 
lion,  and  often  a  painful  secondary  tumor,  they  are  obliged  to 
make  it  known.  In  a  number  of  cases^  I  have  removed  a  can- 
cer occupying  the  entire  Inbititn,  extending  u|>  into  the  Hoor  of 
the  vaginiL.  and  penetrating  the  iiretbr;i  ^bove.  The  wound 
healed  nipidJy  uftcr  ihe  operation ;  and  the  patienESf  so  &r  as  I 
know,  have  dnne  well.  The  cancer  i:*  without  doubt  epitheliid, 
and  in  my  opinion  amenable  to  operation^  In  the  inatiucee  in 
which  I  havG  practised  remuvQl,  there  haa  been  no  recurrence  of 
the  discasCf  although  eome  of  tbera  were  of  tlie  most  formidable 
chniracte^'H 

In  the  coac  of  an  old  lady,  who  waa  auffering  esceasively 
from  a  very  extensive  cancer  of  the  labia  and  a  large  aecondary 
tumor  of  the  groin,  ^ — -in  whom  loi7omotion  was  entirely  pre- 
vented, and  the  discharge  so  acrid  as  to  excoriate  the  surroumliug 
parts  over  which  in  addition  the  urine  jraseod,  —  I  perfortned 
nn  operation,  i-cnioving  tlie  whole  di,=eased  portion  of  the  pu- 
denda 1  and  the  patient  recovered  the  uee  of  her  limbs.  The 
tumor  of  the  groin  was  not  interiered  with. 

Cask    CLXIV.  —  Cancer   of    VnJva.      OpetfUion^      lie- 

cofj^rVn An    unmarried  woman,  36   years  old,  entered  the 

Iloepitai  in  March,  ISG5,  for  an  ulcerated  cancer,  o<'cupying 
the  whole  extent  of  the  left  exiemal  labinm,  also  the  upper  por- 


TUMOE    OF    VAGINA- 


273 


aon  of  ri^ht  Inbium,  impltcntiiif^  the  vulva,  and  extending  quile 
deeply  beneath  the  sui'i'jw.'e.  Ii  begsin,  it  y*;!ii'  bel'>re,  hy  a  hard 
nodulat^l  swellinir  on  the  left  lubium,  causing,  at  firet,  no  m- 
coEiveni^nce.  Jaan.iry,  1805,  it  dischnr^ed  JVeelVi  and  also 
wfla  quite  pninfuL  Soon  utter  tliisT  hard  globular  swellin^'a  ap- 
peareJ  in  the  left  ^oin.  On  the  30lh  of  Mnrch,  nn  opomlion 
woe  performed,  Cr>  remove  (ho  cnlu'e  disease  of  labiu  and  vulva, 
II  wai»  thmjght  ui^desd  to  attempt  to  ramove  the  gl^inda  m  tke 
groin,  the  induration  at  their  bn*ea  being  very  indefinite.  IVben 
the  ereotiie  ttasue  was  cut  into,  the  hemorrhjip;e  waa  pretty  fre«j 
ftnd  many  largo  veasels  required  to  be  tied,—  wliich  is  generally 
the  eaJf^e  in  tliia  operation.  A  few  days  rdlcrwanla,  an  erysipe* 
latiiUH  intljimnkution  occnrrofi  in  the  tnmora  ia  the  groin,  re- 
quirin^j  free  inci&iona.  Sloughing  took  place,  ternunatin^  in 
the  t'omplete  destruction  of  tliese  secondary  tumors.  The  pa- 
tient was  difloliargcd  ivell  on  the  24tL  of  April- 


TUUOR    OF    VAGINA - 

Case  CLXV.  —  CyHic  ISimor  of  Vagina.     liemovaL  — 
A  lady,  2*i  yenrs  of  ag*^,  well-form«l  tmd  lieiilthy,  two  tnonllis 

before  her  conlinement  percoivt-d  a  round  and  clastic  tumur  in 
the  bock  part  of  tlic  vivgina>  At  the  time  of  her  eonEucment, 
it  Wft6  forced  down  outride  the  vagina,  and  fiubacquentJy  pro- 
Irnded  on  anv  motion,  or  on  her  fie^uining  the  npri<;ht  poeture. 
When  she  col]^^ulled  rac  nftevwurds,  ahe  was  in  the  fourth 
month  of  her  second  pregnancy,  and  the  tumor  caused  ^cat 
uneauinesB.  On  examination,  an  elastic  tumor  tlic  size  of 
an  oran;^e  wne  tlamd  arising  from  the  posterior  wall  of  the 
van;ina,  and  extending  from  the  ob  uteii  to  the  extemnl  organsn 
The  finger,  being  paa^ed  into  the  rectum,  could  detect  the  tu- 
mor pressing  book  and  aomowhat  obstructing  the  passage  of 
the  canal.  By  a  little  manipulation,  it  eouJd  be  gnuluaUy 
bi'oiiglit  down  oitteide  t)io  external  organs,  and  was  seen  to  bo 
A  rounded,  elastic  mass,  covered  with  tiic  mueeus  membrane  of 
the  vagina*  Tlie  oa  uteri  wna  quite  large,  soft,  and  patulous, 
and  pret^ented  the  nppearunee  of  a  much  fartlicr  advance  in 
pregnancy  tbnn  adtnittcd  by  the  patient. 


S74 


FHUALE  OEMTO-rBlKABT  OBOAXS- 


She  wae  etherized ;  the  tumor  was  ^racped  by  the  hnnd  so 
&A  to  make  it  tcn^e  ;  and  nn  inciaioD  Iwci  iochea  Jong  made  iii 
the  mediim  line,  and  a  deJicntc  snc  exposed.  Tiiie  wa6  now 
partially  unccvcrcd,  when  it  ^ave  woy,  ood  about  a  giU  of 
cream-colored  fluid  wns  evacuated.  Tbe  «ic  vras  corapieiely 
aepamtcd  from  iu  aiu^'bmeiit  by  the  knife  and  director.  The 
wound  was  lefi  to  take  c&re  of  itsoif,  do  slilchea  beinif  used, 
tihe  hod  no  had  Bvmptotnf ,  and  soarccly  any  «ctifatioDa  to  ia- 
dicftt«  that  an  operation  had  been  done.  She  woe  kept  quiet 
for  a  week,  from  iear  of  the  po^ibility  of  a  miscarriage,  a4id  to 
prevent  tbe  mucous  membrane  of  tJie  vnginn  from  bo^^ing  down 
and  forming  an  incoDvecient  escrcdcence-  Tbe  recovery  was 
oomplete,  and  did  not  interfere  with  her  pregnoncvi  which  went 
on  to  a  We  termiDfttion. 


POLYPtS   CTEM- 


Case  CLXVL  —  Polypus  of  Ut^nts.  J^cmova!  ^  Liga- 
ture, —  During  1847,  ft  lady  fell,  while  entering  her  house  in 
tbe  evening,  and  received  a  ee^-erc  blow  on  the  lower  part  of  ibc 
abdomen  Irom  the  atone  &tcp.  She  was  carried  into  the  bouse 
autfenng  grcallyf  and  a  profuse  uterine  hemorrhage  followed. 
For  some  months  she  waa  confined  to  her  bcd«  scarcely  able  ti> 
turn  from  pain,  and  euffcriDg  from  occasional  returns  of  the 
bleeduig.  Coming  under  tbe  core  of  lui  experieneeil  pmcli- 
tioner,  a  vaginal  examination  wof  made,  which  disclosed  the 
existence  of  a  polypoid  tumor  cilmdeJ  from  the  os  uteri. 
Being  called  in  consultationt  I  od^-iJ^ed  an  operation.  At  thu 
period  !^be  was  suHering  from  amemiat  and  ^o  cxbauctcd  a^  to 
moke  it  unsafe  for  her  to  a^ume  the  upright  position,  a^  tho 
attempt  was  always  attended  by  fainting.  A  ligature  wa* 
applied  to  the  ^>olypua,  and  tbe  tumor  separated  on  tbe  fourth 
or  fifth  day.  the  subse^iuent  recovery  being  rapid. 

The  patient  remained  well  until  l?^51,  when  the  recurrence 
of  liemorrhage  at  tlic  menstrual  periods,  severe  pains  and  bear* 
ilftl^own  dCnsatioDs  in  Uie  back  nnd  li>in^,  indicated  the  exialenco 
of  uterine  di&ea^e.  Added  to  the  aborc  symptoms  was  the 
discharge  of  a  gill  of  watery  tluld  from  the  va^na  once  in  £vc 
or  ^  days. 


POLTPra   tTEHl, 


275 


A  tutror  vtas  discovered  occupying  ihe  whole  fundus  of  the 
«t€ruB,  ami  projecting  into  the  Ta^rina,  With  some  difii- 
culty,  the  fin^r  could  be  passed  into  the  ciLvity  of  the  utertis 
through  the  oa^  which  tightly  eitihrno«<l  the  central  part  of  the 
polypus;  with  the  speculum  it  could  be  distinctly  seen,  its 
parjcles  presenting  a  white,  gligtenirp  appenranee,  A  strong 
ItgnCure,  made  of  whip-cord,  was  applied  to  iu  base  in  the 
following  manner :  Two  porte-nreuds,  threaded  with  the  hifK- 
ture,  were  carried  up  throu*^h  the  os  uteri  to  tlie  base  of  the 
tumor;  then,  by  taking  on?  in  each  hand,  they  were  made 
to  deacrihe  a  semicircle  around  the  polypus.  The  ends  of 
the  lin'ftture  were  now  en^foged  in  the  aerre-nceud  of  Graefe, 
which  beiDfi  carried  up  to  the  root  of  the  polvpuH,  (he  threada 
were  diBenjrngod  from  the  porte-na?ud,  and  the  ends  drawn  as 
licht  as  possible  and  secured.  By  means  of  a  screw,  the  pres- 
sure was  increased  daily  and  the  tumor  destroyed,  bo  that  the 
instrument  separated  at  the  eml  of  a  week,  no  ci>nstitutional 
symptoms  of  eoneefjuence  hnyin^  occurred. 

This  patient  has  since  menstruated,  and  enjoys  good  health. 

C.ifiE  CLXVTTh  —  Pcfrfjmn  nf  Uf^run.  RtimouaL  — A 
woninn,  40  years  of  Jtg*^»  "hcj  had  bnme  a  number  of  chil- 
dren, entered  tlie  Hospitnl  in  May,  1860,  for  men<irrha^na. 
She  at1rihijte<l  It  to  hard  wurk,  and  for  a  year  bad  eirnstantly 
bled  more  or  le?'^  daily.  A  vascular  polypUH  waa  found  pro- 
jectmg  fnrm  the  oa  uteri :  It  was  datf  and  about  the  si£e  of  a 
cherry.  The  jwitient  said  the  tinuor  would  oct^sionally  fill  up  to 
^i  kr^re  size,  ao  ns  to  project  through  the  extermd  organs.  The 
OA  iHeri  was  niueli  enlarged  and  very  hard  »  and  the  body  oi  the 
uleriid  WU8  lt[iped  bac^k,  and  could  be  felt  of  the  frize  of  &  large 
orange  in  the  rectum.  I  twi&ted  off  the  polypus  with  a  force[js, 
but  Cduld  get  no  inslrunient  into  the  us.  Thy  bleeding  at  once 
ceased.  Ergot  in  die  form  of  troehes,  at  the  rate  of  fifteen 
graifis  three  times  a  day,  wu^  then  g:iven,  and  on  the  sec^ond  day 
brought  un  expultiive  pains  ;  but  no  tuuurr  np[>eared.  At  the 
end  of  n  week,  the  ua  uteri  had  diminished  to  half  its  prevtOEia 
al£e ;  and.  a  ^jrluight  aller  the  openition,  there  had  been  no  fur- 
tlter  hemorrhage,  although  she  e<in4taiit1y  hud  the  eenbation  of  Its 


276 


FEMALE    GEMTO-URIPiARr    OKOA>~Si 


returning.  Thp  onlv  resisoTi  to  wliWi  T  ran  jiMcrihe  thr  large 
si7e  of  the  uicrus  ia  the  cunslant  imtation  of  the  bleeding  polj- 
pua  and  the  eiRui  of  blood  for  its  giippJy. 

Case  CLXVUI.  —  Polypus  of  Utcmn.  Iie)»r»val.  —  A 
heoltby,  iinmnrried  woman,  30  yenrfl  old,  of  regidnr  nienatniJi- 
lion,  whilo  making  some  effort  wns  Heized  with  n  pnin  m  ttia 
liac'k  and  a  sfinsalion  of  somediin^  fp^'i'^g"  ^'*y  ^^  '^'^  jjelvis. 
SltortJy  afterwnrdrf,  she  bad  liemorrhogc^j — probnMy  uterine  ; 
Kid,  in  a  few  daySj  noticed  a  substance  projecting  Iictween  the 
Inbift.  At  &vf>ry  sid>&eqnpnt  nieiiPtrunl  [leriod  hIiq  was  flid»j(!ct 
to  iiR'norrhagia,  anri  r&^cnily  tliri  ble&bng  rwiirred  in  the  inter- 
vals. Her  Htreni^th  was  much  reduced,  and  she  euflfefed  con- 
Mantly  from  pain  in  tbe  loina.  There  vfsts  a.Uo  a  leucorrhwftl 
discharge. 

On  examination  iindor  ether,  n  red,  granulated  body,  the  size 
of  a  pigeon*n  eg^,  was  discovered  proiruiljng  between  the  labia. 
On  passing  the  finger  up  ihe  vagina,  the  Tumor  was  found  to  be 
attached  by  a  long  net'lc  to  tbe  inside  of  tfje  uterus.  The  oh 
wae  open  and  everted,  so  that  the  finger  passed  readily  into  llie 
cavity  of  the  womb. 

The  tumor  was  grasped  with  a  pair  of  broad  forceps  (such 
flfl  are  used  for  drawuig  out  the  tongue),  and  twUted  around 
five  or  fliy  times,  when  it  came  away  without  resistance.  I  pre- 
fpiTwl  this  metliod  to  tbe  more  tedious  one  of  ligature.  Titers 
was  no  bleeding,  and  the  following  day  she  was  ([uite  well. 


FORn:ia*j  body  usr  vagina. 

Cahk  CLXTX.  —  Ltrrje  Hair-pin  e^ctrncted  from  the  Fa- 
ginft  of  a  ChUtf  tlnrfei^n  i/enrs  ohl.  —  \  wns  reijiiesteil  l>y  a 
physician  to  see  a  child  whom  he  biid  visiffd  in  the  muming, 
in  whose  vagina  he  had  discovered  a  hair-pin  firmly  impacted. 
Fur  ii  number  of  years,  she  had  been  trouiJed  with  a  jiiirulcnt 
dirtcbjirge  jj-iiiI  ctthei'  symptoms,  fur  which  many  physicians  luwl 
been  consulted,  and  many  npplications  bad  been  made  withont 
avail.  Ah  her  symptoms  were  becoming;  more  urgent,  her  phy- 
sician was  consulted,  who   advised   an  exaniicaiion.      The  girl, 


FOREir.y  BODY   IN  VAOINA. 


277 


finilinff  that  tbia  wna  to  tnko  pince,  confcsflcd  to  her  nootlicr, 
that,  50vcn  yotira  before,  while  In  ciropony  witli  otiior  cbiklren, 
flhc  huJ  introiiui^eJ  pomcthing  into  the  vn^inn,  ami  tbnt  ebc  bed 
ELlwnye  been  nwnre  tiint  its  presence  was  the  CDuee  of  hor 
troubles,  and  hnd  determined  never  to  diseloae  the  fact,  and 
was  now  induced  to  do  so  only  by  tbc  fear  of  the  tbrcotcnctl 
emminaticn.  One  pron*r  of '^  hair-pin  was  dctcctcdjual  within 
the  vnginit,  wbieb  eoiild  be  druwn  down  a  abort  dietance,  expoa- 
irg  tbe  end  of  it  CKtcrniilij;  but  the  other  end,  hc\u^  firmly 
itnpdctcd  in  the  aide  of  tbc  poefiiipe,  prevented  farther  movement. 
In  rh:;  ai'ternoon,  I  wjie  reqiicslcd  to  see  tbc  enee.  The  pdCient 
wiis  a  Jarpe,  heal  thy -looking  ^^^U  thirteen  vears  old,  of  rather 
wore  intellect  than  ia  Udual  for  une  of  her  a^.  Slie  was  ctlicr- 
ized,  rift  tbc  parts  were  swollen,  and  too  sore  to  odniit  of  ttU 
eiploraliun  without  giving;  great  pain.  On  pneainff  the  finger 
into  the  vagina,  the  whole  pasaa^  wftB  found  thickened  and  of 
ftlniost  a  callous  barflneaa.  The  upper  part,  or  benJ,  of  tlie 
hair-pin  waa  in  contact  with  the  cul-dc-sne  i»f  the  vagina. 
Half  of  one  pron:;  was  dee|ily  imphintcd  in  the  wjill  of  [lie 
vagina  to  the  extent  of  about  two-thirds  of  its  lonfftli.  It 
wag  incrustod,  to  a  thiekncaa  equal  to  abnut  a  third  of  lis  di- 
ameter, witJi  calciireoua  mutter.  Uy  careful  iiianipLihttion,  the 
iron  was  produally  bent  to  an  an;»lc  at  the  point  whore  it  pene- 
trated tbe  parietca  of  the  vagina.  Two-thirds  of  it  eouM  now 
be  drawn  outside  the  pnaea;^e.  Before  proceeding  farcherj  the 
finger  was  passed  into  the  rectum  to  n'lscertain  if  tbe  pin  eould 
be  felt  on  that  aide;  but  it  eecmed  to  have  poeaed  more  tow- 
ards the  tuberotity  of  the  ieehium.  By  exerting  eonsiderjLble 
force,  und  twisting  it  in  various  directions,  it  tvae  loosened  and 
drawn  out.  Before  bending;  it,  an  attempt  was  mode  to  pu^h 
it  up  into  ihe  vagina  ;  but  the  passage  hnd  become  loo  narrow, 
from  the  e^leeta  of  the  inllammattojt,  to  admit  of  this  munu^uvre. 
She  soon  entirely  recovered. 


278 


FEStALE    QESrrO-rRlNART    OROAKS- 


OOCLUWON    OF    THE    YAQiflA. 

At  the  time  when  the  first  of  the  following  eaecs  cnnio  under 
my  care,  litlJe  hnd  been  piibljalicd  in  rcD;ard  to  occlueion  of"  the 
vngiiia>  and  8ome  eiul>nrraa?ment  yrn.s  felt  as  to  tho  proper 
courae  to  be  adopted.  Latterly,  however,  more  attention  hna 
been  paid  to  the  eubjeet. 

The  subjoine<i  cnecs  ^vc  Bomo  detaiJs  in  regard  to  the  diag- 
nosis in  retention  of  the  menstrual  eeeretioD,  and  the  mode  of 
giving  exit  to  it,  when  the  nnatomicol  relalionp  of  the  f>artfl  are 
nbnormal  either  from  disease,  con^nital  malformatien,  or  diffi- 
cult parturition,  and  may  be  of  usq  in  future  cDsea  of  a  eimil&r 
character ;  — 


Case  CLXX, —  Occlusion  of  Vcffina  following  «  Te- 
dious Labor.  Vesico-vaffinal  Fistnln.  Retention  of  CatOr- 
menia.  Operation*  Ii''coi>Gry* — 1S50.  A  marricti  wt>man, 
20  years  of  a;^,  a  year  before  had  been  delivered,  by  nieEine 
of  inHtrumentfl,  of  a  doud  child,  after  a  labor  of  four  daye,  Tery 
severe  inflammation  followed,  ntttsndwi  with  slonghino;  of  a 
portion  of  the  veai'io-vagjonl  ije|»tiim,  eo  thnt  the  remnins  of  the 
bladder,  falling  clown,  became  adherent  to  the  posterior  wall  of 
the  va*riiia,  and  obliterated  the  paesnfro.  There  wae  also  a  val- 
vular opening  from  the  neck  of  the  bladder  into  the  lower  part 
of  the  vagina. 

The  menstrual  eccretion  hod  been  retained  since  her  confino- 
ment.  At  first  ehc  Buffered  at  the  rcfjiiliir  periodical  returns  of 
the  catamenin  from  pain  and  distention  of  the  abdomen,  with  a 
aenee  of  bearing  down  in  the  rectum-  Afterwards,  the  pwa 
became  almoet  con-^lanl,  and  so  acute  as  only  tu  bo  relieved  by 
large  dosee  of  narcotics.  From  thcae  cauaea  ehc  was  olmoflt 
bedridden,  and  very  much  emaciated. 

The  constant  dribbling  of  nrino  had  rendere<l  the  orifice  of 
the  vagina  so  extremely  sensitive  that  it  wna  impracticable  to 
make  any  examination  until  the  patient  had  been  placed  under 
the  influence  of  other*  Tlws  cul-de-sac  at  the  commencement 
of  the  vagina  wafi  just  BufHeient  to  admit  the  end  of  the  fore- 


OCCI^USION    OF    VAGINA- 


279 


finger.  From  lis  up|ier  jxirt,  tlie  urine  esoapod  through  the 
vaK'uIar  opening,  so  situated  thut  a  probe  crould  not  be  made  to 
enter  the  bbdder-  On  passing  the  forefinger  mto  the  reotum, 
^  hnnl  Hnd  sli^rhtly  elnstic  liimor  cou!d  be  felt  about  two  ineJies 
from  the  exEernnl  oritice,  pre^.^ing  backwards  and  partially 
obstructing  tlie  bowel.  The  other  hand,  pUeed  on  th?  abdo- 
men, dwtinguUlied  n  large  giobuJar  inasa  rising  nbove  the  brim 
of  the  pelvis,  jiressure  on  wbioh  communicated  a.  distinct 
impul^  to  the  finger  in  the  rectum. 

The  nbove  exaiuination  led  to  the  conclusion,  that  the  tumor 
fek  in  the  itbdnmen  and  rectinn  was  the  uterus  and  upper  part 
of  the  vajrina  distended  by  the  menstrual  fluid. 

The  pihtient,  being  fully  etlterized,  wna  placed  on  the  edge  of 
the  bed»  with  the  liinba  supported  as  in  the  operation  for  lith- 
otomy, and  the  labia  hold  apart  by  silver  hooka.  The  fore- 
finger was  now  placed  in  the  rectum  to  serve  as  a  guide,  nnd  a 
transverse  incision  mode  Bcroas  the  tower  pnrt  of  the  VMgina 
through  its  paricteu,  so  as  to  expose  the  cellular  membrane 
lying  between  it  and  tlie  rectum.  This  di^isectJon,  passing 
under  that  portion  of  the  vagina  which  served  as  n  fimdua  to 
the  bladder,  was  continued  upwards  between  thejie  organs  for 
two  or  three  inuhefi,  until  the  diJJtended  sac  could  be  distinctly 
felt. 

A.  TOrv  lar^G  trocar  and  canuln  was  now  plunged  into  the 
tumor;  and,  when  withdrawn,  a  quantity  of  thick,  larry-loiiking 
fluid  began  very  slowly  to  ilow  through  the  tube.  About  a  pint 
was  allowed  to  escafje,  when  the  canula  waa  withdrawn,  being 
too  short  to  be  \e\\  with  safety,  and  a  female  catheter  introduced 
in  ltd  place. 

In  the  afternoon  of  the  day  of  the  operatitm,  ahe  was  com- 
fortable. At  intervals,  however,  there  were  severe  contractile 
paioi  in  the  nterua  like  those  attending  the  first  stnges  of  panu- 
rition;  and  by  them  the  eatamenial  fluid  was  forcibly  eipellod. 
Warm  fomentalionB  were  applied  to  the  back,  and  un  opiate 
ai] ministered,  by  which  her  sufferingi^  were  temporarily  relieved. 

On  the  followiogday,  I  learned  thut  she  had  passed  an  uneasy 
night ;  the  pains  contiuuing  at  intervals,  causing  a  free  evacua- 
tion of  fluid.     Her  mother  estimated,  that  at  least  two  quarts 


280 


FEMALE   GE:jrrO-CRINAKr  OttOAWSp 


had  passed  through  the  infltrument,  with  the  effect  of  greatly 
dmunishiQg  the  tension  of  (Lc  abilamen.  TowarJa  evetJing,  eljC 
hud  un  access  of  [mm  And  fcYcr,  with  some  obBtruction  to  the 
distharjre  :  the  bowela  heing  coniftipiited,  ahe  was  ordered  caMor 
oili  Tlie  medicine  operated  with  much  relief.  The  uterus 
xeaunied  ita  action,  and  couhi  be  felt  above  the  pubea,  some- 
what tender  on  pressure,  and  contracted  into  a  6uinll,  wcU- 
deBned  tumor* 

For  about  a  week  elie  im|iroTcd  steadily,  (lie  discharge  con- 
tinuing at  intervals.  It  was  with  the  utmoHt  dlfiicuJty  that  any 
iiiBtiumenl  could  he  retained  in  the  opening;  and,  when  dis- 
placed, the  aperture  Wite  found  to  have  su  contracted  na  to 
render  it»  repWetnent  almost  impracticable.  The  external 
orp:ans  were  very  sensitive* 

During  the  second  week,  she  waa  attacked  with  a  cntarrhni 
affection,  during  which,  from  Bome  exposure  or  error  in  diet, 
she  was  suddenly  eeiaed  with  violent  pains  in  tlic  abdomen, 
mclcorism,  great  scnaibility  on  pressure,  with  ctliei  svniptom* 
denoting  peritoneal  inllammation.  Thcac  were  gi^adually  re- 
lieved by  treatment,  the  patient  barely  escaping  with  hex  life, 
Dnrin-r  this  attack,  the  canuhi  had  iieccasEU-ily  been  removed,  and 
every  mecisurc  for  maintaining  the  opening  abandoned.  The 
meuatrual  secretion  came  on  nntuially,  about  four  weeks  atWr 
the  opcr.ilii^n,   and  found  an   exit  without  diHiculty. 

The  Bubsequcnt  Improvement  was  gradual,  and  only  inter- 
rupted in  the  course  of  the  atinimer  hy  an  attack  of  varioloid. 

1  siibsequenlly  heani  tVom  llila  lady  through  her  mother,  who 
infornjed  ine  that  from  a  mere  skeleton  lier  daughter  had 
become  t[uite  robust;  tliat  she  bad  regained  hci^  health  and 
sti'ength  ao  aa  to  be  Jiblc  to  use  e:<ercise  on  horseback  ;  and  that 
the  menstrual  secretion  was  natural  at  the  regular  periods. 


Case  CLXXI.  —  Ocvhtiifjn  of  Vagina  nfitr  Labor.  lic- 
ttntlojt  of  Untffiticiiifi*  Operation.  I^eliff.  —  On  Feb.  4t 
1S50,  1  was  applied  to  by  a  married  woman,  aged  SO,  in 
cuueequeoce  of  ihe  suflTcring  produced  by  the  retention  of  the 
menstrual  fluid  from  un  occlusion  of  the  vagina  aubseqaent  to 
paitmitiuni 


:a. 


281 


In  the  August  preWotis,  *}ie  b^d  been  iltJiycretl  of  licr  first 
cliilil  nftcr  a  labor  of  four  ilavs,  durio;.'  ^l  portion  of  wliicfj  time 
ibe  hiTdd  of  the  infunt  ren^jtin^d  in  ihe  pelvic.  InAlruDicQie 
were  UBcd,  but  ineffeclually ;  imd  the  delivery  woe  ultimntely 
acconii>li3lieJ  without  them.  Very  severe  iiiflanntintoiy  tiviiip- 
toma,  atlended  wrth  a  purulent  d!:^cliarge,  foiluwed  ;  and  hujilly 
it  yfoa  discovered  that  the  vag;lDa  had  become  entirely  ubliter- 
aicil,  Frum  that  time,  the  return  of  every  calamcnml  periud 
liad  been  markcil  by  tJie  most  dislrceaing  palna  in  tJie  buck 
ami  nbdomeD*  lasting  three  or  four  days,  nnd  progrcsfi\c1y 
increasing  itt  violcDce*  accanipanied  Kith  eTiiiie  cuDdtitutiona) 
diaturbance.  Tlieae  rei)eated  attncka  gradually  impaired  her 
health. 

An  examination  ehowed  tlicit  the  va^nna  wna  entirely  clused, 
and  hai'djy  a  t>crceptible  cicatrix  could  be  detected  tu  indicate 
the  line  of  union.  At  the  lower  part  of  the  vulva,  an  orihce 
was  discovered  large  enough  to  luliuit  a  probe,  which,  ou  being 
introduced,  could  he  passed  up  a  dietant:c  of  three  inches  in  tire 
direction  of  the  tilerus,  and  was  distincrly  perceived  throuj^h 
the  rcctu-vaginal  parietee  by  the  finger  introduced  into  tlie 
rectum.  At  lliis  periled,  no  abdominal  or  reetid  tumor  was 
it^ceiliuned  to  exi^t.  It  wua  determined  to  ethcriiee  her,  and 
attempt  to  restore  the  va>^ina1  |ia«3:ige. 

The  patient  being  fully  etherized,  a  bougie  iras  pasr*ed  into 
tlic  fistulous  openiniT-  This  was  followed  by  the  fiugci  :  and, 
by  proceeding  ciirtfully  in  this  way,  distending  And  separat- 
ing ihe  adhcrejtt  pEirt^,  a  free  o^jening  was  made  of  about  three 
i[jchea  iiud  a  half  or  four  inches.  At  this  point,  a  regular  orga- 
nized scptunt  precluded  any  advance,  unless  by  the  ^iasietancc  of 
cutting  instruments.  A  bit  of  sponjje  was  therefore  introduced, 
and  directed  to  be  kept  in  situ  during  tlie  night. 

On  the  djiy  following.  Uie  sjionge  was  renioved,  and  replaced 
by  anotlier,  Tliia  course  was  coniinued  for  a  week,  when,  no 
tumor  being  discovered  in  the  rectum  to  indicate  the  situatioit 
of  the  distended  uterus,  and  there  being  no  trace  of  the  os 
uteri  in  the  vagina,  it  was  detenniued  Lo  r^uspead  any  farther 
procec<Ujk;rat  enjoining  u[Kjn  her  to  u«e  all  neee»iLry  nicana 
ibr  keeping  the  podBage  open  uutJl  the  dialciitkjn  cauaed  by  the 

U 


282 


FEilALE   GEMTO-URlKXnT   OBOANS, 


menstrual  accretion  should  be  ^uf^cterit  to  aerve  09  a  guide  to 
the  knife. 

Two  montJia  ofter,  Laving  rigorously  ibIloweJ  up  the  above 
directioua^  she  visited  me  a  sccouil  time;  auttering^  in  the  eame 
vrny  us  before,  and  urgently  demanding  relief.  An  c\aniina- 
tion  eJiuLtcd  no  change  iu  the  ailuaticn  of  tbe  parte.  Aa  tbe 
pain  wiw  very  distrcsi^ing',  hnwcver,  I  eonaenled  to  make  an 
iacifiion  nt  the  upper  part  uf  the  vagina,  witb  tbc  hope  of  thivjw- 
ing  eonic  light  upon  the  direction  in  whiob  the  eulpirgement  of 
tbc  utenia  waa  taking  plaee.  Thid  waa  d(>ae,  and  tlje  tliaaection 
carried  ue  far  aa  was  ihauglit  sale,  but  with  no  good  refiiilt. 

Un  the  Sd  oi'  May,  I  again  aziw  her.  !Shc  had  tor  four  daya 
been  in  esttremc  pcun.  The  vagina,  eo  far  aa  it  had  been. 
dilated,  I  found  to  be  of  its  natural  dimenJ?ions»  The  finger, 
introduced  into  the  rci^tum,  at  once  detected,  about  two  inched 
from  the  nnua,  a  hard  tutnot,  aucb  aa  might  be  presented  hy  the 
enlarged  prostate  in  tbc  male,  and  with  as  little  ecneatiou  of  fluc- 
tnation.  She  infi>rmed  rac,  tJiat.  for  the  previous  twenty-four 
hours,  there  bad  been  a  bloody  disebarge  from  tbc  vagina;  and 
tracea  of  tlna  aecretioa  were  perceived  when  that  passage  was 
eKamiucd,  apparently  coiaing  from  the  mucous  niccuhrauc-  Not 
tlie  sligiitcst  inilication  uf  any  tumor  could  he  found  In  tliia 
direction*  even  when  the  abdomen  was  dtrongJy  prei^ded  upon. 

Altbougli  tbe  rectal  tumor  waa  free  from  tiuctuation*  1  had 
no  question,  from  my  prcvioua  cjcpcncnee,  but  that  it  proceeded 
from  an  enlargement  by  distention  with  iluid  of  the  upper  part 
of  tbe  vfLgina  or  uterui^i  luid  therefore  propoaed  an  operation, 
which  WQfi  reatlily  acceded  to. 

On  the  3d  oi'  July,  the  operation  was  performed,  tbe  patient 
being  first  etherized.  The  up|>cr  and  back  part  of  the  vagina 
was  cut  freely  through  with  a  round-bladed  bistoury;  and  very 
aoon,  with  H  dight  dlsdection,  the  tumor  which  had  been  felt  by 
the  rectum  preaeoted  itself,  but  much  softer  and  more  elastic 
than  when  examined  tlirough  the  iutcatlnal  wall.  A  large 
trocar  was  now  plunged  into  it  in  a  direction  oljliqucly  back- 
ward, in  order  to  avoid  wounding  the  oa  uteri,  in  cose  that 
organ  projected  into  the  vagina.  A  free  diecbarge  of  the  black, 
tarry  substance  described  iu  the  last  caae  at  once  took  place. 


OOCLrSlOS   OF   VAOINA. 


2SZ 


About  half  n  pint  of  fluid  havir^  escaped,  \\\c  cfmu]si  wils 
with<lrrtwn,  nnd  the  fingor  introduced  into  the  opciung,  which 
vftxa  enlarp^ctl  in  eilbcr  dii-cctUm  with  a.  probc-poiotcd  bialoury. 

On  exploring  the  cuvlty,  no  dietiact  projection  an^wGiing  to 
the  oa  uteri  rould  be  di^eovei-ed.  The  whole  interior,  both 
of  the  utcrufl  and  vflginn,  eecmed  to  form  but  a  diugie  receptacle, 
a  little  coutriLCted  at  one  point,  like  tiie  hour-glnse  eontraction 
of  the  utcrufi,  this  nppnrently  nadwering  to  the  ^ituntiou  of 
the  oa  liiLGe.  The  mucous  membrane  npjjcarcd  much  swollen, 
and  trftversed  by  largo  vcseclfl,  v^lkich  etood  out  in  bold  relief, 
A  long,  narrow  bit  of  sponge  was  paaf^cd  into  the  \flgina,  half 
of  it  being  allowed  to  remain  within  and  half  without  the  open- 
ing juet  mj^dc.  The  patient  declared  herself  at  once  rchevcd 
from  all  her  d[Btrc»aing  ^^mptome. 

From  the  difticulty  of  maintaimng  the  new  opening,  it  waa 
found  ncceesary,  a  fe>s'  days  after  the  opcnition,  to  introduce  a 
sponge  tent,  which  was  removed  daily,  and  gruduidly  increaeed 
in  fli7c.  At  the  end  of  a  week,  the  patient,  jjaving  exposed  hcr- 
Bcir  immediately  ai^cr  the  sponge  had  been  removed,  was  seized 
with  Bererc  pmna  in  the  abdomen  and  in  the  lower  part  of  tlie 
hack*  tympanites,  and  all  the  symptoma  denoting  infiainmation- 
Tho  treatment  consisted  in  the  application  of  leeches^  and  tho 
other  measures  usually  adopted-  In  tliree  or  four  days,  the  ptun 
and  tendome^s  gradually  concentrated  at  the  lower  and  left  side 
of  the  abdomen,  where  a  large,  hard  tumor  could  be  perceived 
through  tht  parietea*  These  *jTnploms  were  suddenly  relieved 
by  the  discharge  of  a  quantity  of  pus  iroia  tlie  vagina.  The 
tumor  in  the  abdomen  now  gradiiiilly  aubside^l.  The  intestinal 
oanal  remained  for  a  length  of  time  "iLite  irritable,  diarrha;a 
being  produced  whenever  she  took  solid  food. 

She  left  town  nr  July  31st,  <juile  weak,  but  improving. 

She  wae  Ji(lvise<]  to  have  a  Hinall  reilal  bougie  passed  into  the 
openiug  iu  the  va^^^inat  ilaiEy,  avs  the  dif([KKsitiou  to  contraction 
was  still  great;  and  it  wan  tliought  unsafe,  through  fear  of 
exciting  u  fresh  attack  of  infhLmmation,  to  mmnlfilii  any  sab- 
Btanee  constantly  in  the  ajierture.  For  quite  a  number  of 
yeiira  after  the  ojjeraiion,  she  required  to  he  kept  under  treat- 
ment, nt  timeaT  to  prevent  the  reenrrence  of  the  ocelu»ion  ;  but, 
in  [he  intervals,  enjoyed  verv  fn-u'  lieahh. 


d^ 


-Wh 


mt  ^  gnr  inu, 

m  A  rnnn  inllun- 
io  the  alititut 
At  Uttt  estii- 

:^  fufnrd  from  iLi^ 
L&BdnQ  ceased  to  he 

cnntUiiI  wilJi  Julian  in 


br  HI  uliiojiim  of  its 

^mrt^tfi  TTM  tJi«  'dufttf  of  il>i} 
^^  lOK  ftf  tfaft  faDrtioo*  of  the 


^— ^  irhic*  i*tJ  ai  fiiTt  only 


OOOLUSION  OF   VAOrXA, 


289 


Case  CLXXV.  —  Occlusion  of  the  Vagina.  Heitntion 
of  the  MenHnial  Fiiud.  Opcrntioiu  Jichef.  —  A  girl, 
16  ycara  old,  wna  ^i^at  takerit  in  185^1  with  pame  in  the  hack 
and  Joine,  such  us  precede  the  mcnatrunl  l^ux,  which  did  not, 
however,  nppoar-  The  psiiag  wcro  ro^watotl  every  month, 
Uflually  Jnt^tiog  throe  or  Jour  daye.  In  Jimuary,  1857,  sho 
fiuJTered  irom  rctenlion  of  urine,  which  was  relieved  by  the 
U6e  ol'  the  tiithelcr.  The  same  thing  occurred  in  Fcbmary  nnd 
March>  In  Aprils  while  passing  the  catheter,  it  wob  found  to 
cnccqntor  a  rcgtsting  0ubet:iiice  ;  and,  in  order  to  |^et  it  into  the 
hludder^  it  wne  neces[=ary  ^ofltly  to  dcprcae  tlic  bindlc  and  ele- 
vate the  point,  to  Burinount  the  obstacle-  Her  phyaiciiiiL  then 
mode  a  furclicr  eKiiniinatiun,  imd  dificevercd  a  round,  hard  turner 
in  th?  abdomen,  and  another  projecting  into  the  rectum. 

I  eaw  tliia  patjcnt  on  tlte  ^(lih  of  April,  and  discovcrod  an 
occlin^lou  of  the  vagina*  and  a  ^rent  collection  of  the  menetrunl 
fluid  in  the  uteniH.  It  being  inconvenient  to  ti-ent  the  patient  at 
her  GV.TI  home,  it  wan  decided  by  the  &ienda  to  send  her  to  the 
Hospital,  under  my  care- 

Frevioufi  to  the  operation^  the  followinrj  were  the  phenomena 
elicited  by  an  examination :  A  E^uUde-sac  about  half  an  indi  in 
depth  coribtitijlcd  the  vagina,  at  the  loner  part  of  which  was  u 
wlute  line,  or  puckering/ perhaps  a.  cicatrix,  the  result  of  some 
prcvioufi  inflammatiun,  A  catheter  could  not  be  passed  directly 
into  the  blrtddcr,  a«  It  cnoountL^red  an  chxstJc  tub^tancc;  and  it 
wa*  neccsBiuy  to  olcvalc  ihe  inslrurncut  almost  per|>eudicularly 
IV  btrcKlucti  U  into  that  cflvity.  In  tfio  roctum,  a  large»  hard,  in- 
*^'  ■      r  wft/i  to  he  tclt,  two  inches  or  nmrc  frt>ui  the  anus, 

hl  .-  ..  :....Li^  Hhi  pdvi»»  A  large  tumor  could  al^o  be  dialin- 
piL^hM  in  ihti  abdomen,  extondinj^  juat  above  the  umbilicus; 
■iXtil  the  patient  uaid  iJmt  occariinnrdly  cilic  could  feel  two  Intend 
^norft  tiK!TC,  Ihiring  Apriii  t!i'  :.  v-^-  'irui  bucn  ineessantt  as 
"fi^  the  wcpul*i<ni  at  flumc  nf-m  the  body*     The 

4cr  ilftlcd.  in  »p]«intioii  of  \ho  ciumc  of  the  oblitAration,  that 
ha*!  '.        '  •'  ■!'■''  '  '    ■     .   ■  lii.'n   tlie 

-1]  iilcer 
ion. 


ifi^ 


\ 


28i 


FEMALE   GEMTO-lTElX.Uir  OnGATfa. 


Case  CLXXJI.  —  Ouni/eiuffii  Occlusion  of  J'atfuin.  Op~ 
erntlon.  Jiecover^.  —  I80I.  A  girl,  iiged  17  years,  liad  Lteu 
eufTering  for  two  years  with  a  aenae  of  ilietCDtiim  and  weight 
in  the  lower  part  of  the  abdomen  and  back,  atleinled  hy  a 
forcible  jjresseirt  in  thu  vagina,  as  if  fur  the  jHirpoee  of  exjielling 
some  foreign  ^uh^tance.  She  had  aisa  been  greatly  annoyed 
with  a  fi'etjueut  dt'piii^  to  iiiicturaLe,  and  passed  water  as 
oflen  OS  CTery  twenty  ramules  thrtmgh  the  day,  but  less  ire- 
qucally  at  night.  She  suffereti  much  seviTU  [m'ln  at  the ' 
extremity  of  the  i^retbra,  whidi  was  aggravated  by  the  pyj^fiage 
of  the  water.      She  ImwI  never  menrttruateil. 

The  followiijg  H|j|>earaTi<"es  were  finmd  :  On  sejiarating  the 
externa]  labia,  no  traces  of  the  vagina  were  viaible.  At  the 
central  put  of  the  foss;;,  nsnally  ocx^iipicd  by  this  outlet,  the 
mCittus  urinariiis  waa  perceived  surrounded  by  suinll  vcgeta- 
tiong,  which,  on  the  slightest  touob,  ehdted  the  Taost  violent 
refiifitance  and  erica  from  the  patient-  A  prolie  being  pasted 
into  the  iiretJir&,  its  farther  progress  wa^  resijited  at  the  dUtiiiice 
of  au  inch  from  the  orifice  ;  but  jinally,  by  turning  it  upwiirds 
in  almost  a  vertirjd  directi<:»n,  it  entereil  the  bhidder,  which 
was  very  nnn'h  contracted. 

Tlie  finger  was  introduced  into  the  rectum,  nnd  at  once 
detect^  a  harvl  Uirnor  two  incheB  from  the  tunis,  pressing  back- 
w^iirdH  against  tlic  »4ptne.  It  seemed  quite  soJid,  and  without 
the  slightest  indications  of  elasticity.  On  passing  the  hand 
over  tJie  abdomen  at  its  lower  part^  a  hanl  projeetton  was  felt 
in  the  centre  just  above  the  pubiP,  having  a  prolontjHtion  about 
four  inches  in  leugth,  extending  into  the  right  iliac  region. 
Pressure  on  thin  swelling  enured  a  movement  of  the  tumor  iii 
the  rectiiTn,  and  was  attended  with  uiueh  ^nfferitig. 

No  doubt  romaLned  in  my  mind  that  ihese  tumors  were 
cftuaed  by  a  retention  of  the  nienstrual  Hnid  in  the  uterus,  upper 
part  of  the  vagina,  iLnd  the  Fallopian  tubes. 

The  patient  being  fully  etherized  with  chloric  ether,  an  inci- 
sion was  mojlo  transvei'sely  across  the  mucous  niembmne  of  the 
lower  part  of  the  vflgina.  This  disclosed  muscular  fibres,  which 
being  carefully  divided  through  the  aperture  tlius  made,  a  deli- 
cate membriine  uf  ii  dark  color  protruded.      It  was  suggeeted 


OCCLrslOS  OF  VAGIKA. 


285 


>y  t>ne  of  Cho  "[cntlcmcii  prceont,  tlint  this  might  popEibly  he  tlie 
peritoneum t  wtiichi  in  Ji  vase  of  lual formation  and  non-exieten<?Q 
of  the  vn.^nn,  hnU  tnken  nn  abnormal  {Uroction.  For  tlio  pur- 
puse  of  tceting  this,  I  attempted  to  separate  it  from  the  ear- 
rounding  tcxtnr»?s,  knowinn;  the  loose  character  of  the  ecUiilar 
tissue  which  attaehca  the  |>critoncura  to  ihc  neighboring  organs 
And  the  pelriB.  Thia  was  at  ouco  fount]  to  Iw  impraeticjible ; 
and,  on  a  renewal  of  the  effort,  the  resifJting  pjut  }'iclJed,  nnd 
the  fin^r  pns&eJ  tlirou^h  into  whnt  appeared  nt  tret  to  be  the 
abdominal  eavity,  so  well  defined  was  the  anatomy  of  tho  wnlla 
of  ihe  pelvia.  The  abeenee  of  inleetines.  and  the  appearance 
of  a  smull  quantity  of  dark-colored  fluid  by  tlie  eidc  of  tlie 
finger,  agon  rniule  it  e^'tdent  [hat  the  vaL^nn  had  been  opened. 
The  eize  of  the  cavity  ocou|iyinp:  the  entire  pelvis,  and  the  com- 
plete al>seiiec  of  os  uteri  or  other  boundary  between  the  uterus 
and  va<;;ina,  were  on  examination  auttidently  evident  to  all  pres- 
ent. 

By  the  aid  of  sJight  pressure  on  the  abdomen,  about  half  a 
pint  of  thick,  tenacious  Huid  escaped.  As  thij  uterus  did  not  at 
oucc  take  on  contractions,  no  further  elTorts  were  made  to  evacu- 
ate the  fluid  ;  but  a  bit  of  sponge  was  introduced  into  the  o[>en- 
ilAg  to  prevent  the  parietcB  from  adhering,  Tlic  vegctalioDs  at 
the  orihcc  of  the  urethra  were  now  removed  by  the  aciaaore,  and 
the  base  of  the  tumors  cauterized  with  nitrate  of  silver*  To 
flhow  i]ic  extrenje  aensibihty  of  these  tumors,  it  may  be  ob- 
BcrvcU,  that,  as  aoon  aa  they  were  interferetl  with,  the  ]Mitient, 
although  well  etherized  and  perfectly  passive  through  all  the 
prcnoLis  operation,  immediately  drew  back  aa  If  in  estremc 
pain. 

On  the  day  followin^j  the  operation,  ehe  woe  reported  to  have 
passed  a  good  night.  The  spong-e  waa  removed  from  the  vagi- 
na, and  a  free  di^^charge  of  the  peculiar  fluid  took  place  ;  ni^cr  a, 
few  hours,  it  was  again  introduccdi  No  urine  bad  been  paascd 
since  the  operation ;  during  the  sueccci^ng  night,  however,  a 
copious  evacuation  of  the  bladder  took  place.  She  continued  to 
improve,  and  the  tumor  of  the  abdomen  to  diminiah,  Tlie  fin- 
ger, passed  into  the  vagina,  could  distinguish  the  oa  uteri,  as  it 
were,   gradually  forming  iteelf.     It  waa  about  tho  aize  of  a 


286 


FKSIALE    GEMTO-UIUNARY    ORGANS. 


tumbler,  with  thick  tulles,  and  eovcrwl  with  Jilated  blood- 
vesaelfi.  The  s[njn|^  tent,  when  withdiawu,  waa  very  otien- 
eive. 

A  week  nfter  the  operation,  she  waa  quite  well;  the  urine 
was  piie^ed  natumn}'  and  without  pain,  the  senBiiive  tumors  of 
ihe  urethra  having  been  deatroyed ;  the  discharge  from  the 
va^dna  hnd  parlinlly  ccasedf  or  had  hcen  replaced  by  n  ecrotu 
exudfition  ;  and  her  appetite  and  digestion  were  natural. 

At  her  urgent  rer|iieel,  she  was  then  allowed  to  return  honie 
to  the  country,  where  the  treatment  was  continued  by  her  phj- 
eician.  A  month  at^er  th<!  ojjoration,  the  vagiaiU  discliarge 
ceaaed,  and  she  woe  reported  to  mc  as  well. 


Case  CLXXIIT. — ■  Conff&mlal  Occhisian  of  ths  Vagina, 
OpotYitioji.  Hdi^f.  —  A  giH,  14  years  old,  be^n  to  eutFer, 
two  years  before  I  eaw  her,  with  piiins  in  the  Jower  part  of  the 
back  and  abdomen.  These  pains  p-adually  assumed  a  perio<ii- 
cal  charaeier,  coming  on  at  an  interval  of  lour  weeks,  and  were 
ao  inienpe  as  to  require  alleviation  by  means  of  medicine. 

A  physician,  lieing  consulted,  su&pected  an  obstniction  of  the 
vi^na ;  and  nn  examination  confirmed  hia  anspLcioaa.  showing 
this  paeaape  to  be  coinplelcly  occluded-  An  incision  was  made 
lbrou;:b  the  solid  obstruction  which  preseniGd  at  that  part^  with 
the  hapCB  of  die  covering  a  cavity  con  taJning^  the  menetriial  fluid  ; 
but  the  operation  met  with  no  succees.  From  this  time,  the 
sufTerinffs  of  the  pjttiem  gi'adually  increased,  and,  at  the  men- 
strnal  periods,  were  eo  severe  as  to  produce  a  degree  of  prostra- 
tion which  confined  her  for  some  days  to  her  bed,  and  finally 
even  thrciitened  life, 

"When  1  firat  aaw  her,  the  external  organs  of  generation  were 
BO  Heneitive  as  to  cause  great  complaint  on  any  attempt  at  nn 
examination.  The  external  labia  were  lound  to  be  well  devel- 
oped.  The  orifice  of  the  urethra  occupied  its  normal  pOBition, 
or  was  a  little  li>xver  than  natnml.  Below  thia,  not  the  slighCeat 
dcproflsion  inditiated  the  orifieo  of  the  va;^inu.  The  fint^cr,  being 
introduced  into  the  rectum,  dctcctcdi  at  the  di^tunee  of  about 
two  inches  from  the  anus,  a  hard,  globular  tumor,  the  size  of  a 
billiard-balh     Before  removing   the  fiugcr   from   the   rectum, 


OCCLPHTON   or  VAOrTA. 


287 


a  catlieEer  WFut  paAjie<I  intir  ike  blaJJt^r  :  nml  tlilfi  wtin  dL  uii[;u  fVlt 
by  tlie  fiugiT  in  ihe  i'e4:tiizii.  in  l]i4?  nictlinn  linr  >  tliu  ctrniM  iii' 
the  bladder  jliii]  rtHTtvim  unly  iiiU^rvcnin;^,  firr  ii  iIjkLhiil'l';  of  onu 
or  Cvro  tndiefl,  th&t  is,  as  Btr  a«  the  above-mcu turned  tiimor. 
At  tliifl  priiEkt,  ilie  ralliRter  c^juld  lie  niailu  Ii»  jiii>j<  ttn  vmz\i  hiiIk 
of  the  luniiir.  buL  was  witli  dlUkult^  drU'ctcd  in  i}k  rcrliiiri,  I 
had  no  doubt,  from  tbe  result  of  the  rxriiiritmtiiin,  tbAt  tbo 
tumor  fck  in  tbe  reclunj  wa»  the  uji|K-r  \mri  <rf  the  va^iim  raid 
uterus  dUienilet J  by  fluid,  and  iJic  cause  tii'lJjc  *eriuufl  oym}iOjia» 
under  which  iJie  |iaLieiit  lal>areil.  An  ci[H'rHlji>i]  wiu  tlwrH'^ro 
proposed,  and  at  uDC«f  vritb  tbe  ajwlBtaace  uf  ber  phy«iciAiti 
performed.  An^itLesia  being  induced,  a  tranAVcnto  inciiion 
was  made  djrcdly  bel<iw  tlie  orifr-e  '>r  the  urctbnL.  Willi  iniirii 
cuilJoBr  a  diAflcctiun  wa^  now  made  between  tlie  rectum  and  the 
bladder,  mttO.  by  cuttiug  and  Ki^'irniiif^  tbe  ttMUCi  n'\l\i  tin; 
fibgen,  tbe  lumor  dcM:ril>cd  da  felt  in  tb*:  nxtum  wia  rrarhcd, 
Ijiog  rery  deep,  dtid  &flbrduij^  btii  Uitli?  ir|t|j<irfimUy  ftir  a  fair 
eKamioaUaii.  The  depth  al  wlijch  it  lay,  and  Jia  apjmierit 
aaUdiij,  for  9  niiiDiail  cauAod  •ooie  cmbamuameat  M  lo  this 
proper  nmrwK  to  he  pon^jal.  c^jccaally  a^  one  of  IIh  gewilwnfo 
pRBcnl  ieemed  conTmced,  Iraio  tt«  bavdneaa,  that  it  eould  tvA 
eoabiB  a  fanL  Boi,  fettUy*  boii^  aalufied  in  tny  own  mind 
that  tk  t^Bor  «idd  fae  ooltii^  dae  Uit  vrbai  had  l«m  w*- 
pertcd,  Idetonflnd  os  pawtiiriag  it.  Tbecacajjerif  the  tJiirb, 
ttrTyJuJdMOMCBcnifcml  Uw  truth  oC  the  SMfaam.  The 
wfitrtmBt  was  amr  ^ilvipd  ao  an  to  Mtw  two  fayai  In  pas* 
^vtAj  ofi  lala  tke  earitj  *^'*****^*g  the  fluid,  wfairli  wna  appaiw 
csdy  the  vtervasBd  ^iper  part  «f  the  vagiaa  ilitf^iJ^  ao  aa  lo 

IW  MtaeaCcaa  twui'mi^g  IraiB  tbe  rifcttt  of 


Ike 

dK  aMnwd  «n  «^  Ike 

CUCXIT. —  Cbc&MPw   ^  fie    Tw^uMi    oBfvm'a^ 


386 


FEUALE  OQMTO-U&l^AKY   01tGA>'S. 


was  a  widow,  45  years  of  age.  The  account  abe  ^Te  waa. 
tJial  elie  waa  miirncd  at  an  early  agej  that  les  prcmtercs  tip^ 
pt^ocheti  du  mari  were  ao  violent  aa  to  cause  a  severe  inilam* 
uiLtir>n  of  the  vnpna^  wlucli  cvcntunlly  tornunatcfl  in  the  almost 
complete  doaure  of  the  upper  part  of  the  t^anol.  At  the  c&ta- 
menial  periods,  much  difl^culty  and  euflering  were  experienced 
in  the  egreaa  of  menstrual  Huid,  whicK  waa  discliargcd  slowly, 
an<i  nppjircntlj  by  a  eircuitoue  route-  Slie  surtcrctl  from  thia 
cause  uutil  within  three  years,  when  thut  function  ceased  to  be 
pcrfurnicU,  but  was  replaced  by  a  njucoua  accretion.  Her  health 
was  poor,  and  she  had  been  more  or  l^a  troubled  with  paina  in 
tlje  back  and  loiu?,  all  of  which  &he  attributed  to  tljc  retention 
of  fluids  in  the  uterua. 

An  obetiTiction  waa  detected  about  two  inches  from  the  ori- 
fice of  the  vug'ina,  caused  apparently  by  an  adikc^lon  of  ita 
parietea.  With  the  aid  of  the  apeculum,  a  eniali  aperture  was 
observed  on  one  aide,  into  'n'hicb  a  probo  pcDetratcd  a  abort 
distance. 

As  the  patient  insisted  on  having  an  operation,  I  conecntcd  to 
do  it ;  although,  at  the  aamc  time,  I  infornicd  her  tliat  it  was 
very  douhtlui  whether  the  obstruction  wa^  the  eauae  of  the 
aymptoDis,  coiididcnng  tlie  prc^nt  etatc  of  the  fuuctiona  of  tiic 
uterus. 

A  director  waa  forced  into  the  paaaag;c,  which  had  at  firal  only 
sdiuLttcd  a  probe.  This  waa  fuiiowcd  by  v,  larger  instrument; 
and,  by  proceeding  gradually,  it  waa  shortly  found  poeeible  to 
use  the  dressing  forcepe.  By  thia  means,  the  passage  waa  finally 
enlarged  so  as  U>  admit  tlic  little  Jinger,  when,  by  tearing  and 
dietcnding  tlic  parts,  almost  the  full  size  of  the  original  pnsaage 
waa  restored^  and  the  extremity  of  tbc  os  uteri  exposed,  buried 
ill  the  adjacent  atructures. 

The  calibre  dF  the  canal  was  maintained  by  the  same  meana 
as  had  been  reported  to  In  the  preceding  casea.  The  patient  en- 
presaed  herself  much  re]ie>ed  by  tlie  operation  ;  and,  when  seen 
a  month  afterwai-da,  there  had  been  no  lecurrcnce  of  the  previ- 
ous symptoms  under  which  ahe  had  Bu^ered. 


OCCLUSION  or   VAGINA- 


289 


Case  CLXXV,  —  OcchiJtio»  nf  the  T'trgha.  Retvjiiioft 
of  thf.  M^nxintnl  Fivid.  Opffraiioii.  Relief.  —  A  girl, 
16  yearn  old^  was  first  taken,  in  1855,  with  piiins  in  tJie  bick 
and  loice,  sut^li  04  [irercilc  tlio  meusJ.nml  flux,  nlimh  did  not, 
however,  nppear.  The  pniiia  were  repewtLil  evtry  muDlh, 
uaually  lasting  three  or  four  duya.  In  January,  1857,  she 
fiufl'tred  fniiri  relention  of  nrine,  which  was  rclieveil  liy  the 
use  (if  the  <:iLthcter.  The  p&nie  thing  occurred  in  Fi^ljiuury  uud 
March.  In  April,  while  pii^F^ing  thu  catheter,  it  W](8  foitud  ta 
encounter  a  resisting  ^itbE^tiince  ;  and,  in  order  ta  get  it  into  the 
hladder,  it  y»^^  iiect-s^ury  grwitly  to  <le[ireHs  the  handle  and  ele- 
vaitc  tlie  piijnt,  to  aurmotnit  the  obntoole-  Her  physicijin  then 
Ukiulo  a  further  examination,  and  diEcovered  a  round,  linrd  tumor 
in  the  alxlomen,  and  another  pnijeeting  into  the  rectum. 

I  tiaw  this  [latient  on  the  2Gth  of  April,  and  dia^ivered  an 
octluiiun  (if  the  v&gina,  and  a  grejit  collection  of  die  menstrual 
fluid  in  the  uteiois.  It  heing^  inronvenient  to  treat  the  patient  at 
her  own  hoLne^  it  was  decided  by  the  friendu  to  Benil  hi^r  to  the 
ITotipiial,  uncJer  my  care, 

Previoud  to  the  operfltiou,  the  followiaLj  were  the  phenomena 
elicitet]  hy  an  examinatUin :  A  oulnle-wic  ahonl  half  an  indi  in 
depth  condtituled  the  vaj^ina,  nt  thij  liiwer  piirt  of  which  waa  a 
wliitu  line,  or  puckering,' perhaps  a  ('icatrix,  the  result  of  Bomo 
previous  iiidainmntion.  A  cnthelcr  could  not  he  pa^t^e^l  directly 
into  die  bhulder,  at<  it  encountered  an  elustic  uubstance  ;  and  it 
was  necceaary  to  elevate  tlie  instrument  nlmoat  per[>endicnhirly 
to  introduce  it  into  that  cavity.  Tn  the  rectum,  a  hirve,  hard,  iii- 
ehi^tic  timior  y.-wA  to  he  felt,  two  inelicH  or  more  fn)iu  the  aiiUH, 
nearly  filtiiiy  the  pelvis.  A  largo  limior  could  ^dsSO  lie  dii*tiii- 
guiaheil  in  the  alidomen,  extending  just  above  tht;  umhdicus; 
and  the  patient  ^tiid  that  occnFiionnlly  she  could  feel  two  lateral 
tumors  there.  During  April,  the  pnina  had  been  incessant,  uh 
if  for  the  expulsion  of  some  substance  irom  tlie  body,  Tlie 
fiister  Htafed,  in  explanalion  of  the  cauHe  of  the  oblitentliou,  that 
she  hail  lieard  the  parents  say,  that  for  a  long  thue,  when  the 
child  wna  two  or  three  years  old,  it  had  been  affected  hy  ait  ulcer 
in  tfiat  region- 

The  patient  being  etherised,  and  the  bladder  emptied,  a  &ee 

37 


290 


TEUALE    GENITO-UKINAET    OttGANS. 


tmnsverHc  lacUion  was  inmle  iionj^s  the  ciJ-ile-sjw;  wkI,  witti  n 
liulu  diflaiiiititjii,  a  ihVuMc  blaJder-like  HiibsUnce  wua  Inniglit 
into  view.  Prcflflure  being  now  made  on  the  alidomeu,  and  Lhe 
pelvic  tumcir  madt;  tense  ho  as  to  prnject  through  the  incL^ion,  a 
lai-gc  tmt'iir  waa  plunged  into  the  cavity,  and  at  once  a  tliick, 
taiTy  fluid  be^in  to  flow  eluwly  t>ut-  Tlie  finger  was  nuw 
gradually  iasinuatcil,  ft  bistuury  introduced,  and  the  opening 
Euliuged  so  as  to  leave  no  feeling  of  confltrictioii  in  any  direc- 
tion, Tlic  forefinger,  being  jwisaeil  freely  into  tlie  Crtvity,  could 
detect  no  eac ;  but  tlie  n&llt)  of  the  (lelvia  could  be  feii  on  all 
sidpijt  the  colleetion  of  fluid  having  been  so  great  hjh  to  distend 
the  uterus  to  its  utuiotit  eapaoity,  and  render  lir^  walU  so  thin 
tbnt  tbey  could  scarcely  be  dit^tinguished.  She  was  placed  in 
bed,  and  tbe  fluid  allowed  to  escape  gradually,  which  it  eon- 
linued  to  do  during  the  day.  About  a  quart  of  fluid  escaped, 
wbidi  at  once  coagulated,  expelling  but  little  serum-  Dr*  Cal- 
Tin  Ellis  made  the  following  niieroBCopic  oh.servalions :  "The 
meDStnial  fluid  removed  from  the  vagina  eunhuued  epilheliutii 
cellji  ^  yellow,  granular  corpu^eles,  of  various  bi/cti ;  blood 
glohulea,  evidently  recieut ;  and  very  sinalJ,  translucent  globules 
with  distinct,  though  pule,  outlluea."  On  tlie  fo]lr)wing  and 
seciind  days,  the  oa  uteri  was  ohaerved  to  be  slowly  farming  it^ 
self,  and  the  thick  wulls  of  the  uterus  could  be  detected. 
The  patient  rapidly  recovered- 
la  tlie  first  of  the  cases  which  have  been  givon,  the  only 
apparently  feasible  way  of  arriving  at  the  distended  uterus 
was  adopted  ;  viz.,  that  of  penetrating  to  it  by  n  dissection  car- 
ried up  between  the  rectum  luid  vagina.  Tiie  proceeding  even- 
tnated  more  HJLti-sfnctorily  [lian  could  have  been  cx]>ected.  The 
greatest  obstacle  to  a  nii>td  recovery  wa^  the  dilRculty  of  main- 
taining the  new  o|ieningr  on  aeeount  of  the  dispoaiiion  to  eon- 
traction  ;  and  thia  wiis  found  to  be  true  in  all  the  caties.  Wliat 
appeared  to  be  a  large,  free  opening,  with  no  reatriction  on  any 
fiide  but  the  bnnca  of  the  pelvie,  in  the  course  of  a  few  days 
was  eunti^eted  to  a  Arm,  unyielding  ritig,  into  whicli  it  was  diffi- 
cult to  introduce  a  mnall  bougie.  The  sponge  tent,  when  it 
could  be  borne,  at  once  dilated  the  aperture  again  to  a  size  us 
great  lu^  could  be  wished  ;   but  the  e):trerne  t^ensitivenesa  of  the 


OCClil^lOK  OP  OS  TTTEHI, 


2!*1 


parts  pmliibitwl,  in  the  case  un<If;r  nnnsulenitiijn^  a  rpnort  to 
this  powerful  a^at.  In  (act,  it  was  GniJIj  fuuinl  necessary,  on 
account  of  the  great  refiiHtnnce  made  hy  the  pitient,  to  daaifit 
eniirely  fri;»ni  all  ajipl  Sections,  and  leave  the  course  of  it  In 
nature-  The  wubfiequent  mnntli.  tJie  nilameniJL  wppenred 
sligiitlj;  and  there  waSp  sn  for  u  I  kaow,  no  obatrucUon  to  It 
afterwards  i 

In  tlie  second  case,  the  obliteration  of  the  vngina,  which  yvi\x 
closeil  tliroughuiit  imarl}'  JU  \vJinle  ext^^nt  i'roiit  tin?  upper  part 
to  tJie  vulva,  wn3  also  caused  by  lalxjnous  paiturltiim. 

It  may  serve  as  an  example  Ut  ^how  the  necesaity  of  making 
inquiries,  after  a  severe  t^nse  of  labor,  as  to  the  degree  of  local 
ill  flam  mat  ion,  and  of  taking  nieijwnrca  for  preventing,  if  possi- 
ble, such  adhesion  as  i>eciirred  in  the  second  instance.  Tliiw  is 
ji  nmlter  of  difflculty  and  delicacy;  but»  us  so  much  ia  at  «bd(e, 
these  con  side  rationfl  should  give  way  to  u  correct  appreciation  of 
tho  danger  wbich  would  enavie  from  neglecting  an  ciammiitiDnT 
when  the  dij-charge  from  the  vugina  is  so  offensive  as  to  su^- 
gpst  tlie  possibility  of  gangrene  and  snhspijnent  adhesive  inflam- 
mation. 

It  may  not  lie  useless  to  call  attention  to  Uie  great  resistance, 
and,  in  two  of  the  cases,  entire  want  of  fluclnalioni  which  ex- 
isted in  tike  distended  sac  formed  by  the  uterus  and  vagina,  as 
felt  tliroiigh  the  rectum,  since  this  might  lead  the  surgeon  to 
douht  tlie  accuracy  of  his  diagnosis,  did  not  other  marks  assist 
in  forming  it. 

Recently,  I  have  had  two  cases  of  apparently  entire  oLlilera- 
tion  of  the  vagina  in  marned  women,  m  whom  coneeirtiim  has 
taken  place,  and  at  the  time  oFlnUir  tlie  heiid  of  tJie  child  fon'ed 
its  way  through  the  septum  without  injury  to  the  neighboring 
parts.  Both  rases  have  done  well,  and  [here  has  been  no  return 
of  the  occlusion. 


OCCLLPION  OF  OS   UTERI, 


Case  CLXXVl.  — Occlusion  o/  Oh  JJUrL  Colhrtion  of 
Put  in  Ulertis.  Operativn.  Protfrcxiii'Mtf  Recovery  Jrora 
UUriae  Di9etuK,     Death  Jrom  Oaetric  Disoi^fr.  —  In  the 


S9S 


FEMALE    GENITO-TTRINARY    OKl^ANSi 


followmg  cns^,  I  wns  called  in  oonsultnlicm.  A  younp;  womnn, 
17  years  of  n-gc,  on  the  second  dny  of  her  re^lar  menstrual 
period^  wet  her  feet;  the  catamenkl  discharge  smldenlj  ccBfiecl, 
and  fllie  lind  a  rigor,  iVilkiwpfl  hv  pidn  from  left  ilhim  to  ribs. 
After  a  little  treatment,  ahe  wns  able  to  be  about.  The 
menses  not  ap[>enring  six  weeks  subsequent  to  (Jieir  su|>pre*iBiofi, 
fihe  consulted  a  physicinnj  who  noticcil  nn  unnflual  fdlness  aboTe 
the  pubea.  This  rapidly  increased,  and  \u  a  few  wppWs  the  pa- 
tient presented  the  appearanee  o£  a  person  at  the  seventh  month 
of  utero-geBtation .  On  eiamiliation,  ilie  uterus  gave  the  sen- 
Bntion  of  being  distended,  and  no  entrance  eould  be  made  into 
its  cavity  with  a  bougie  or  sound. 

At  the  time  I  wae  called,  the  abdomen  was  eligbtly  sensitive 
to  pressure,  and  projected  anteriorly  to  a  great  degree  :  but  there 
waa  no  eoix^sponding  lateral  fulness,  which  we  usually  Bee  in 
pregnancy. 

Ailer  a  careful  examination,  I  decided  tf>  puncture  the  os, 
and,  passing  a  trocar  into  it  with  considerable  force,  seven  pints 
of  offensive  pus  were  evacuated. 

For  a  time  the  girl  improved  ;  and  at  a  second  operation,  four 
weeks  after  the  first,  tliroe  pilita  of  pus  were  removed- 

About  n  week  after  the  second  operation,  tlic  patient,  having 
previously  lived  on  a  liquid  farinaceoua  diet,  ate  immoderately 
of  potatoes  and  cabbage.  She  was  immediately  seized  with 
purging  and  bilious  vomiting,  which  resisted  all  remedies,  and 
sank  rapidly  and  died.  Her  physician  informed  me  that  no  un- 
favorable re-action  followed  either  operation,  and  that  she  was 
doing  very  well  up  to  the  time  when  she  committed  the  above 


excess  m  eating. 


No  poet-mortem  was  allowed. 


Case  CLXXVU.  —  Occhmwu  of  ih^  Uterus.  liupture  of 
ihe  L^ft  Fallopian  Tube.  Fer^ionilis.  BtatL  —  lSb^. 
The  patient  wa*  a  woman  40  years  of  age,  large  find  fat. 
About  tlie  year  1854,  she  bad  a  very  severe  confinement,  and 
had  never  meuetruated  eiucCi  For  ihe  last  nine  raonlhflT  f^Ijo 
had  been  for  the  most  part  coiifiued  to  her  bed,  and  auffered 
extreme  pain.     Dr.  D.  Brown,  on  examination  of  tho  abdomen, 


OOCXTJeiON   OP   03   UTEBl- 


293 


found  a  Hrgc,  firm  titmor,  which  he  at  once  rcco^ired  as  tlic 
ulcriid  diatcnded  by  the  retitincd  mcnatpual  iluid.  When  I  saw 
her,  in  coneultiition,  this  tumur  wii»  very  projuincnt,  atiknding 
out  in  boid  relief  from  the  abiJomcn*  Ita  up^jcr  pmt^  toward  the 
fltcmum,  wild  flat;  below,  toword  the  pdvb.  roiiml  ?  and  in  itfi 
centre  was  a  deep  deprcflfiion.  On  esnTuina-tiuu  uf  the  vagina, 
thia  canal  was  ibund  to  tcnninate  in  a  smooth  eul-do-soc,  and 
not  the  elightcHt  mark  of  the  oe  uteri  could  bo  dist[ni^Jt*hc<3, 
nor  any  thing  to  mark  the  point  of  its  oblitcratioEi  csccpt 
&  rcry  alight  roughness  on  the  vesical  eidc  of  the  rogina. 
By  the  rectum,  no  tumor  could  at  first  be  foupd ;  but,  by 
prcfleing  the  tinger  very  high  up  into  the  pclvb,  the  point  of  a 
firm,  solid  mass,  of  a  conicaJ  ahapc,  could  be  rcjiched.  The 
patient  being  in  great  Huffering,  it  was  decided  to  appoint  a 
day  for  cutling  down  at  the  upjjcr  part  L>f  the  cul-de-eac  of  the 
vagina,  and  uttempting  to  reach  the  tumor.  On  the  day  before 
the  one  lixed  for  the  operation,  her  phyaioinn  culled  on  mc  to  aay 
that  it  would  be  unneccesary,  aa,  very  shortly  af'lcr  the  investi- 
gation had  been  made,  a  bloody  or  tarry  discharge  from  the 
vagina  had  commenced  to  flow,  and  had  continue<l  to  do  so  since, 
being  accompanied  by  forcing  uterine  pains,  and  with  a  great 
diminutiim  of  the  abdominal  swelling-  Under  the  cireumfitanccHi 
it  was  thought  best  to  make  an  examination  with  the  sjxiculum, 
on  the  following  day,  in  order,  if  necessary,  to  take  the  oppor- 
tunity of  enlarging  the  opening  into  the  uterus.  A  speculum 
being  inCrotluced,  at  once  revealed,  at  the  upper  port  of  the 
ragina,  a  thin,  bladder^hke  tumor,  from  which,  by  a  sdirII 
o])ening,  tlic  tarry  fluid  exuded  more  freely  when  pressure  was 
niflde  on  the  abdomen.  The  speculum  being  withdrawn*  the 
finger  at  once  penetrated  tlie  thin  partition  alluded  to,  and  could 
be  carried  for  some  difllanc^■.  in  a  cnncd  direction,  toward  the 
right  groin,  being  prevented  from  passing  toward  the  ab<.]ocieu 
by  a  firm,  unjielding  tumor,  which  npj>c;u^  to  be  the  uteru«, 
firmly  distended  by  iiuJd,  A  catheter,  being  passed  into  the 
bladder,  showed  that  organ  to  be  forced  down  hito  the  pelvic ; 
and  the  finger  could  easily  be  passed  beyond  it,  It  was  decided 
to  temporise,  especially  as  the  dischai'gc  c<intinued,  and  the  pa- 
tient was  getting  eB.ac.     In  the  mean  tune,  it  should  bo  stated, 


294 


FEMAJ^E    GENITO-URISAKY    ORGANS. 


the  right  lobe  rif  the  abilominul  tumor  had  disappearod.  The 
pntient  sulfpred  no  inconvenieace  or  pain  from  the  esaminatiou, 
whi4.'h  vmA  a  alight  one. 

The  following  dny,  ehe  wa*  suddenly  seized  with  a  violent 
pain  in  tlie  abdomen.  All  the  ei^s  of  high  peritoneal  irri- 
tation were  evident,  and  coatlnjed  for  about  two  days,  when 
alie  died- 

A  post-mortem  examination  expkined  the  eauee  of  death. 
The  right  lobe  of  the  lutnor  had  bten  formed  by  the  uterus, 
which  had  emjitipd  itself  through  the  vagina.  The  left  lobe 
consisted  of  the  left  Fidlopian  Uibe,  enormously  diatcnded  into 
a  very  delicate  sac,  by  the  retained  menstrual  HuiJ,  There  was 
no  communication  bet^vecn  the  Fallopian  tube  and  the  uterus ; 
and  the  former  had  ruptured,  and  discharged  its  contents  into 
the  sibdominal  cavity,  causing  death.  This  ttimor,  which  waa 
felt  through  the  wallj^  of  the  vagina  and  uterus,  had  beeji  forced 
over  into  the  rigfit  groin.  The  cavity  of  the  nterua  was  con- 
tinuous with  the  vagina,  the  os  uteri  being  obhteraced.  In  one 
or  two  cases  of  occlusion  of  the  vagina  which  T  have  had,  both 
Fdlopian  tub^,  in  a  distended  state,  could  be  felt  lying  on 
the  uterus,  but  were  completely  emptied  by  the  operation,  at 
the  same  time  with  the  uterus. 


HTFERTROFHT   OF   CERTCX  TTERU 

Case  CLXXVTIT.  —  Btfjiertropic  Elongation  of  the  Cer- 
mx  Uteri  of  Iw^nty-six  years'  standintfy  with  Projection  of 
the  Enlarged  Os  beyond  External  Organs,  Ulctratlon. 
IJemorrha(fe.  Operation,  foUoited  hg  Cairiphte  Cure.  — 
1862-  The  following  case  iidly  suBtains  the  anaioniical  de- 
scription of  tiie  disease  as  gi\Gn  hv  Iluguier  in  his  very  inter- 
esting and  important  work.  It  also  shows  how  unsafe  any 
surgical  procedure  would  be,  based  on  the  idea  of  a  simple 
enlargement  of  tlic  os  and  cervix  uteri,  without  tating  into  view 
the  very  remarkable  diiiplocementa  of  other  organB  which  oceur 
in  the  course  of  the  disease  when  it  haj?  proceeded  so  fnr  as  to 
be  projecled  to  any  extent  beyond  the  labia. 

A  Indy^  56  years  old,  and  of  rather  a  delicate  constitution, 


im^-ERTROPllT  OP  CERVIX   UTERI. 


295 


mftrriod  when  Iwenty-nme  yenrs  of  age,  shortly  after  her  mar- 
nage  took  a  long  vojage,  and  eutt'ered  aeverely  from  eea-riick- 
ne8B»  ftillowed  by  a  niiflcarrioge.  About  a  year  after,  she  waa 
confined  with  bor  fir&t  child,  Ixaviog  ti  tedious  labor  r  this  was 
followed  hy  BomG  prolnpHue  of  the  womb.  During  a  eubae- 
quent  pregnancy,  the  pro]n|>8us  woe  relieved;  hut,  after  the 
birlh  of  the  child,  it  wae  reproduced  in  a  greater  degree  than 
before,  and  eince  then  ehe  mny  he  said  to  have  been  iiontinually 
Buffering  from  disease  of  the  womb,  "When  I  first  eaw  her, 
the  OB  uteri  wns  enlarged,  and  projected  between  the  exiemd 
organs,  irritating  all  the  neighboring  parta,  and  giving  nee  to 
conBtimt  embnrraasment  in  locomoiifin.  The  brain  nlso,  to  a 
considerable  e^ttent,  was  sympathetically  afJceted ;  and  for  a. 
number  of  years  she  had  been  ecaroely  ever  free  from  a  eense 
of  weight  and  pain  in  the  hend-  For  Borao  niontha  before  I 
fir^t  attended  her,  ahe  hud  been  confined  to  her  room,  both 
from  the  irritation  of  tlie'diseaee,  which  c-aueed  great  dir^eulty 
in  walkinr^,  and  from  the  debility  produced  by  repeated  and 
aevore  homorrhagen  from  an  ulcer  of  about  the  size  of  a  quarter 
of  a  dollar,  gituatetl  near  the  end  of  tlie  tumor,  and  similar  to 
the  ulecmtions  noticed  in  eueh  cases  by  M.  Hiiguier.  The  tu- 
mor seemed  to  be  of  an  erectile  character,  having  periods  of 
increai^e  and  diminution  of  eize,  the  former  state  being  ac- 
companied by  an  effusion  of  blood  from  its  face. 

At  the  time  of  the  operation,  she  was  quite  pate  and  thin,  and 
BO  feeble  as  scarcely  to  be  able  to  move  about  the  room-  The 
tumor  presented  the  following  appearances  :  It  was  from  thrco 
to  four  inches  long,  and  about  four  inohes  in  eireumference  at 
its  eslremity,  its  base  covered  by  mucous  mombrane,  which, 
from  long  exposure,  had,  to  a  certain  extent,  assumed  the  char- 
acter of  ekin.  On  the  under  and  buck  part  of  the  tumor,  near 
its  end,  was  the  opening  of  the  os,  into  which  the  finger  could 
be  introduced  to  the  extent  of  from  two  to  three  inches.  A 
probe  passed  about  two  inches  farther.  At  the  base  of  the 
external  tumor  waa  the  meiitua  umarius.  A  catheter  intro- 
duced into  the  bloiMer  took  a  downwanl  direction,  and  its  point 
could  he  felt  half-way  down  the  tumor.  Of  course,  tliere  was 
no  cul-de-s&c  of  the  vagina  in  front ;  but  behind  the  tumor  the 


29f> 


FEMALE   aENITO-URlNAET  OROAKa, 


finger  could  be  introduced  lo  a  depth  of  from  two  to  thres 
inches-  Oa  esplonng  the  rectum  by  the  touch,  the  finger 
could  be  hooked  downwrirds  into  the  peritoneal  cul-de-ane, 
which  was  dragged  di>wn  by  the  tumor  to  a  distance  of  about 
two  inches  external  to  the  cavitj'  of  the  pelvis.  The  body  of 
the  uterus  was  felt,  about  the  thickness  of  the  thumb,  and  an 
incb  and  a  half  loug,  in  its  natursJ  positiou,  Ii  will  be  seeo, 
from  the  above  defscription,  that»  by  any  operation  for  re- 
movini^  nil  the  tumor  which  projected  between  the  labia,  about 
a  third  or  a  half  of  the  bladder  und  a  oonsidenible  portion 
of  tlje  peritoneal  cul-de-sac  would  bo  included  in  the  mci* 
aions. 

The  operation  was  performed  on  the  18th  of  November,  1862- 
The  patient  being  etherized,  the  legs  bent  aa  in  the  operatifjn  for 
lithotomy,  the  extremity  of  the  tumor  was  tinnly  seized  by 
strofig  hooked  forceps,  and  drawn  downwards  and  forwards. 
An  indHion  waa  made  ifi  the  back  part  of  the  tumor,  alxmt  two 
inches  from  its  extremity,  and  jnac  in  front  of  the  peritoneal 
cul-de-sac,  which  was  marked  by  the  finger  booked  down  into 
it  from  the  reetnra.  Thia  investment  being  dissected  bac^kwards, 
the  enWged  cervix  was  cut  into  iibout  iin  inch  higher  up,  until 
its  cavity  wna  opened.  Large  vceseU,  which  now  spouted  in 
every  direction,  were  tied.  The  diftseetion  was  then  continued 
in  front.  The  tumor  being  carried  l^ackwards  and  a  catheter 
introduced  into  the  bladder,  an  incision  was  made  directly  in 
front  of  it,  and  the  bladder  dissecte*l  off  fi'om  the  tiody  of  the 
tumor  aa  far  as  the  level  of  the  incision  on  the  posterior  aspect 
of  tlie  cervix.  The  section  of  the  tumor  was  now  completed, 
the  base  of  it  being  firmly  held  by  the  booked  forceps  until  all  tha 
bleeding  vessels  were  secured  by  ligature*-  The  furm  of 
tlio  iuciaion  is  well  i^hown,  in  tbc  woodcut,  by  tlie  enrve^l  dotted 
lines  :?,  8.  Great  care  was  taken  to  make  the  diasectiou  elowly, 
and  to  secure  every  vessel  as  soon  as  cut ;  uid  by  tliis  means, 
although  many  vpascls  were  divided,  the  loss  of  blood  was  very 
moderate.  On  rt'laxing  the  hold  with  the  forceps^  the  portion 
of  the  uterus  which  remained,  together  with  the  adjacent  organs, 
resumed  their  natural  poflitiou  in  the  pelvis.  At  the  end  of  the 
operadon,  the  pulse^  probably  froto  the  ailmulus  of  the  etiier, 


HTTEKTliOrHY   OF  CERVIX   UTERI. 


297 


wns  niiK'h  strnnger  thau  at  tlip  coinmenceuient.  Tlmre  was 
Mime  ii!urs(^ii  [inHlui^eil  hy  Lhe  ether,  litil  nu  vuiiLiLtng.  Slitr  taak 
brnnJj'  tn  the  course  iif  tlie  night,  anil  imregoii^,  fur  a  pfiin  ia 
llic  abiltiinen.  All  went  on  >\tll  fur  two  or  three  ditys;  on  the 
23cl,  hiiun^  sonic  paid  in  ihe  abdiJincn^  slie  waa  relieved  hy  a 
hot  fomentuliLin,  On. the  24th  waa  eomfortjiMe;  liui]  un  opi- 
ate Hi  ninlu.  On  the  tJ^th,  having  gune  uii  perftcUy  well  for 
a  week,  she  waa  BeizeJ  wlili  a  \try  Mcvure  chill,  whidi  ItiHted 
thre<^-([ijiirter^  of  un  hour,  mul  wms  followeU  hy  gi-eiiL  re-uclioc, 
hot  skin,  intcnee  hcudnphe,  groat  tliirnt,  ^i%  I  could  col  dis- 
cover the  siyit*"5t.  leiidcmepta  of  ihe  Jibdoiiien  or  any  ether  evi- 
dence of  hmul  Irouhte^  and  L  was  told  that  she  Wiia  subject  to 
fiiinihtr  nt(aL-kj4.  I  hnd  thus  far  been  unwilling  to  disturb  the 
bowels  with  iiiediL'ine.  An  enemji  was  oi'dereJ,  which  had  no 
olicL'tf  and  w:m  folLowed  hy  a  duse  of  tincture  of  I'hoburb.  Ou 
the  following  day^  tbe  2l?lb,  she  was  wholly  free  from  fever; 
and,  the  medicine  having  not  ypt  opecaled,  a  dose  of  iiifnaion  of 
rhubarb  wjis  given,  wirh  The  effect  of  producing  two  JejecJiona. 
After  ihici,  she  hejjau  to  tnke  wjlid  food.  On  tiie  1st  of  Decem- 
ber, bIig  hnd  another  chili,  whit-li  was  relieved  as  before-  Ad 
eiajiiinnl.laii  ait  tfn^  lime,  wirh  the  speculum,  showed  the  ^urfiicc^ 
froin  which  the  Imnur  b:id  lii-en  ivmovcil,  conmvckil  to  tfie  si^e 
of  a  quarter  of  a  doUrr  ;  two  or  three  lignturca  which  still  aj- 
hercd  were  taken  invny.  About  four  weeks  nftcr  the  opemliorit 
tbe  patient  was  able  to  wiilk  about,  and  was  c[iniplett'ly  relieved 
of  all  irritation  uhout  the  pelvic  organs,  which  were  retalued  m 
tlieir  rmtund  pnsijioMs-  The  pain  and  feeling  of  weight  in  the 
head,  which  had  oppressed  her  so  long,  had  pnased  off  fw  if  a 
cloud  had  beer  swept  away.  She  returred  home  about  the  niirl- 
dle  of  December,  and  1  had  the  ^mtii^ taction  of  treeing  her  en- 
tirely cureil  alxjul  two  moniha  later.  During  the  latter  part  of 
ner  stay  nt  rlie  Hoppital,  she  waa  kept  on  as  full  diet  jth  she 
could  bear,  and  porter  and  epirita  were  given  freely,  with  the 
effect  of  relievmg  the  very  anicmic  condition  under  which  she 
labored  when   she  entered. 

This  ease  ia  interearing  from  the  perfect  cure  of  a  comphonted 
and  rare  disenj^e  of  many  yeni'fl'  durntioiiT  and  from  the  openitlon 
being  the  only  one,  bo  f:tr  as  I  know,  lliat  haa  been  done  in 


aYPERTROPHT  OP  CERVIX   UTERI, 


299 


In  eonnectioTi  with  thia  case,  the  following  one  of  hypcr- 
tropic  elougiition  of  the  cervix,  mid  eulnrfjeracat  of  Ihe  os  uteri, 
together  with  fibroua  tumora  of  the  bcHiy  of  the  organ,  may  be 
mentioned :  — 


Cabs  CLXXIK. -^  Bypertroph^  of  Cervix  UUri.  —  A 
widow  lady,  48  yeara  old,  and  the  mother  of  one  ehlldi  came 
under  my  cnrc  at  the  Mas^iuehusetta  Gcnerai  Hoepital  in  May, 
1863.  Fifteen  yenra  betijrc,  ehc  discovered  a  ^rnojl  tumor 
in  the  left  aide  of  the  abdomen,  which  gradunlly  iDcrcn&ed 
in  fljzo,  attended  witli  a  sent*atIon  of  weight  and  bearins;  down, 
but  without  aeute  (min.  Tliis  was  followed  il  year  a*tcr  by 
a  paridytic  attack  of  the  left  side  of  the  bwly,  from  which 
eho  piiilially  rocovcrcd.  Profuse  flooding  Imd  occurred  several 
tintca  during  the  four  or  five  inoatha  immediately  preceding 
her  ndmiasion  to  the  Hospital,  motcrinlly  diminidilng  her 
Blrength.  She  experienced  much  difficulty  in  poesmg  urine,  a 
fiiet  easily  e^cplnined  by  the  displacement  of  the  uterus  and  sur- 
round ing  organs. 

She  was  a  good  deal  cmacintcd,  but  had  a  fair  pulse,  and  waa 
able  to  take  aonie  cserrii^c  ont  o^  doora  every  day.  The  abdo-^ 
raen  woe  enlarged,  and  of  a  cuniciU  form,  from  the  preacncc  of 
a  tunrior  of  about  Iwkc  the  size  of  a  coeoa-nuti  An  elongated 
tumor,  nearly  three  inches  long,  and  of  about  the  snme  circum- 
ference, projected  liclwcen  the  labia,  Thia  tumor,  which  might 
at  tirat  flight  have  been  mietaken  for  »  eimple  prolnp&us  of  the 
vaginiv,  roneiatcd  in  reality  of  the  elongated  and  hyperirophicd 
cervijf  and  ofi.  The  meatus  urinariud  opened  npoa  the  upper 
and  front  part  of  the  tumor.  The  boundary  between  the  tumor 
and  the  coata  of  the  vagina  wns  marked  by  wrinkles  of  the 
mucous  membrane,  A  careful  expluralion  of  the  abdomen  dis- 
closed two  tumors,  one  above  the  other,  which  together  filled 
the  eavity  of  the  pclvia,  and  encroached  on  the  rectum.  Simp- 
son's  sound  ciiuld  be  passcrl  but  a  short  distance  inUi  the  oa  : 
the  finger  waa  nn-e&tcd  at  the  oh  internum  ;  but  the  obstacle  was 
coeily  overcome  by  the  use  of  n  apongc  tent,  and  tlic  finger  then 
passed  readily  into  the  small  cnvity  of  the  organ, 

A  consultation  with  several  geutlcmca  distinguished  in  the 


300 


FEMALE   GENlTO-TJfilNAIlT   OliOAKS. 


obatetcnc  art  resulted  in  a  dociejon  unftivorabk  to  any  operative 
interf'ei-e»ce» 

Tbc  patieat  remained  undor  observation  in  the  Ho^pitnl  about 
a  fortnight,  when  she  was  flcized  witJi  paioa  in  the  abdomen, 
aiid  died  witli  ft^niplome  of  pentnniti^. 

On  post-mortem  examination,  a  Im'ge  intra- mural  tumor  waft 
diflcovcrcd^  oblitemtin^  nonrly  the  whole  ciivity  of  the  uterus. 
Thifi  wag  the  tumor  which  hnd  been  felt  immediately  above  the 
pubcfl.  Tlio  second  tumor»  which  hod  been  felt  abo70  the  first 
one,  wita  attached  to  the  extcri^>p  wall,  directly  over  the  other, 
and  was  connected  with  the  uterus  only  by  a  email  pedicle.  A 
third  tumor,  of  tho  size  of  a  pi^oon'a  egg,  wna  found  ne^ir  the 
upper  port  of  the  cervix,  making  its  way  into  the  cavity  of 
tbc  utcrufi,  and  ini;*lit  probably,  after  a  time,  have  made  ita  ap- 
pcurancc  ihj-ongh  tho  o&,  and  thui^  have  come  within  reach  of  n 
surgical  operation.  The  external  tumor  proved*  OA  bod  been 
EU|iposed,  to  he  the  oii  and  the  greatly  elon^^ated  nnd  hyper- 
trophlcd  cervix*  which,  hnd  there  been  no  other  disease  to  forbid 
it,  might  have  been  removed  ae  Ju  the  coao  juiit  related. 


OVAtUOTOMT. 

The  extiq)ation  of  large  ovarinn  titmors  haa  been  orcnsion- 
ally  practiflcd  for  a  long  time.  Witliin  t\  few  roara^  tbc  opera- 
lion  ha!^  been  revived  in  Kiighuid  and  in  thie  country  with 
remarhnblc  eucceee  ;  many  putients,  othcrwiee  doomed  to  a  lin- 
gcrin-r  death*  having  been  completely  eured  by  it.  The  great 
obetaele  to  the  Jiiore  free  |>orforu>ance  of  uvnriotomy  ia  the  hesi- 
tation which  ilie  surgeon  feds  to  advise,  or  oven  to  permit,  a 
patient  in  the  enjoyment  of  moderate  hcjLlih  to  undergo  an 
(jperation  whii;h  may  ulmot^t  immediately  prove  fatal.  In  it^clf^ 
ovariotomy  is  not  more  dangerous  thim  many  of  tiie  reeogniicd 
enpitul  openilions ;  tlio  difference  being,  however,  that  these  last 
are  done  in  n  jireeeing  emergency,  while  ovariotomv  generally  ia 
not.  The  proper  course  of  pntctiee  woidd  therefore  ecem  to  be, 
to  miike  a  fair  fitatement  to  the  paiicnt  and  frienda  of  whrit  they 
have  a  right  to  expect  from  the  operation,  leaving  them  to 
decide  for  themselves,     I  bave  once  been  cojuplctcly  Buccc&efal 


301 


in  the  treatment  of  an  e^ormoiia  unilocular  cj5t  of  the  ovary, 
in  which  resijiration  wns  impede*!,  the  liinba  ceJematous,  and  the 
l>atient  riijdJIy  fuilinj,  by  evacuating  the  cyst,  and  Jcaving  tlie 
caniila  in  pudition  ;  making  occaalanaJ  uac  aftcrvranla  of  iodine 
iujectioosi  to  correct  uffenaivc  di^harge»» 

One  point  to  he  eapecinUy  noticed  in  the  manner  of  perform- 
ing ovariotomy  ia  the  method  of  eecuring  tlie  bleeding  vee- 
cclfl  oF  tlje  pedicle-  The  plnn  now  most  in  favor  ia  by  drawing 
the  fltiimp  out  of  the  woundi  and  comprcBsiDg  it  in  a  clamp 
made  for  the  purpose.  This  proceeding,  however,  is  aomelimea 
iblloned  by  severe  pain  afler  the  opernlion,  e^ipccinllj  if  there 
is  much  tenaion  of  tlie  parts.  Professor  Simpson,  of  Edinburgh, 
haa  lately  recon J  mended  '^  acupitsaure'' aa  a  aut>&litnte  for  tlie 
clamp,  and  claims  for  it  substantial  advantngea. 

Although  it  ecema  almost  superfluous  to  give  the  preenution 
not  to  mistake  pregnancy  for  ovarian  tumor  or  dropsy,  yet  1  am 
led  to  do  it  from  the  fact  that  aucb  mistakes  do  occur*  The 
difTcrcnlid  diagnosis  fa  not  always  easy  between  ovari.tn  lu- 
inur  and  pregnancy,  and  we  should  remember  that  ihcy  may 
co-ej:iaL  I  have  heard  of  iu^taucea  where  the  abdomen  of  a 
pregnant  woman  has  been  puncturett  for  sui»poseil  ovarian  di\)p- 
»y.  The  rollowing  cioses  in  my  practice  are  adduced  as  illuatra- 
live  of  the  aubject;  — 

A  patient  applied  to  me,  wlio  enid  she  had  a  tumor  appear 
under  her  ribs  immodlalcly  after  her  last  confinement,  and  at 
the  end  of  nine  months  —  when  I  saw  her  —  her  abdomen  was 
immensely  distended.  Rhe  said  tlmt  she  had  been  fidviaed  on 
operation*  Not  ha^in^  the  time  to  examine  her,  I  sent  her 
to  a  fricntl  distingui.^hed  in  the  obstetrical  art,  who  informed 
mei  that,  nl^er  a  thorough  examination,  he  fi^uud  pregnancy 
existing^  with  n  great  aiipemhuitdnnce  of  amniotic  fluid.  She 
was  confined  very  soon  ailer,  with  a  healthy  cluld.  In  a  caae 
of  supposed  ovarian  disease,  sent  to  me  from  a  great  distance 
for  operation,  the  symptoms  had  been  anomalous^  and  such  as 
early  to  lead  to  the  auspiciiju  of  tumor.  On  auscultation,  1 
heard  the  sounds  of  the  fa'tal  lieurt.  It  is  very  possible  that 
pregnancy  In  this,  as  in  the  next  case*  had  supervened  on  the 
original  tumor.     lu  a  third  case,  and  one  which  would  be  much 


802 


F£HA1.B    OeWITO-UKlHAKT    ORGAPTS. 


more  likely  to  Ipad  lo  error^  a  womnn  njiplief]  at  the  Hnapital 
with  an  ovaririn  tumor  <jF  one  aiile,  of'eif^hteen  months' stnndirg. 
She  waa  l.realed  by  die  iiilernal  ntlminidlration  and  external  H,p- 
plri'Mtioii  tff  iudirjc.  Slie  ftjijjljcd  once  or  twii.'e  afterwards,  at 
intcrvnla  of  two  or  throe  moniha,  the  tumor  gnidijully  enlnrjiing. 
Finallj',  having  delayed  for  sii  or  seven  months,  a.  tumor,  winch 
was  supposed  to  be  the  same,  waa  found,  filling  the  tvholfi 
abihMnen.  She  wjln  Bhorlly  after  eoniinedn  ;ind  since  then  I 
Lave  not  heanl   from  her. 


Cask  CLXXX,  —  Lnrge  Ouarian  Ct/^ti.  Pifnrlr/Tf.  Ca- 
nnid  hft  in  ihc  }\'infnd.  Cure.  — A  married  womnn,  nged 
41  yours,  enter&l  tlie  Hospit.il.  Marah  1,  I860,  with  n  large 
ovnrinn  tiinior  filling  th**  entire  nlnloTiii?!!,  presBing  tip  the  ribs, 
and  encroaching  ro  much  upon  the  cjivity  of  the  chest,  as  to 
cnuse  great  difficulty  in  reepimtion.  The  limbs  were  in  a 
highly  (pdemafona  state,  and  she  was  m  a  very  feeble  condition 
anJ  rnpidly  failing- 

The  tumor  hpgun  fourteen  months  before,  and  increneed 
griiJually  until  it  measured  four  feet  m  its  greatest  circuraler- 
ence. 

As  it  was  suspected  that  the  tumor,  which  was  tiniforndy 
elastic  and  ^uotuiiting,  waa  unilocular,  U  wne  decided  to  punc- 
ture it  with  a  large  trocjtr,  nnd  lenve  the  caniila  in  the  wound, 
This  I  did  March  4tb,  and  drew  off  eighteen  quarts  of  light, 
strnw-colored  fluid.  The  onniihL  was  left  in  the  wound,  and 
secured  there.  March  Kith,  the  plug  was  removed  from  the 
canula,  and  n  pint  and  n  half  of  Jluid  escape*!^  thicker  and  mora 
gelatinous  thnn  thnt  drawn  firi*t,  Mnrch  iS^lh,  the  diflcha:'go  from 
the  canida  was  thicker,  and  somewhat  of  a  purulent  character- 
In  April,  from  exposure,  a  sudden  swelling  of  the  abdomen 
took  place,  with  considerflble  tendemes:*,  attended  by  a  febrile 
AttAck,  the  dtschai'ge  from  the  sac  becoming  somewhat  ofTensive. 
A  weak  solution  of  itHlfne  was  thrown  in  witfi  good  efTect,  and 
corrected  the  offensive  ttate  of  the  secretion.  Const  it  utioiud 
and  local  means  were  also  u^ed  to  nllnv  the  irrltatioQ, 

April  28th,  the  &ac  had  contracted,  very  much,  sr>  na  to  form 
quite  A  smrdl  tumor  in  the  abdoaien.     All  the  aymptonis  de- 


VESrCAL    CALCULtlS. 


BOB 


tailed  nbove  —  such  q3  difficulty  in  brciithiiig,  Jropsy,  &.c. — 
were  com|it<^tRly  relieved  ;  ant]  hIih  left  the  Ha^pitid  in  iiii  improv- 
iQg  condition.  I  fieurd  frum  her  a  year  afterwards,  fjuite  well 
and  sLouI. 

The  v.(ic  then  formed  n  dTiiidl,  Itnrd  lumor*  ubuut  the  tiize  of  a 
billinrd-balt,  on  the  leil  j^Ide  of  tlie  abdomlDail  ciiviiy. 


VESICAL  CALOCLDfl, 

Case  CLXXXT.  —  Large  Vesical  Cafculuft  in  Femalt, 
fiUiiitj  the  it?hole  Sht/iffer.  Litkith'iitf.  Tit^corenj.  — In 
Jiirie,  IMG5,  ;i  woman,  *S6  yejiia  of  nge,  entered  tbe  Hospital 
under  the  care  of  Dr.  Francis  Minot,  in  nn  ejctreme  atnte  of 
emnciiilion,  suffenng;  from  dispose  of  her  blndder.  Dr.  Minot 
eoundeil  her,  and,  detecting  a  Blone,  referred  her  ti>  me.  It 
Beem§(  thul,  twelve  years  before,  after  the  birth  of  twins,  mieto- 
riCLon  bucniEie  painful  and  fre^^uent,  unil  the  urine  waa  niixeil 
wiih  bhjod.  The  nymplonis  were  then  alleviated  until  her 
second  pre^imcy,  when  they  returned.  For  the  last  eight 
raontliH,  these  aymploma  bad  been  constant,  confining  her  Id 
her  bed,  with  a  degnw  of  pain  ref|uinng  tlie  constant  use  of 
htrge  diiJ^c^  of  nn>rphine.  S^^e  had  no  power  to  retpiin  the 
urine,  whieh  dribbled  away,  mixed  with  mueiis,  pus,  and  blood. 
Or  a  ebemieal  evariinalton,  it  wiu  found  to  be  very  strongly 
alkaline,  eiaita(n|ng  a  ihiek,  ropy  deposit,  with  some  alhiimen- 
Under  the  niieroscope,  many  bl^ud  and  pus  eoqiusdes,  epiihe- 
lia]  scales,  and  crystala  of  the  triple  phiisplintes,  were  observed- 

On  eoundini*  the  bhidder,  it  was  found  nearly  filled  with  an 
iumeni^e  cdctdus. 

A  question  arose  in  thia  caae  aa  to  the  clioiec,  ennsidering  her 
feeble  state,  between  lithnlritv  and  lithotomF,  It  was  decided 
that  this  should  depend  u[iou  the  hurdnes^^  of  the  Atone. 

She  wna  etlierized,  and  the  Bione  aei^ed  with  the  llchotrire  in 
ita  shortest  diameter.  The  screw  was  npplie*?,  and  the  stone 
easily  crtithed ;  the  fra^mentu  were  aeiied  twelve  times  with 
great  rri|Jidify.  ami  thoroughly  broken  up-  The  dtjbria  was 
lln'n  seized  with  a  htl^,  spiton-biUed  femnle  lithotrite,  —  which 
J  bud  contrived  lo  work  with  one   hand,  —  for  operating  in  tbe 


304 


FEMALE   GENITO-UaiNAaY   ORGANS. 


fbtufilc  blnddcr ;  the  othci'  hand  bcin^  oi^cupicd  in  tliG  vii<^mn  id 
Biipporting  the  blndJcr,  and  guiding  tLe  fmgmctit^  into  the  jawa 
of  the  instrument-  For  three  ot  four  days  after  the  operation, 
no  rru*ruiente  cscnped,  althou;;h  there  wae  a  ^real  acnee  af  relief. 
At  the  end  of  a  wecU,  tiic  operation  was  re|Jeftted  with  the 
fcmalo  lithotrite,  and  a  great  quantitj  of  fran^menta  removed* 
At  tlic  end  of  another  wcick,  it  was  a^min  repeated  under  other, 
aad  the  blaildor  to  zdl  nppcoranee  etfceCuuliy  cJcixred.  The 
atone,  ia  its  largest  cireuiuterencc,  must  liave  been  at  leaal  ax 
inches.  The  pntientf  from  a  stale  of  exhaustion  and  constant 
eutlcrinfij,  wa3,  at  the  end  of  five  weeks,  restored  to  better 
health  than  she  had  ever  before  cnjoved.  Two  raontha  al^er  the 
first  operation,  &  second  waa  rcrjuired  to  remove  a  Btnali  frag- 
ment which  remaiueth 


HEXAL    CALCULUS. 

Case  CLXXXII.  —  Oalculuft  in  the  Kidneij^  toiih  «  FU- 
tulona  Opening^  supposed  to  be  Carionit  Jione.  J^eath* 
Aittopfiy.  —  A  widow,  fi^^ed  45,  entei^d  the  Moaaaehuaetts 
General  iiuapital,  Oct.  1,  1858,  with  what  waa  suppuacd  to 
be  cariea  of  a  lowoi-  rib  or  of  the  tvunsver^c  proccse  of  onu 
of  the  vcrlebrB3,  Thirteen  years  before,  ehe  had  fidlen  down 
two  paira  of  atairs,  and  wa?  supposed  to  have  broken  one  of 
her  ribd.  yhc  soon  i"ecoTered  autficicutly  to  be  able  to  work, 
bat  etill  had  eone^tnnt  pain  in  the  side.  Ten  years  afler^  the 
pain  increa:^ed.  attended  with  Pwclling.  and  an  abecees  formed 
in  the  loina  juat  below  the  last  rib,  which  waa  opened,  and  a 
quantity  of  ptis  evacuated  ;  u  fistuloua  opening  remained  i  and. 
when  ahe  entered  the  Hospital,  it  was  recorded,  that  dead  bone 
eould  be  felt  by  the  probe- 

Oi:t.  3d,  a  eponge  tent  was  introduced,  and  the  opening  grad- 
uuUy  eolargedi 

Oct-  Ifjtii,  the  patient  waa  ethemed,  and  the  surgeon  in 
charge  made  a  amall  incision  so  as  to  facihlfite  exploration.  No 
hone  co»jld  be  detected.  This  examinolion  was  repeated  on  the 
22d,  at  which  tiiuc  the  discharge  from  the  wound  was  conaider- 
able. 


RUNAL  CAI^CL'LUS. 


305 


NcT.  Sihf  she  cfLine  under  the  care  of  another  of  the  aur- 
geons.  No  dead  bone  cuuld  be  found  wkh  tiic  probo  ]  but  on 
I>ec-  2Qth,  the  patient  being  etherised,  an  iDcUion  was  mn.de, 
and  bone  waa  supposed  to  be  felt,  but  could  not  be  removed. 

March  1:J,  H^^y,  ehe  came  under  my  care.  A  bent  probe 
was  passed  deep  into  tbe  wouiLd,  ftn<l,  bein^  (!urrii^d  under  tbo 
rib,  oooosionalJy  atruck  what  appeared  to  be  hone  dtvcstcd  of 
pcrioHteuin.  All  the  other  surgeons  present  pr<.»beJ  tho  wound  ; 
and  the  conclusion  arrived  at  waa,  that  the  substance  f<?lt  was 
too  deep  for  a  portion  of  rib,  but  probably  wae  the  tranavorae 
process  of  a  vcrtebm  in  a  carious  condition. 

From  the  depth  and  circuitoue  route  at  which  the  eubslanco 
was  rcnchcdi  and  the  great  solidity  of  the  surrounding  tt^^tures, 
which  hod  been  so  long  iaHnmcd,  it  was  found  quite  impracti- 
cable to  seize  the  supiiosed  bone.  The  opotiiD^  waa  thurcforo 
dilated  by  powerful  ibrceps,  free  incisiona  being  out  of  the  quoa- 
tion,  irom  the  danger  of  cutting  into  the  thoramc  or  abdominal 
cavity.  Tbe  attempt  at  removal  was  necca&anly  discontinued 
for  a  time*  as,  from  the  very  feeble  condition  of  the  patient,  the 
administration  of  ether,  probing,  or  any  unu«aal  interference, 
was  accompanied  by  great  depression  of  the  pulse  and  exceasivc 
firoBtration. 

The  patient  luid  a  rery  ycUow.  almost  jaundiced,  complexion, 
through  the  whole  duration  of  the.  treatment,  with  litdc  or  no 
appetite,  bowels  cxceeslvclv  constipated,  and  i\  constant  nauaca. 
The  urinary  secretion  waa  very  scanty  and  disturbed.  Au 
attack  of  nausea  and  vomiting  always  followed  the  use  of  the 
probe,  so  that  1  was  very  averse  to  interfere  with  the  wound, 
and  avoided  doing  so  unless  stnmglj  sohcitcd  by  hcr- 

Aprit  liJth,  she  had  severe  pain  in  the  aide^  which  was  a  little 
rehcvcd  by  opiates. 

On  the  night  of  the  21st»  there  wqfS  severe  pnin  in  the  bowels. 
During  ttic  morning  of  the  22ti,  she  was  very  weak,  with  eon- 
aiderable  tympauitea.  k^hc  ioiled  rapidly,  and  died  in  the 
evening. 

The  autopsy  wo*  mode  by  Dr.  Ellis.  ''The  pleura,  lungs, 
and  heart  preaente<l  noUiing  very  remarkable.  The  perito- 
neuiDt  omentum,  and  other  parts,  were  reddened ;  and  a  large 


306 


FEMALR    fiENITl>lTKIXART    ORGjIKS- 


qimntity  of  piiB  vvll^  found  in  l)ie  caviiy  of  ihe  (ient*iTiciim- 
The  liirge  inteHtineri  were  quite  firiuly  iidlierent  id  Uie  kft  hiiii- 
bat  region, 

"  The  fient  of  tlie  left,  kidney  wits  orni[j)ed  hy  a  dense  ma*iB  of 
fibrou-^  ami  !i<li|to9o  tissue.  Tlic  truL  ^nrfnee  of  thiA  preHenieJ, 
for  the  nioBt  part^  the  i^ame  upjueiiruiice  ha  the  exterior  ;  but  in 
iJie  L-entfe  viiui  a  portion  of  reililUli  ^nh^taneei  perhaps  un  Inch 
in  diiiineter,  nnd  near  it  otliers  of  mnallL-r  size.  Witbin  this  waa 
a  smaller  ctivity,  liiipil  with  a  serous  memhriine.  Thia  resembled 
the  pelvid,  nnd  was  oct'upied  by  an  irregular,  britn^^heil  ciilc^ulua, 
of  small  »[zv^  of  a  yelhiwish  wOiite  izulor,  and  lauunated.  It 
vfiw  retjiineil  in  ili*  ])i.wilii)n  by  one  or  more  prolongations.  At 
the.  part  which  ailhef^d  to  the  poriterior  wall  of  the  ub(]omen  was 
an  opening  through  which  a,  pn»be  passed  into  the  cavity,  und. 
came  in  eontitirt.  with  the  caluuhis.  TIlij^  opening  n-ns,  undoubt- 
edly, continuous  witli  the  dJnu^  known  to  &xUi  before  death  ;  but 
tlie  point  was  not  investigated  until  after  ihe  separalion  of  tlie 
kidney-  Nothing  was  noticed  indiealive  of  recent  inftainniatlon 
having  its  oHgin  in  this  part  of  the  abdouieii.  There  was.  no 
caries  of  any  bona;  but  the  sinua  ran  just  below  the  lost  rib, 
wiiieh  eonJd  be  touched  jjy  a  probe. 

"Wliat  appean^l  to  be  the  remains  of  renal  subwLanee  waa 
examin(>(l  by  the  miero^eope  ;  but  the  infiltration  of  Fat  globules 
made  it  impossible  to  distinguish  any  thing  else.  There  was  no 
traue  of  healthy  tissue. 

"The  cortical  substance  of  the  right  kidney  had  an  unusuall/ 
white  appearance." 

ABSE>XE    OF    VAGINA    AMD    UTERUS. 


Case  CLXXXTTT. — Absence  of  VfifftJia  and  Uten/s.  —  A 
very  delicate  and  intelligent  young  woman,  21  years  of  age, 
applied  to  me  in  March,  18S0,  and  after  same  hesitation  in- 
fonne<l  me  that  she  had  never  nienptrnatp<l ;  ami  that,  an 
eKamination  having  been  miide  by  some  female  physicinnj  she 
bad  been  informed  thsit  a  malformation  existed  (iboui  the  organs 
of  generation.  To  my  question,  whether  any  symptoms  ever 
occurred  of  a  disposition  in  the  menstrual  secretion  lo  establish 


307 


itPcIF>  slie  eaij  tJint,  vrUen  about  fifteen  vears  of  nge,  ehe  was 
Beizcfl  n'JCh  Yiolcnt  paioa  in  the  back^  loina,  nnd  Icga,  which 
recurreJ,  itn*!  ktpt  up  at  intcrvnle  for  the  BpEice  of  two  or  three 
weeks  ;  and  that  ahe  wns  informed  by  ber  physician,  that  it  was 
probably  an  attempt  of  the  system  to  estabbah  the  re^bir 
montbly  pcriLKla,  This  attaok,  however,  passed  off  without  the 
menatruatzon  making  ita  ap]>e!irance  ;  and  there  bad  never  been 
nny  indication  of  the  pcrlurmancc  of  that  function  ainco,  or  any 
vicarious  ilischar^  claewhcrc  to  take  its  place- 
On  a  ]>artial  examination  at  tliia  time,  witb  tlic  patient  lying 
on  her  aidc^  1  felt,  in  the  u^Uitl  eitnatiun  of  the  vagina,  a  ainatl 
opening,  into  wbidi  the  probe  pasaeJ  up  readily  three  or  four 
inchee.  1  therefbrci  perhaps  too  hastily*  informed  the  patient, 
tb^t  the  n^dimcnta  of  a  vagina  existed,  though  quite  emuU,  and 
could  probably  be  enlar^l  hj  an  operation*  I  made  no  farther 
examination  at  the  time,  but  could  not  explain  why  the  men* 
fitrual  Huid  shouJd  be  retained  while  the  passage  existed,  which, 
thougb  very  small,  must  apparently  lead  up  aa  high  oe*  the 
uterua ;  and  at  the  same  time  why  there  waa  no  tumor,  and 
none  of  the  ueual  autfering  attendant  on  retention  of  the 
menatrual  fluid  within  die  uterua-  The  patient,  baying  no  con- 
venient place  in  Bijston  for  the  operation,  decided  tu  enter  tlje 
Maitaaehuf^'tta  Gem;ra!  Hospital,  wbidi  abe  flid  about  two  weeks 
al^rwardsi  when  elie  vrta  etherized,  and  a  thorough  investiga- 
lion  made  of  her  case. 

On  ocular  inapection  of  the  external  organs,  I  at  onoc  foand 
that  I  vras  mistaken  as  tu  tbe  existence  of  any  opening  into  the 
vaffiua.  The  o|tuning,  in  fwct,  which  I  bml  taken  for  it,  was 
that  of  the  urethra  displaced  from  ita  usual  aituation  below  the 
pubes  to  a  poitit  about  tbe  centre  of  the  vulva,  perhnpa  an  incb 
in  front  of  the  anus.  A  catheter  bein^r  introduced  tbrough  tliis 
aperture,  tbe  contents  of  the  bbidder  flowed  freely  out.  Tlie 
catheter  being  left  in  the  bladder,  a  flnger,  introduced  into  the 
rectum,  came  at  once  In  contact  with  the  instrument ;  tbe  vagina 
beia]^  absiznt,  and  nothing  but  tbe  coats  of  tbe  rectum  and 
bladder  iTitervcuiiig.  The  finger  being  now  pae^ed  higher  up, 
aud  hooked,  tut  it  were,  into  tlie  cul-de-aac  of  tbe  peritoDciini, 
no  uterus  could  be  discovered;  but  its  place  was  occupied  by  a 


3oa 


FEMALK   aEKlTO-URlKARr  ORGANS. 


cord  somewhat  larger  at  tlic  centre  than  eidea,  and  this  cord 
being  (ijUowod  lip,  at  the  distnnco  of  two  or  three  inches  from 
the  central  purtioHf  a  body  could  h^  foil  about  the  i^ize  of  a 
common  gnrdcn  bean.  The  pn.tient  in  other  respects  seemed  to 
be  well-developed  and  perfectly  formed. 

The  nnnoimeement  ot  the  actuni  etJite  of  the  case  to  her  CAueod 
grcflt  diftreaBi  As  it  was  of  importance  to  discover  whctlier 
the  ueual  ecxuol  pcculiaritica  existed,  1  made,  with  tie  iiiuch 
delicacy  as  poapJbJc,  eorae  qiieationa  on  this  jwint;  to  which 
she  replied,  that  she  had  alwa)ra  ooneidcred  herself  a  woman  m 
every  respect. 

]  made  n  second  examination  of  the  eu^e  some  days  oftet^ 
wards,  with  the  patient  in  the  erect  position,  thinking  that,  if 
any  uterue  wcro  present,  I  ahould  tbiis  be  more  likely  to  detect 
it  than  if  ahe  were  on  her  back,  but  with  the  same  result  as 
before. 

In  a  late  number  of  Guy's  Hospital  Keports,  an  interesting 
case  is  given  of  ahscnce  of  the  vagina,  where  the  literua  beeame 
so  diatcnded  by  the  menstrual  tiuid  as  to  ret^uire  an  operation. 
When  the  patient  was  first  examined,  the  surgeon  pnaaed  hia 
linger  into  a  passage  supposed  to  be  the  vnginai  but  which  be 
soon  discovered  to  be  the  dilated  urethra.  The  uterus  wa^ 
punctured  through  the  rectum  to  the  entire  relief  of  the  patient, 
the  aperture  remained  open,  and  she  was  beard  from  af^rwards 
as  havino^  the  mcnf^truol  disehargo  regularly  through  it,  and 
without  any  difficulty. 


Case  CLXXXIV.  —  Complete  Aiisence  of  Vuguta  nnd 
UCerus. — April,  1858,  a  patient  supposed  to  have  an  oeelu- 
eion  of  the  mgina  was  sent  to  me  hy  a  mcdieal  friend.  She 
wna  25  years  of  a^,  wdl  developed,  about  five  feet  two  or 
three  inches  in  height,  and  hod  been  married  four  years.  She 
had  never  menstruated;  and  it  may  be  mentioned,  that  her 
mother  did  not  menstruate  till  the.  ngc  of  twenty-onei  afler 
she  had  beer  married  one  or  two  yeara. 

On  examination,  I  found  whjit  at  iir^t  appeared  to  be  a  very 
em&ll  varrina,  which  would  only  admit,  with  much  suffering  to 
tlic  paticut,  the  little  finger.     The  sensation  imparted  was  as  if 


ABSESCt  OF  TA^^DTA  AS7>  tfTBSTrB. 


SOS 


the  firg^  had  pusswl  through  thp  tiasue  of  an  old  ci(7atrix- 
Suppoj^ing  thiB  tn  Itr  tlit^  vngimi  cfintracled  Ironi  some  iiifluiiima-' 
torr  procesa  wliidi  had  occun'ed  at  un  early  [H^riod  of  Jifc,  she 
was  adviecd  to  go  into  the  nfispitJiJ  fur  fwrther  investigation. 
Having  entered,  aftfir  the  hipse  of  il  few  days,  bLc  was  ftho 
ized  previous  to  an  cxiiudnalioiii  both  to  eave  licr  fLtillnga  on 
thti  ACUTe  of  delicucy,  and  also  to  allow  of  any  surgical  opera- 
tion. If  oue  should  bt  deemed  neccssjiry. 

On  inspection,  the  hreitsts  wera  found  to  lie  well  deveh)ped. 
The  external  organs  of  generation,  the  clitoHfl,  nymplire,  &c., 
were  Dormnl ;  there  wiia  hair  on  the  pubea.  In  the  fiituatiuti 
UflnrUly  occupied  by  the  vagina  was  an  ajKrturu  large  enough  to 
jtdmit  the  liltle  fif»ger.  No  nrethni  could  be  fount!;  and  thia 
amused  euapieion  as  to  the  true  nature  of  the  ca^C'  The  finger 
Wild  mtw  |)H>sod  into  the  cruinl,  itnd  the  ether  hand  being  plut^ed 
on  tlie  exterjiid  wiJU  uf  the  abdomen,  it  wna  evident  that  both 
coverings,  or  ratlier  both  walla  of  tlic  bhulder,  were  not  em- 
braced between  them.  The  finger  being  withdrawn,  and  a 
catheter  inti'i^hjcecl,  the  urine  at  once  flowed  liirough  it,  show- 
ing eondusively  that  tliis  whs  the  bhulder,  and  that  the  finger 
hiid  been  pas:4ed  through  the  ililate<1  urethra.  Tiie  finger  being 
intnxiuceii  again  n*i  before,  and  a  fingur  of  the  other  hand 
passed  into  the  rectum,  no  tracca  of  vagina  or  uterus  euuld 
bv  found  ;  while  (Le  forefinger  of  the  left  band  in  the  rectum 
could  Ik;  hooked,  as  it  were,  into  the  culMle-sau  of  the  perito- 
neum, and  tiiijn  dragg*^!  down  ne:irl/  to  tlie  Miua. 

From  tlie  result  of  this  exanunation,  il^  was  at  once  evident 
that  no  snrgical  operation  could  be  of  any  benefit.  I  was  dl^ 
posed,  however,  to  keep  her  under  observation  until  the  next 
uien^dual  etfort*  which,  uccorduig  to  her  account,  took  pl^e 
niouthly,  and  was  announced  by  pain  in  the  back  lasting  four  or 
five  days.  In  case  any  rudiment  of  the  uterus  exisled,  it  wae 
thought  probable  it  would  be  manifested  at  that  time.  She 
was  therefore  advised  to  remain  In  the  Hospital  to  afford  further 
observation  of  the  case.  Nothing  however  wus  di^eovcreil  bear- 
ing ihe  leaft  resemblance  to  a  uterus. 

During  tlie  four  years  of  her  marnsge*  so  ftir  as  I  could  leam, 
A  very  partial  indulgeuce  In  sexual  intercourse  took  place,  which 


310 


FEMALE  OENITO-URINARY  OHGANS. 


resulted,  probrtbly,  in  the  grcMt  dilatation  of  the  uretLra  which 
was  ob  served - 

The  above  caee  is  interesting  from  the  fact,  that  the  patient 
pfesented  perfect  oxteranl  development,  flceompanied  by  the 
uaiial  Bf^xu^l  feelin^d*  with  a  eninplete  nb^cnoe  of  two  cjf  tlie 
importniLt  organs  cngarred  in  the  sexual  tunetions.  It  may  be 
added  tliat  no  viearioue  discharge  of  any  deeeription  supplied  the 
pliice  of  the  uienstnial  secretion. 

In  one  or  two  infitances  which  have  fallen  under  my  no^cc 
when  the  vagina  and  wtenia  were  wanting,  the  urethra  wae 
pliioei!  lower  down,  as  in  tho  above  erase;  and,  insteiid  of  occupy- 
ing its  ordinary  aituation,  it  ibnned  a  continuiition  of  tlie  rudi- 
mentary vagina. 

A  case  of  entire  absenee  of  menetmation  in  a  younfj  woman 
may  here  he  mentioned,  who  ooneultod  me  some  years  since- 
A  sound  wfts  passed-  into  the  utenie,  but  no  obstruction  was  de- 
tected. This  patient  had  a  vicarious  blocxly  dischiirge  from  the 
rectum  onca  in  six  weeks,  lastinjr  some  days.  Development 
and  eexual  feelings  were  normal. 


HEHMAPHRODISM, 

Cask  CLXXXV,  —  Sttppofed  Encephaloid  Tvsttoh. 
OpGrvxtlon.  Deaths  Autopsy,  I/er^maphrodism*  Zhfinase 
proved   to  have  li€Gn  Ovarian  Tumor.- — A  pcrpon  pHn^  the 

name  of  Thomas  M ,   21   yoars  of  age,   apphed   to  me  in 

April,  1851),  on  accoLnt  of  a  great  cniurgcment  of  what  appeared 
to  be  the  ri'^t  Iceticlc*  His  external  appcnrnnee  w^ie  tbiit  of  a 
young  working  Iriahman.  The  beard  waa  full,  etronjj,  and 
black,  the  Jaryos  of  the  ordinary  size,  and  the  voice  masculine  j 
the  ehouldcra  were  broader  than  the  hips;  the  muscles  vrcro 
well  developed;  height  ^ixty-fivc  inches,  of  which  thirty-throe 
were  above  the  pube^,  ami  thJrty-two  below. 

The  patient's  own  history  of  the  case  waa  as  follows  :  Early 
in  life  he  lost,  or  had  had  removed,  the  left  testicle,  but  could 
give  no  particulars  of  it.  This  account  waa  probably  folia- 
eJous. 

The  right  teaticle  was  greatly  enlarged,  measuring  thirteen 


TLKRALIPHEEODISM. 


311 


inchca  in  circuinfurence,  ecven  und  tliree-qiiarters  in  len^h, 
en;i^-aha|ie<lT  and  extended  nearly  tw^o-thirda  of  tlie  distance  trom 
the  pubes  to  tlie  knee.  It  wa«  i^JcceueLvcly  tanset  hard,  and 
seemed  tw  henvy  to  be  supposed  a  hydrocele,  aJthougli  tbe 
grcnt  evenness  of  tte  surface  sccmcd  to  make  f^iidi  a  i^uppuaitiun 
probiiLlc.  There  were  large  veins  on  its  auifuce.  What  seemed 
to  be  the  Bpermutio  eonl  woe  well  defined  uhove  th«  tumor, 
thoujfli  11.  little  hji-rder  than  natund.  There  wns  considcmhte 
complaint  uf  |Hiin  in  the  hack  and  luiua,  which  was  attribuied  to 
the  dniggin^  weight  upon  these  parta-  The  paia  in  the  tumor 
itseU'  WflB  ncit  csecGeive.  The  testicle  had  been,  he  fiaid,  of 
normal  size  till  about  a  yeur  before,  when  he  received  a  severe 
kiek  upon  it.  Aflcr  the  tirat  oeuto  symptoms  had  subsided,  it 
bej^^an  to  ewcll  slowly  ;  hut  within  the  laat  month  it  luul  in- 
creased very  ropidly.  The  eesual  feelings  and  power  of  erec- 
tion continued  natural  till  ^ix  weeks  before  I  saw  IuiUt  and 
since  then  they  had  completely  disappeared-  He  never  had 
sexual  intereourse-  About  a  zuontb  tiinec,  both  hrcasta  began 
to  swell  and  become  painfiLl ;  and,  upon  examination,  I  found 
them  to  be  of  the  size  of  those  of  a  young  female ;  the  glutidulur 
structure  could  be  distinctly  felt,  and  the  disk  wne  about  four 
inches  in  diameter.  No  fluid  iasned  from  them  on  pressure-  I 
eould  not  learn  from  him  whether  they  hud  prevJoualy  been 
larger  than  natural ;  but  the  present  inereneed  i<i;te  seemed  to 
have  oorrer^ponded  ifk  time  with  tlie  loss  r>f  sexual  desire,  lie 
stated  tluit  hie  health  was  failing,  he  had  lost  his  appetite,  and 
woe  deBirotiB  of  an  operation  to  roUcvc  him  from  suffering. 

He  was  sent  to  the  Mosfiachusetts  General  Hoapital,  where 
tiie  tumor  was  removed  on  Wednesday,  Ajiril  13tli,  and  the 
supposed  cord  tied  en  r>iagse  near  the  abdominal  ring;  some 
dieaeetion  being  neccif^ary  in  order  to  reach  it  nbovc  the  disease. 
PrevioiiJj  lo  the  operaticuT  be  had  been  excessively  diflidcnt 
about  having  the  genital  organs  examined,  and  at  this  time  the 
following  a|jptarance3  were  first  remarked.  The  glans  pcnifl 
appeared  normal,  but  impcHorate ;  the  body  of  the  penis  was 
from  two  to  three  inches  in  len<;th.  Cummcncing  al>out  an 
inch  from  the  gluns,  and  oictonding  to  wi(hin  two  inchea  of 
the  iomsj  was  a  fissure  having  on  each  mde  two  flaps  of  delicate 


312 


FfiUALt:  G£KJTO-L-RIN.\Br   ORGAITft. 


eftfilM^lium,  pim'tJy  resembling  the  rymphsp,  whit^h,  liein^  eepa* 
ralui^  prcwni^,  as  it  were,  the  extern^  or^uis  of  tLe  femtde. 
At  t)ie  iovrer  part  of  tliis  fiaaurc  cunuiienced  up|Hirently  tlie  ure- 
llira;  nnd,  tin  instruineDt  lieini^'  iiilrtKluccd  riljout  Uiree  incbesi 
nrutcr  rwaped  freely-  Extemnl  to  the  fiaaure*  the  0k.1i]  wiA 
llrin  imt\  dcViPtiXe,  like  that  in  tbe  npi<rhlM>rh(HHl  of  the  J«]A]e 
urgniu  of  gencrntioa.  The  pubea  wna  very  fully  fiovertid  with 
hair,  wblch  vra«  bhuved  ta  tiicilituie  Uh?  dretnt^ing  uft«r  the  oiiera^ 
tion.  Dr.  Dyer,  boiise-aargeon  of  the  Hospital,  at  my  request 
took  A  caat  of  the  breasts,  their  □p[>eaFance  was  so  UDiiMid. 
My  inrjitiri^Fi  wnulil  hnve  been  iniich  more  jmrticular  in  rcgnnl 
U>  i\k  jjrcyiuuH  hirilury,  aiiJ  e^^fK^oiiilly  lis  Ilj  any  th'mg  retiem- 
bJittg  tbo  tuetibtruul  diudmr^c,  if  I  hud  had  ihi  slightest  eiupr^ 
diiti  o(*lhc  pflticm'ii  sex. 

TIk!  day  nhcr  tbo  D|)cnLlian,  the  jintient  coni[ihiiiitx]  n  great 
dind  ijf  pjLin  in  tlie  HlHlcimen^  iind  inuoh  fever,  slUo  of  tJiir^l* 
nhich  wnji  [Jiirlly  attributed  to  the  edier  adiuinUlered.  T\m 
ftrbrili.i  iLcrion  j^radtmlly  inoren^ed  from  day  Ut  d.iy  ;  ibe  swt^litig 
ant]  (luin  hi  tlie  ihbdnn^en,  however,  subsiding  until  duiith,  wbiiJi 
l***.k  |i|)U'o  on  tliG  *oventb  day  afler  the  operation. 

Am  lAfLniiniithin  of  the  body  was  ninde  on  the  following  day. 
Itridi  liinj^M  were  found  tituddcd  with  Jurge  musi!ii?4  of  eam^erous 
mutter,  unci  vrero  ulhorent  at  ccrtnin  points  to  the  pleurre.  Tha 
liver  nt  firiit  iip|i(-an-il  healthy  ;  but.  on  ]>eing  cut  inUi,  il  numlker 
of  euvilim  were  diricoveved  about  the  «ize  of  a  lilltert,  containing 
n  thirk  ndlky  ^uld.  On  tlie  ^line,  at  the  rout  uf  tlie  mesentery, 
wan  u  miLAti  or  enbu'god  lymphatic  glands*  the  ebAni  of  them 
ujiU'iulhkf^  diuvii  from  tk>  edge  of  the  rim  of  the  jmlviK  nearly  to 
t\w  ^niiii,  iniii'h  duUontil,  and  not  |>eree|ttible  clirough  the  nralla 
uf  tlie  nbdijiiit'iki  The  neig-hborbood  Chf  the  nng,  ju«t  ttbave  the 
»|Hil  wliero  tho  llgiLlnre  hud  been  applied,  wns  in  a  ^ngrenoiu 
uitidlliim.  The  ihU^JsEJinvi  brinir  removed,  ex^KHied  tike  fuHow* 
U\^  reiniirhikh](i  ai^pearam-es  in  the  jtelvic  orguu :  The  bljidflcr 
wiin  nniniMvhiiL  disteikiKd^  aiid  jutt  bclund  it  lay  a  wcll-fi irnieil 
ni(ii  LiM  111'  iitilnrtd  ^liie,  na  in  il\c  unimpre^iated  state.  On  the 
b^i^  lide  of  Ute  utoruH,  the  Fnllopian  tul>e  terminated  in  it»  fiai- 
brinlinl  rvheniily.  midir  whieb  by  llic  o^Tiry,  rather  smaller  than 
iiLktkinLl.  uiid  \\ilh  one  or  ivny   liiUc  bdtadfi  of  adbe^iou  running 


HERMAPrrRODTSW. 


ai3 


between  it  and  the  Fnllopian  lube.  The  ovary,  being  incited, 
diapl:iyctJ  ita  orilinary  slriicture.  On  the  right  siJc,  the  tube 
ran  nlcng  unUer  the  poritiincdin,  titrntid  upwiw"<]rt,  and  wns  lost 
in  a  diai'a^Gd  maas  in  tho  ri<^ht  givin.  The  ^uirtB  wsm  now 
removed  whh  grent  care  irinn  the  pelvis  by  Prut'easor  J,  B.  S. 
Jackaon. 

All  the  jwlvic  oTgana  licing  remuvcd,  and  placed  on  a  table, 
we  proeeedeil  to  invet^ti^^te  the  rclntian  of  the  dlffbrcnt  organa. 
A  probe  was  paa&e<.l  into  tlic  uretlira,  and  went  reailily  into  the 
bladder;  being  witlidrawn,  and  depressed  a  little,  it  passed 
with  ef[i.ml  fueility  to  the  fdndua  of  the  uterus.  The  parta  were 
now  turned  over,  aud  the  back  of  the  vfl^na  and  utcrua  laid 
open.  Tilt  vagina,  which  comrienccd  about  no  Inch  from  the 
external  orilicc,  waa  nearly  four  inches  in  length*  and  tcrmiaaled 
in  the  OB  uteri ;  which,  however,  did  rot  inakc  much  of  a  relief 
in  the  vagina,  nlthmigh  the  dialinclion  in  the  two  textarcf*  wna 
fiilly  marked,  Tlic  arbor  vine  was  very  distinct,  and  bcautiliilly 
ehown  :  it  extended  nearly  up  to  the  fandiis  of  the  ulcrus-  The 
blowpiiie  being  introduced  inlo  the  left  Fallopian  lube,  air 
parsed  freely  through  It,  and  out  of  the  firabrialed  extremity. 
A  probe  cuuld  be  passed  for  a  certain  distance  freely  in  the  right 
Fallopian  tube,  but  air  did  not  pius  through  it  as  in  the  other. 

In  regard  to  the  tumor  removed,  the  whole  aubstaiice  of  it 
Bcemcfl  to  be  converted  into  cnecphaloid  matter,  and  its  natural 
etriK-Inre  lost.  The  external  covering  was  adherent,  except  at 
its  anterior  part ;  it  was  cut  into  early  in  the  operation,  and 
about  a  gill  of  a  yellow-colored  serum  eseaped^  exposing,  on 
the  upper  part  of  the  organ,  a  collection  of  beautiftiUy  colored 
cystd,  of  all  sizes,  like  a  laaa*  of  brilliant  cryatais- 

It  would  have  been  cjttrenidy  intereating  in  tbia  cnee  to  have 
decided  whether  menstruation  had  ever  taken  place  through  the 
urethra;  but  this,  unfortunately,  I  bad  no  means  of  determine 
ing. 

The  organs  being  given  to  Dr.  Hodgca,  the  demonstrator  of 
anatomy  to  the  college*  for  the  purpose  of  a  more  minute  dia- 
section  and  inveatigation,  be  kindly  furniehcd  the  following 
report :  — 

40 


314 


FEMALE    GEN rrO-ITRI NARY    OBOANS. 


''  PilmiK  Hevtflnpfnf^iil,  llisil  "f  jl  irmle.  Pi^iiIh.  uIlil'Ii  is  rfiul  of  An 
adulu  JiiiU  not  uf  a  yoaiiu  mtu^iiies  ul^iig  its  dur^um  two  and  b  liali" 
indicfl.  The  ^lane,  of  pro[»orlio(mto  ^iec,  13  wtvereil,  excofit  in  llie 
immediflle  vitinity  of  wlier*  (he  tViPiiLira  should  Vie,  by  si  weU"developpd 
pjTipuce.  Thu  uiiiihra  being  deft  from  ibe  meutud  batkwiirJp.  llie 
prepuce  ]s  not  frotnplcted  uiidcmcaTli,  but  bccomca  IoaI  in  tlie  aheAlh  of 
tLti  pen  13. 

''Th6  ui^fhra  ifl  tmcenble,  along  the  under  enrface  of  the  penis,  from 
the  mentns  3J  inches,  and  disujipi^nra  in  nn  uriHce  2-^  iurln-'s  in  front 
of  iKo  nnuB.  Tbroughout  Ihis  dislanoi-j  it  crio?i^l3  onlj  of  a  fi&sure,  or 
bqIguBi  tlie  aides  of  wliiuh,  hiiring  irreguiar  burd^irs,  arc  in  appoaitioi]. 
It  iri  tilled  wid;  uell-dinmi 'tended  miinoLis  membnini';  and  liaa,  at  vari- 
ous poiiila.  dia(ia(^t  LKuna'- 

^^  Divcra;[Dg  obljqucJj'  up^va^d8  aud  outwnrds  from  tlio  aides  of  the 
nrelLra  Rve  fold^  of  inu^gnmi-riU  ■'on  slim  ting  di^lint'i  Inbiai  mnj»m  and 
minora.  On  llit;  left,  iit  tht  Mv  ef  lliedo  lubiu,  arc  ludUttuct  lutuks  of 
cJL'at  rices. 

*'  KsaTnined  iTiicmidly,  the  peoia  tronsisis  of  two  corpora  cavcrnosft, 
meiisuHng  from  tbo  meniiia  to  their  bifmvntion  4  inchea.  They  ler- 
miLUiti^  ill  ;^Tll-Jlt]lrkeJ  orura  «  atid  Ibe  ui-rvirs,  arteries  atid  vslus  of  ibe 
dorsum  of  tlic  pcniSf  hnve  iht?  miml  siao  and  position.  Tho  corpus 
spongiosum  ia  well  developed^  but  split  longitudinally  mio  two  hnlvep, 
nhidi  iiTf.  to  Ire  ^eeii  on  diljer  aide  of  iind  beldiid  tliti  f^iqH>ru  ciLver- 
no&a,  Ainil  corrcfijiond  cxtorntdl^  to  ivo  Iblds  wlilijb  form  the  ijibia 
minora. 

"  CdWpcr's  glandft  were  not  found, 

^' TLu  mutfcli^  of  th(j  perimLum  nvK  soiacvth&i  eonfu^i^d.  bul  the 
following  were  dUlint'tly  mudu  out:  eroctorofi  pcni^s  comproasorcs 
nrtOirae,  Itvuior  and  apbincHir  aoi ;  anterior  to  the  latter  was  anorher 
ellijiLirul  gphLiicteE'  mu^ide,  I'orre^fionding,  probztblyf  to  tlio  Hpbincler 
TagiiiiC-     Tho  Irftosver^us  ijeriuti,  as  /^ucll.  was  not  mndu  o«L 

"  The  bladder  is  of  ordinary  fliao,  but  its  tnuaculnr  development  ie 
greater  iban  u^naL  It  hjia  two  ureters,  normel  its  lo  their  entranc^e  and 
olLtirwisi^p  Fnjiii  the  iDlt;mhi  orilli:c  of  tho  hbiddvr  [tj  the  'vagina 
uruLbrolis  '  it  is  I  ^  iui-h.  Laid  open  uJon^  its  nntcriar  surface,  it&  nOck 
19  Embrflced  by  a  bi-lobed  pro^lato  glauii  of  about  half  the  natural 
adult  dimensions;  pttsieriorlj  to  rliU.  tlii-  nGc-lc  ]a  Lhi<;kenEd,  and  ths 
section  ie  as  llirougb  a  fitructure  resembling  the  pitrsiatO'  Ou  sijufei- 
ing  Lbi!  jirontQliJi  ils  Be<:relion  is  seen  lo  i&aiie  ibrough  euvernl  aporturca 
on  each  J^ide  of  the  urethra,  where  the  prostaiiu  eiuus  usually  exists. 
There  is  eo  venuDontanum ;  but  where  iL  should  be»  and  where  the  aiuus 
pocularifl  would  be  foundf  the  urethra  and  vagina  blond,  and  a  probe 


HEB«ArjTR0Dl8M. 


315 


maerted  uml  pnsaeil  bzirkwartla  cii!frs  \\\e  vnglna  ;  papspj  forwanle,  it 
nppours  extermilly  at  the  orifit'e  in  iVont  oi'  fUe  nnua.  llehirid  the 
bliulcfpr  are  found  the  titenis  tuid  viigma..  On  dlsi^t^t^frng  up  the  hlnddt^r 
froru  ihb  vngina,  as  fur  djwu  as  the  proeUkLc,  do  vesiculic  acrnmales  are 
to  be  foQUti 

^Tfae  uterus  and  vagina  are  5J  inches  in  length.  The  uterufl,  2^ 
inches  long  ami  1^  inrh  wide  at  its  widi-'ft  jinrL  f^iiHist*  of  ruiid]i9, 
bodv,  npck,  nnd  os.  The  m^ck  lin?  uninsuiilly  well-marked  aibrir  viloj. 
Jusi  williin  Ihc  05»  the  mucoua  munihriine  npfn^nre  abraded.  The  body 
has  a  trinn^lar  cnvity»  into  wlii'-h  the  Fiillopmn  iiilw»9  tnier  by  large 
erifloL'S-  nie  vngina,  .'^  inrh«,i  long  jirul  Ij  hicdi  widti,  ia  ru^oiia, 
eapedally  near  its  lerminalion  anLtriorly,  ord  liaa  disiincl  tolumna. 
AuterioiLy  it  contraclB  to  turminaic  ia  the  eontiE  ofHiLinon  to  it  and  the 
urtihra,  uDit  nt  ihis  ^oIdI  hns  a  sulHL-icuily  vretl-marker]  hymen. 

"Till:  Falliijiiikn  lube  uf  the  n^hl  dule  prnaji^  uirto  he  hluwn  through 
itfl  whole  Icfi^lh.  Near  ila  inrmi nation  in  a  fimhrialed  cxtrcmityi  it 
htii-ome^  a  little  convcluted  anil  dilated,  iLs  Length  ia  3J  inches.  At 
a  dimanre  nf  '2\  ineEie^  fTom  ihe  iiIt'niKf  on  the  ]e(i  side  and  in  its  dsuhI 
poAiiiou*  ia  ibii  ijvary  »ilh  a  lubulatt'd  auiTacep 

"  The  broiid  Ij^unent  na  cai'h  side  e^iats  as  in  an  ordinnrj  female 
uterue^  On  tho  left  side,  (he  ruund  ligament  i^  to  be  M3on  diverging 
frrjro  iIhi  Uro»d.  juid  pun*iiing,  sii  fnv  oA  lrnc('iihlu»  ihe  iisnal  eoiiree 
whidi  it  would  put-sijij  uudtr  ordinary  ncalomk'ol  £.'oniil(i>nn.  On  tho 
right  eidu,  the  Fallopiaa  tube  ndnits  the  passage  of  air  only  for  a  cer- 
taiu  dlsianc'e.  N&arll}e  uEerua,  it  is  of  large  size  ;  hut  it  soon  dimioifibes 
and  hecomuB  dEnallur*  It  'us  tracL'ahle  to  Ihe  (loiut  at  which  ihe  *eord' 
of  ibo  tumor  W[i3  divided,  and  ia  acctjmpnnicd  by  ihc  round  lignracnl  in 
its  whole  distanee  ;  uo  appearance  iodicating  the  usual  divergem^e  of  It 
frnm  the  Fallopian  t\i\te  on  ihe  anterior  siirfaee  of  tbe  broad  lignmant- 
No  ovary  ia  fbajid  on  this  aide. 

"The  reclum  lies  bohind  ibo  ulorus,  and  is  in  all  irapcets  normal." 

Dr,  Ellis,  raicroscopist  tf>  tlie  Hospital,  gives  U9  tlie  follow- 
ing reeiiiifl  of  his  invoeti|ritioa  :  — 

**  Exiimined  witli  the  luicrosfope,  llic  breaate  were  found  to  be  com- 
posed of  lihmus  tifsnt,  nnd  a  t'nw  Bmall  nuclei.     No  lobuk'S  wtre  aeen. 

**Tlie  masd  reinovod  before  dealh  ronsialed  of  two  jiarUi,  the  largest 
of  wliidi  wa.^  rounded  and  ftuhd  ;  ibe  ulher  was  c?*iDfH>»cd  of  cy^\s.  The 
former  vvua  4^  biijlita  long,  '^\  wiJi?,  and  'J(  thick;  Ihe  Inll^p,  two  or 
three  Incdiea  in  diaioerer-  On  c'ioee  examitiation,  nuiUing  like  a  vaa 
defercaa  euiiJd  be  fouud ;  bnl  at  out!  part  were  a  number  of  puridlcl 
blood  veut^b*" 


316 


FF^MALE  QENTTO-UBIKAnT  OBOAKfi. 


Mtmarhs,  —  The  iiitcrnnl  or<;jnTifl,  in  the  fmHC  wc  havo  been 
considcria^,  accm  evidently  to  btltm-^  to  tlic  female  ecs,  with 
the  exception  of  the  pi^oetate  glunJ-  The  iinpoitant'c  of  diia  ua 
connected  witb  the  mnle  acxuol  Gr;^na  has  diminished  in  ibe 
eyc8  of  diatinguishcd  piiiloeuphical  anatcmii*td  who  have  lately 
writtca  on  the  tiuhjectt  bcin^  coneiderod  ad  much  an  nppemliige 
to  the  urinary  organs  aa  to  the  sexual.  We  therefore,  with 
aonic  difficulty,  account  fi>r  the  impttut^  given  to  the  external 
mide  organization,  heard,  larynx,  peni?,  and  general  niaseuline 
formation  of  the  body  \  and  the  viewa  we  have  entertained  iit: 
regard  to  the  eft'ect  of  tl»c  sexniil  organ^^  on  the  cxtcrnjJ  charae- 
tor  aeem  to  be  very  niueh  diaturbeJ  by  the  proeent  cneo.  It 
mi^lit  be  very  interesting  to  truee  tbc  nnalogiee  between  dift brent ' 
organs  in  the  male  ftud  Pcmule  Byetcnw,  which  are  euggcatcd  in 
this  instance  ;  but  we  will  i"cfer  to  the  very  thorough  and  inter- 
esting paper  of  the  distiiiguialied  Profeasor  Simpson,  of  BdiiL- 
burgh,  on  hermajihrodiaia,  in  the  second  volume  of  bis  obsletria 
works,  edited  by  Dr.  Pricatly  of  Edinburgli,  and  Dr»  Horatia 
R.  Storcr  of  Boatoni  where  this  whole  subject  has  been  moiA 
fnlly  elaborated,  and  we  may  almost  aay  cxhauetcd. 

In  connection  with  the  above  caae,  I  append  the  following, 
reported  by  me  to  the  Boaton  Society  for  Medical  Improvement, 
in  May,  18a7,  and  extracted  from  their  records  ;  — 

"The  Riihject  oflhis  very  nneommoa  deviaiion  from  naiure  was  25 
yenra  of  nge,  bora  in  Maine,  of  healthy  paronle.     He  was  by  oecopa- 
tioQ  vt  aailor;  Jind  ihc  aptieurancGH  to  be  iJodczrlbcU  weit^  only  dj^ovot-ed 
whca  brought  to  the  prison,  where,  or  being  undresat*!  to  put  on  thftj 
pHsoLi  elulherL.  lie  w^s  ilioLj;^ljt,  froni  Lhi:^  lur^e  &i/e  of  tht  brcoslN  Co  bm] 
a  female  in  did^uise,  and  wa.'^  tlicrefurti  Li^aQafcrrcd  to  iho  surgeon 
cha  institution,  Dr.  Morris,  for  extmiiimEion-     On  my  visil  to  hi£  eel 
he  seemed  to  have  nn  objeelion   Lo  an  examination,  when  it  vras  e: 
plained  to  him  tli^t  it  WLts  for  a  edealific  object. 

"Beginning  with  the  iaee,  the  fcaturoB  aro  i^oEl.  and  the  osprofiBJoa 
mild;  thpre  ia  no  lii*ard.  Tlie  nenk  is  of  medium  ^xtx  and  length,  but 
rising  tovhujd  tlii;  huc'k<  as  iu  tht;  f^nm^c.  The  shoulders  are  tdoplug, 
round  and  smoolh,  the  lausdea  not  beiug  prominent.  Th^  upper  ex- 
tremities are  ilelicate,  and  llio  hamls  t^miLlL  Tlio  breastB,  which  ar<s 
th&  nichit  striking  fii:tiiJre  in  (hia  peraon^  are  large,  nroM-dtvelopEd  tivt^n 
fbr  a  fomal^T  quite  handsomely  formed,  with  large  blue  velna  rtinning 


HEBHAFHBODTBU-  817 

overtheoa,  ha  in  &  nursing  woman ;  the  nipples  being  largef  wttb  a  broad, 
dark  areola-  The  abdomen  is  quite  prombenc;  ihenavddeep;  the 
hipB  very  broad,  aa  in  the  female.  There  is  a  small  penis.  The  scrotum 
and  teslicles  are  very  small,  the  size  of  the  latter  being  that  of  a  bean. 
The  logs  are  short,  the  middle  of  the  body  beings  by  measurementf  half 
way  between  the  umbiliuus  and  the  pelvia,  instead  of  being,  as  in  the 
male,  at  the  pubic  region.  The  voice  is  maaculliie;  the  sexual  propen- 
siUes  normal. 

*^  Tbe  remarkable  feature  of  this  case  la  the  fact  of  the  small  male 
organs  of  generation  impliinted  on  a  body  almoet  entirely  female.  Cases 
constantly  present  themselves  to  the  observation  of  medical  men,  of 
malformed  genital  organs^  hHving  the  appearance  of  a  combination  of 
the  male  and  female;  also  of  men  with  a  large  manamary  organ-  In 
this  case  there  can  be  said  to  be  no  malformation." 


CILiPTER   VIII. 


THE      EXTREMITIES. 


FRACTnilES. 


The  great  impcrtnnco  of  these  injtiriea,  and  the  absolute  ne- 
ceeaity,  in  most  caaea,  of  proper  treatment,  have  given  them 
a  very  prominent  place  in  the  surgery  of  nil  nrres.  From  the 
enilieat  times  of  wliich  we  hjive  any  record,  down  to  [he  present 
dfty^  the  trentinent  has  been  oaeillating  between  the  employnient, 
on  the  one  hund,  of  powerful  eng'inea  for  their  reduciion  and 
retention  in  place ;  and,  on  the  other^  <if  simple  rest  in  an  oflsy 
position.  Both  of  those  evEreme  modes  of  prncLice  bave  l>een 
exfensively  employed  within  the  past  thirty  yenre,  and  Loth  bave 
undergone  grent  improvements. 

In  my  early  pracike,  I  was  in  the  habit  of  Inying  great  stresB 
on  an  immediate  nnd  exact  application  of  retentive  measures  t 
often,  I  Tioiv  think,  to  the  discomfort  of  the  patient,  urid  per- 
haps in  deference  to  the  prevailing  opinion.  1  have  since 
become  convince"]  of  the  propriety  of  dning  as  little  as  posaible 
ffjr  the  first  few  days  ;  and  have  generally  been  content  with 
nijikintr  a  sUirbt  e^ttenjJiion,  so  as  to  brina;  the  broken  ends  of  the 
bone  to*retber  so  far  as  they  wjII  come  without  violence  ;  then 
wailing  until  the  irritabiJity  of  the  muBclea  Las  subsided,  befora 
proceeding  to  the  application  of  the  permanent  apparatus  of 
splints  nnd  bandages.  In  many  fractures,  wliere  great  immediate 
tJiatortion  is  produced  by  muaculur  contraction,  after  a  few  days 
of  rest,  combined  perhnps  with  gentle  extension,  the  broken 
boQca  seem  <juietly  to  settle  down  into  their  proper  places  ;  and 
the  whole  treatment,  sifter  the  proper  upplieimon  of  splints, 
resolves  itself  into  careful  watcliing,  with  occasional  slight 
mnnipnlationa  to  remedy  accidental  diaplncements,  and  to  prevent 
excoriation. 


FRACTITRER- 


31*1 


Professcir  Tlflmilton,  of  New  Ywk,  by  ihe  ediibitior  of  a 
greal  number  of  cnses,  treateil  with  the  best  received  jippflriiius, 
Ims  laid  the  profession  under  great  obligaiionflT  by  showing;  that 
the  perfect  iwlnpl:Ltii3n  of  broken  bone,  and  n  cure  without  de- 
formity, is  the  exception,  nnd  not  the  nile.  To  any  one  who 
takes  a  rational  view  of  the  question.  It  will  easily  be  perceived 
that  it  18  not  the  bone  nlone  which  is  injured  in  cnsea  of  frac- 
tutx? ;  but  thiLt  the  soE\  parts,  auch  ae  periosieunii  must^leSi 
fiuctA,  ami  integuiuenC,  are  more  or  le^i^  implioated.  Swelling 
ensues;  and,  even  if  it  were  possible  to  exactly  discover  the 
siluaiion  of  tlie  fnictured  ends,  the  manipulation  is  reaiateJ  by 
the  patient.  £[her,  wltich  of  lute  yeur»  has  nsttisred  ao  much 
in  die  dla^osls  of  these  coBea.  ie  not  alxvays  at  hand;  and, 
evon  if  the  bone  is  replaced  with  its  assistance,  displacement 
may  at  once  recur  from  the  Irritated  musclcB.  Generally 
fipcaking,  a  sliirht  inequiLlity  about  the  bones  is  of  little  conae- 
quence.  AJthouffh  looked  on  hy  the  public  a»  owing  to  a  want 
of  skill  on  the  part  of  the  surgeon,  it  is,  in  reality,  unavoid- 
able ;  and  ultimately,  jp  moat  cases,  nalure  remedies  any  incon- 
venience caused  by  it. 

Fractures  in  the  nejghhorhooil  of  joints  are  always  senou3  in- 
juries ;  and^  with  few  exceptions^  are  apt  to  be  followed  by  more 
or  less  permanent  deviation  from  the  natural  position  of  the 
bone  or  bonce  implicated.  In  fractures  about  the  hip-joiut, 
years  may  elapse  before  the  lameness  is  overcome;  and,  in 
many  ca!?ea,   it  is  permanent. 

It  ia  impossible  to  state  exactly  the  time  necessary  for  the 
union  of  a  fractured  bone.  It  depends  on  a  number  of  circum- 
Bianccs  ;  namely,  the  health  of  the  patient,  the  manner  in  which 
the  fracture  was  received,  the  pnria  injured  which  are  ntterwatds 
en^a^ed  in  the  reparative  pnxx^s,  and  the  treatment.     In  chil- 

Idren,  nt  the  end  of  a  month  after  fracture,  I  have  often  observed 
myaelf^  and  requested  others  to  observe^  perfectly  dry  crepitus 
tliat  could  be  felt  between  the  broken  ends  of  the  bone ',  the 
limb,  at  the  seat  of  the  fracture,  being  Hrm,  and,  to  ail  appear- 
nncesr  able  to  be  used. 
Angular  distortion  after  fractures  FihouM  be  treated,  as  soon 
as  discovered,  by  gradually  increased  preASure,  applied  by  meona 


320 


KXTIfEMITIES. 


of  a  *trflip;ht  splint  nnd  roller,  or  nJhcaive  atrnps.  It  Js  worthy 
of  remiirk,  that  very  grcnt  deformity  may  be  corrected  in  ihU 
vray  in  young  persouflT  ^VQ^  lorig  Mftei"  the  receipt  of  the  in- 

Fnicture  of  the  clnvit^le  is  pcchnps  one  of  the  moat  comraon 
of  the  injuries  to  bonee*  and  is  one  of  the  most  troublesome  to 
treat  according  to  the  old  eomplioflted  method.  Miiny  years 
since,  the  simple  npparritng  of  Dr.  Foic,  of  PhiWelphia,  was 
intnjducL'd  by  me  into  the  Massncluieetts  General  Hospital, 
where  it  cominuc;)  to  he  used  with  some  sliijht  modifications. 
It  consists  essentially  in  a  pad  for  the  axilla  nnd  a  bag  for  the 
arm  elung  from  the  well  shoulder.  Many  eases  of  this  fracture 
do  well  without  eapeeial  trentment ;  and  we  often  see  it  already 
in  a  fair  way  to  recovery  in  ^'Inldren  broii^lit  to  na  for  supposed 
lameness  of  the  shoulder,  resulting  from  a  fall  a  week  or  two 
before. 

Frequently,  from  the  swelling  of  the  soft  parts,  the  cellular 
jnciubrnne  in  the  neighborhood  oi'  the  clavicle  being  very  loose 
nnd  extensible,  it  is  almost  impracticable  to  discover  the  frag- 
menU.  By  placing  the  patient  on  his  back^  with  perhaj>a  a  pillow 
between  the  siionlders,  ns  the  swelling  subsides,  the  frngmenls 
will  generally  L>e  fuund  to  hn^c  assumed  as  good  a  posltioa 
SB  they  would  have  done  with  the  most  elaborate  apparatus.  In 
comminuted  fr.ictures,  the  central  fragment  or  fragments  are 
usually  beyond  our  couItoI.  In  one  inatanee,  I  have  fleen  a 
shar|>  piece  of  the  bone  st^inding  at  a  right  angle  between  the 
outer  oncfl^  wliicli  could  not  be  displaced  by  any  justifiable  force, 
nnd  threatened  to  make  its  way  through  the  integument.  This 
was  prevented  by  means  of  adhesive  plaster,  npplied  in  such  a 
wnv  as  to  bring  different  portions  of  akin  suceessively  over  it, 
nnd  thus  too  long  pressure  at  any  one  spot  prevented-  The 
eluirp  point  w.aa  nltitnately  partly  abaorbeJ,  and  partly  efl- 
veloped  in  the  callus  ;  and  the  patient  recovered  perfectly,  with 
the  exception  of  a  very  slight  irregularity  of  the  bone.  The 
reeulta  of  fracture  of  the  clavicle  arc  almost  always  favorable. 
In  the  very  large  number  of  caees  which  have  come  under  my 
notice,  r  have  never  known  union  to  fail  e?ccept  in  one  instance, 
—  thiit  of  a  sailor  severely  injured  at  aea  by  a  fall  from  a  maat, 


PRACTCBEB. 


32L 


imd  not  subjected  to  trcntmcnt,  the  blow  being  a  direct  one  at 
the  Bcat  of  fracture.  The  ordmnry  obortening  wltich  occurs 
after  thia  fracture  doea  not  accm  to  iiupftir  the  power  over  the 
arm. 

The  diag-noeis  in  fracture  of  the  con<IyIcfl  of  tlie  humcrua, 
with  dislocation  of  the  foi-c-ann  bwckwanlfl,  or  Sn  fracture 
of  the  humerus  just  above  the  elbow-joint,  in  the  adult,  is  ren- 
dered very  ubscurc  by  the  swelling  whjth  almost  immediately 
cnsuea.  The  foi'c-arui  may  uaiially  be  ca::Hily  drawn  into  place, 
and  the  injury  thua  di^tinj^r'uUhGd  from  a  eimpio  dislocation. 
Splints  are  borne  with  ditticulcy  ;  and  it  h  nccesaary  to  keep  the 
patient  ju  bod,  with  the  arm  rcs^tinf^;  on  n  pillow,  nnd  apply 
cooling  lotione  to  reduce  the  inliammntion.  When  this  is  ao- 
compUdiod,  angular  Bpiitita  of  wood»  guKn-pcrcha,  or  paatc- 
boarj,  may  be  used  to  steady  the  joint.  ThU  fracture,  under 
the  beet  trentiticotf  is  apt  to  tcriutuatc  ^vitli  more  or  Ic^s  loss  of 
power  to  flex  and  rotate  tho  fore-arm.  Ultimately,  however, 
very  serviecaLle  uhc  of  the  limb  may  be  gained.  The  injury 
uaually  occurs  from  a  dii"cet  blow ;  and  the  inflnramntion  of  the 
Boft  porta  in  the  neighborhood  of  the  elbow  is  more  acvcre 
than  in  aimi>le  dislocalion  which  rcpulta  from  iadireet  violence. 
Fracture  of  one  of  the  condvlea  of  the  liumoriirt  into  the  clbow- 
joiiii  ifl  very  apt  to  Im  foUo^vcd  by  aillic^iona  ami  lose  of  motion. 
When  there  ia  lujtjUion  of  the  joint,  in  addition  to  the  fracture, 
BpUnls  beeome  necessary;  but  ahould  be  removed,  and  passive 
motion  begun,  as  soon  as  the  tendency  to  displacement  la  over- 
come. 

Fracture  of  tho  lower  end  of  the  radiLS,  which  ia  of  so  fre- 
quent occurrence  in  winter^  from  a  fail  on  the  honil,  ia  apt  to 
be  followed  by  deformity,  and  impairment  of  the  motion  of  the 
part.  1  have  treated  tliia  fracture,  in  many  cases,  with  the 
simple  ond  Jngenioua  spliut  invented  by  Dr.  Henry  Bond,  of 
Philudelplua.  For  facility  of  application,  as  well  as  for  tho 
comfort  of  the  patient,  it  appears  to  tne  to  otlbr  im])ortant 
advanta^  over  any  hitherto  invented  :  not  excepting  the  fa- 
mous piBlol-abnpcd  splint  of  Nfkton,  which,  however,  in  some 
caeca  perhaps,  may  be  found  very  useful,  ca^iecially  in  those 
attended  with  much  lateral  displacement.    In  Dr.  Bond'a  Gplint, 

41 


EXTEEWTTIES. 


Ac  hand  grasps  n  wonden  jjfld,  the  fint^e  beir»g  left  froo  during 
the  treatment,  txtal  suihcicut  mtftiun  jtlluwcU  llicm  to  prevent  llic 
etiffnesfl  which  is  npt  to  take  pJnoe  where  the  crm  ain>  hand 
cro  confined  by  brtiidnp;e3  between  two  epUnta. 

Fracture  of  the  lower  third,  or  email  part,  of  the  lep,  is 
often  diffieuU  to  manaj^'e,  «winj;  to  a  projection  of  the  tibia 
which  occure,  attended  with  more  or  Ices  dcvlaticm  of  lie  leg 
irom  a  elnu^jlit  line;  giving  rise  oceiLeioiinlly  to  lamenc&fl,  by 
rcBtricting  the  ran^re  of  dexion  of  ihe  ankle-joint.  This  devia- 
tion is  best  avoided  by  placinf^;  the  limb  upon  a  double  inclined 
plnnc,  ajjplj'in*;  extension  and  counter-extenaion  by  meane  of 
adhesive  fitrupa,  faetened  above  by  upright  Btanchiona,  connected 
Tvith  the  leg  part  of  the  nppiiratus,  itnd  below  to  the  foot-piece. 
Where  the  akin  is  tender,  ondobnoKioue  to  pressure,  jsuepeneion 
may  be  tried;  the  foot  bein^  well  elevated,  Thia  fracture  may 
aJso  be  saeceflsfidiy  irentod  liy  the  starched  or  }>lafitcr  bandage. 
A  slight  decree  of  deformity  ia  almost  always  left  where  the« 
hoA   been  diephicenient  in   the  bcpnning. 

For  fracture  of  the  fibula  near  the  anlde,  with  displacement  of 
the  lower  fra^'nieut,  the  powerful  aide-^pJint  of  Dupuylren  fill-. 
file  nil  indications- 
Transverse  fracture  of  the  pritellaT  attended,  as  it  often  h,  by 
great  aeparation  of  the  frjif^ments,  may  be  moat  flnccesafiilly 
treated  by  position  alone.  Thia  1  tried  at  fir^t  with  the  body 
elipfhtly  bent,  and  the  limb  raifled  at  a  ^Tcat  an;;le  fixjiu  the  bed- 
Tbe  eflfect  of  flexin*,'  the  thi^'h  i^o  tnucli  waa  to  render  the 
patient  very  uncomforlable.  I  waa  therefore  led,  aa  an  ejtperi- 
mcnt,  to  place  the  hmb  perfectly  flat  on  the  bed,  which  1  found 
answered  better  than  the  theoreticul  posture  devised  with  the 
idea  of  mare  perfect  muscular  rela^Lation,  The  old  methods' 
for  confininj^  the  upper  frajrment  by  bandages  are  jdwuye  ineffi- 
cient, ucleps  aided  by  a  correct  position  of  the  limb,  and  nre 
Tiaelcas  with  it.  They  give  riee  to  great  swelling  and  mucb 
necdleHe  sufferinp^,  besides  oetually  dernn;;inii^  the  position  of  tho' 
fragmente  by  ao  tilting  them  as  to  prevent  their  pmpci:  approx- 
imation. By  the  u*e  of  the  ingenious  ateel  hooka  of  Malgaignc, 
it  \s  claimed  that  a  still  more  necnrale  adjustment  of  the  pirta  ia 
obtained ;  but  the  plan  has  found  littlo  favor  in  this  country. 


FEACTHRB9. 


323 


The  inatancea  cf  this  fracturi?  ^vl^ic^l  have  occurred  ia  ray  prac- 
tice have  been  chiefl/  liic  rcf^ull  of  direct  violence,  though  quite 
a  irnmbcr  of  them  were  cimscd  by  tuuactjhir  contrnclion  done- 
Twice  I  have  met  with  fracture  of  the  patella  from  the  kick  of 
a  horac ;  one  case  did  well  under  the  use  of  a  starched  bandage, 
there  ht'ing  but  little  scpiiration  of  the  fingmcntJi ;  'ii\  the  other, 
the  banc  was  broken  into  acvcral  pieces,  and  the  knec-joiTit  im- 
plicfltcd,  prmliit'ing  an  inflammation  which  retiulted  in  death, 

Trjuiavcide  fracturea  of  tlie  patella  are  united  by  li^;uncQt, 
acconhng  to  my  obaervation,  aod  perpend icu Jar  onea  by  bone. 
The  latter  leave  no  troublesome  crt'cctfl  as  a  rulci  the  opposite 
being  true  of  the  former* 

Fractures  of  the  thigh  of  late  years,  unless  for  eome  epeeial 
rcodon,  have  been  treated  by  the  apparatus  of  Deanult,  modified 
by  the  late  Dr.  Flagg  uf  thic^  city.  It  conaldte  eancntially  of  a 
lung  outride  and  a  ^hort  inside  splint  x  a  band  around  the  bodj 
with  a  periacjd  sti^ap  attaclLcd  to  it,  fur  co u a ter-ex tension,  and 
a  croes-piccc  hclow,  uniting  the  outer  and  inner  splints,  with 
straps  of  adhesive  plaster  between  for  cxtenAiun,  The  inechod 
of  cxtenaion  by  banda  of  adhesive  plaster,  by  whicb  auch  good 
results  are  ohtaincdi  la  due  to  Dr.  Joeiiih  Crosby  of  Mandies- 
ter,  N,[I.  I  have  employed  euccetisfiill/  at  tlie  Hospital, 
within  a  few  years,  as  have  other  surgeons  of  tliat  inatitutjon, 
the  plan  proposed  by  Dr»  Buck,  of  extension  by  meanH  of  a 
weight  attached  to  tlie  ibot ;  the  thigh  being  supixirtcd  by 
ehort  padded  epluita,  and  thu  counter-extension  ohtiuiied  by  a 
periuenl  strap.  By  raiBing  the  foot  of  tlic  bed,  the  weight  of 
the  paticnt^a  body.  In  most  inatanoea,  gives  sufBcienC  cotinter- 
cxtcnaion.  Dr.  tiwinbumc,  of  New  York,  has  modllicd  Dr. 
Buck's  apparatus  by  dispeneiug  with  the  use  of  all  splints  tor 
the  thigh.  Evcrsion  is  prevented  by  placing  bags  of  aand 
by  the  side  of  the  limb.  The  great  advantage  of  this  treat- 
ment consist:^  in  leaving  the  lunb  open  to  inspection.  It  must 
be  flaid,  however,  that  we  can  use  this  method  only  with  in- 
telligent and  perfectly  docile  patients.  In  very  old  and  feeble 
|Ksreons,  who  frc^jucntly  cannot  hear  even  this  eligbt  restraint, 
the  double  inclined  plane  or  tractnrc  bed  arc  to  be  preferred  to 
any  other  apparatus,  and  permit  a  greater  change  of  posture* 


3S4 


EXTttEMlTIKfi. 


I  have  fleen  a  few  cn§e3  of  oblique  fracture  of  the  lower  part  of 
tlie  fetintr,  just  sbuve  llie  camlyles,  cfLiised  by  a  ?a\\  from  ft 
lici^lit,  iiii  (lio  knee;  the  upper  fni^nitTil  pnijectiu^'  up  juBt 
above  the  joints  and  reaifiting  all  e^orts  for  its  reduction.  This 
wiis  the  result  of  perfuralion  of  ihe  muscles  bv  tJiK  upper  sharp 
fragment.  In  Sir  Astley  Cooper'e  grea.1:  work  on  iJialocationa 
ard  Fractures,  this  is  well  depicted.  The  process  of  restora- 
tion goes  on  very  slowly,  and  the  result  is  that  the  fragments 
unite  »t  iin  nngle.  It  is  po^aibler  when  the  nature  of  the  t^ase 
IB  detected  early,  that  the  bone  inio;|]t  he  disengaged  by  man!* 
piilaliane  under  ether;  but  the  swelling  caused  by  ihe  injury 
ensues  so  nipitlly,  and  U  eo  gi-eat,  that  the  exact  condition  of 
the  parts  is  liable  not  to  be   reoognized. 

In  oblique  fractures  of  the  femur,  except  perhaps  in  very 
young  children,  more  or  less  sliortening-  always  remains,  even  un- 
der the  most  skiiful  treatment.  It  ie*  however,  generally  so  slight 
na  to  be  of  but  Itttte  consequence,  frequently  not  exeeeding  a 
quarter  to  a  half  inch  ;  In  which  case  k  is  compensated  for  by 
a  deviation  of  the  pelvis.  The  lime  rerprireil  for  the  union  of 
a  fracture  of  the  thigh  is  usually  HtntL>d  at  six  weeks ;  but  it 
does  not  follow  that  the  callus  has  Income  firm  enough,  by  this 
time,  to  udmit  [>f  the  use  of  the  limb  in  stamlin^  or  walblntr. 
The  too  early  use  of  a  frjtetnred  limb  is  often  followed  by  the 
gi-aduid  bending  of  tlie  bone,  resulting  sometimes  in  conaider- 
able  dpformiiy.  If,  for  any  reaflon,  il  is  thought  proper  to 
allow  the  patient  to  rise  frrrm  bis  bed  at  this  stngc  of  the  trent^ 
ntent,  the  liuib  should  be  aupjiorted  either  by  splints,  or  iha 
fitarchsd  or  planter  bandage,  mid  crutches  ueeil  for  a  time. 

Patients  with  fracture  or  dislocation  of  the  Bpine,  the  latter 
helng  seldom  unaccompanied  hy  the  former,  I  have  often  treated 
in  public  and  private  practice  ;  and  have  a  few  times  cut  down 
upon  and  removed  fnictiired  and  di.splaced  pieces  whicli  were 
pressing  upon  the  spinal  eord.  In  one  instance^  —  a  man  wbose 
neck  was  dislocated  from  being  auddejily  and  forcibly  bent  down 
by  striking  agjiinrtt  a  beam,  while  passing  into  a  sbcd  on  the  top 
of  a  load,  —  a  temporjiry  reatonition  of  innervation  was  jirodueed 
by  making  tractions  on  tbe  liE^ad,  by  which  tlie  dialocatiou  was 
reduced.     After  thie,  the  patient  waa  placed  in  bed,  the  Leocl^ 


FH  ACTITRES . 


325 


of  it  "beinjT  raisec! 


form  an  mclined  pL 


ith 


Btron|T 

hxn<X  uiirlci"  bis  chin.  He  died,  however,  with  the  usual  eymp- 
tomfi  atteodlng  thU  accident-  I  do  not  remember^  out  of  quite 
a  ]nr*ro  number  of  ihese  injuries  thai  Lave  fallen  under  my  ob- 
eervaiion,  a  sin|T|e  axse  that  nas  benefited  by  any  o[)er]itive 
procedure.  It  may  poaaibjy  be  the  case,  that  this  bus  been  too 
much  neglected  of  late  years  from  tlie  want  of  EUCcess  attending 
the  operation.  An  insfsince  may  oecur  now  and  then  in  which 
an  operation  iiiigltt  re^uU  bappiJy.  The  suhjeet  haa  recently 
excited  coneiderable  discussion  abroad. 

Of  modern  npplinncos  for  the  Ireatiaenl  of  fraeturefi,  the 
ftfarfhed  bnnda;re  of  Seulin,  or,  still  better,  tlie  dextrine  band- 
age of  VelpGfiu,  or  the  plaster  of  Parla  apjxiratiu,  ore  among 
the  most  important.      There  are,  (n   fact,  but  few  fractnrea 

in  which  thev  are  not  useful  at  some  stam^  of   the   treatment. 

■  o 

In  simple  fractures,  where  there  is  not  much  injury  of  the  soft 
parts,  the  bandage  may  often  be  applied  with  advantage  im- 
mediately upon  the  receipt  of  the  injury.  In  other  cases,  it 
is  necessary  to  wait  nntU  the  ewelling  and  inflammation  have 
subaided.  After  union  has  been  ejected  by  the  use  of  other 
appIiimL-es,  the  starched  or  dextrine  bandage  is  very  useful  in 
supporting  the  nowly  formed  callus,  and  guarding  the  limb 
agikiui^t  accidents  when  the  patient  leaves  hia  bed. 

The  application  of  these  bandages  is  very  simple,  A  dry 
roller  of  old  linen  or  cotton  is  first  ap|tlied,  to  prevent  adhesion 
of  the  bandage  to  the  skiO'  A.  common  roller  is  to  be  dipped 
in  the  adhesive  liquid,  either  starch  paste  or  solution  of  dextrine, 
and  is  then  to  bo  applied  to  the  limb  in  the  ordinary  manner, 
taking  care  to  make  as  few  reverses  aa  possible.  The  dextrine 
solution,  which  may  be  made  in  part  with  alcohol,  driea  sooner 
than  the  starch,  and  make^  a  firmer  ca^^e  wilh  the  tiume  tiuok- 
ness  of  roller.  If  starch  i^  used,  the  whole  should  be  strength- 
ened by  strips  of  wet  pasteboard,  placed  on  the  outside  of  the 
dry  roller,  before  applying  the  fctiirchwl  ono- 

The  plaster  apparatus  consists,  first,  of  a  soft  dry  roller  or  a 
thin  layer  of  cotton,  applied  next  to  the  skin,  and  covere*!  by 
a  second  roller,  wet  with  water.  The  whole  bandage  is  then 
covered  with  piaster  mixed  with  water  to  tlie  consii+tent^y  of 


326 


EXTREMITIES. 


thick  crcnni,  and  confined,  if  necessary,  by  another  roller.  The 
aurruce  of  thie  may  be  smoothed  with  a  little  more  plaster,  ajv- 
plit:d  vrith  the  palm  of  the  hand,  and  the  whole  apparatus  com- 
pleted by  a  coat  of  ehelluc  viimtEdh,  This  appnrntitB  ia  easily 
applied,  and  becomes  perfectly  solid  in  the  eourec  of  tlic  short 
time  required  for  its  application.  The  platter  ehtmld  not  be 
wet  until  the  moment  it  is  to  be  used;  and,  if  it  still  Mta  too 
quickly,  a  little  alum  water  may  be  added. 

The  etarchctl  bundn^^^  may  be  emplnycd  with  grent  benefit  in 
those  vexatious  And  often  unmanageable  injuries,  —  apraina  of 
the  ftriklc  ;  thus  allowing,  in  some  cases,  of  locometioTi  at  OTiec, 
whcro  n  tedious  confinement  would  be  necessary  under  other 
treatment,  I  have  alao  employed  it,  for  the  purpose  of  com- 
presaioQ,  with  cxecllcnt  reaulta,  In  that  very  trouhlcsomo  dJscaae, 
milk  absceas* 

Case  CliXXXVl.  —  Fracture  of  the  Malar  Bone. — 
1861,  A  gentleman,  walking  iu  State  Street,  was  run  against 
by  a  drimkcu  man,  who  atruek  him  on  the  aide  of  the  fuec  with 
hia  head,  fracturing  and  eftuaing  the  depression  of  the  cheek- 
bone. I  saw  him  immediately  after  the  nceidcut.  He  eaid  that 
he  felt  at  the  time  ne  if  he  Eiad  received  a  blow  from  a  hammer. 
The  malar  bone  I  found  broken,  and  the  external  portion  drirCTi 
in,  and  firmly  fused.  1  made  an  effort  to  raise  it:  firat,  by 
mani[)ulntions  on  the  outside  ;  and  afterwards,  by  ]jnssing  the 
fingers  into  the  mouth,  and  forcing  them  up  under  the  zygo- 
matie  arch.  Failing  in  Uiia  attempt,  a  wooden  spatula  who 
pressed  up  in  the  same  way,  as  Far  as  it  would  go»  and  an  effort^ 
made  to  pry  the  bone  into  place.  The  effort  woe  ineflectual, 
ati<l  the  bono  did  not  eccm  to  yield  In  the  least.  I  thereforo 
ndviacd  the  application  of  an  evaporating  and  anodyne  lotion 
to  the  face;  and  asked  him  to  report  himself  to  rae  again  in  a 
wcok,  ofl  be  lived  out  of  tov^.  At  the  and  of  that  period, 
1  f'iuD<l  tlmt  he  bad  ]>rotty  much  recovered  from  the  soreneaa 
produced  by  the  blow  :  but  the  depression  of  the  bone  aiill 
continued. 

I  had  oecaaion  to  ^ce  this  patient  for  another  aecident,  nearly, 
a  year  after  the  date  of  this  injury ;    and  found  the  face  quiti 


FHACTURES, 


827 


well,  ftnd  the  irrejriil^rit/  of  the  >>oiie  <?om|jletel7  oblitovntod. 
The  pnlient  informod  ine  that  he  hnd  experience  J  no  interference 
either  in  the  mu^eular  or  nervous  apparatua  of  the  fiiee.  The 
orhit,  iQ  Chlfl  case,  was  not  ap{>irently  implicated  in  the  fmc- 
ture. 

In  a  BimilAr  case,  which  occurred  about  the  same  time,  the 
flccitlent  being  produped  by  a  blow  of  the  fiat,  nnd  in  which 
T  irnde  the  same  efforts  to  reidnce  the  bone,  but  without  efleet, 
the  nltiinate  result  wivs  the  same.  So  Jlir  its  T  kii[>w,  thU  im  the 
u?iinl  history  of  those  cases  ;  JLltempta  nt  ropliiceinent  being  in- 
effectual, and  the  results  generally  favorable. 

Ci^E  CLXXXVn. — Fracture  and  Depression  of  the  An- 
terior WaH  of  the  Superior  Ma^eillary  BoTie,  with  the  Malar 
Bone.  —  The  following  is  the  only  instance  I  have  iieeo  of  this 
uncommon  ncc^ident.  A  gentleman  coming  one  from  bjithing 
slipped  suddenly  on  the  seaweed  ;  and.  before  he  could  protect 
himticlf  with  his  hunds,  fell,  n  prtijeotin^  rock  striking  him  under 
the  eye^  and  depregi^ing  ihe  midar  and  the  upper  part  of  the 
maxillary  hone  at  the  [nargin  of  the  orbit.  The  aufferijig  ttt  firi>C 
wne  intense,  and,  na  it  suhsitkd.  left  the  jiiw  and  the  teeth  of 
that  ijide  in  a  booumhed  state.  Tlje  depressed  portion  wa&  6xed, 
ftnd  of  course  coidd  not  ha^^e  been  eleiTited  except  by  means  iif 
a  trephine.  Tlie  patient  recovered  well,  thoHp;h  slowly,  and 
without  peroeptihle  UoEormity  ;  the  nerves  of  the  tuotb  being, 
for  a  long  lime,  in  an  in^en-tihle  state* 


C\,SE  CLXXXVUl. —Frtichire  of  both  Upp^r  MaxiUm^if 
Bonefi-,  and  Separation  ft^m  Jiones  of  Face.  —  An  old  lady, 
aged  TO,  descending  some  ateep  steps  into  a  cellar,  foil,  and 
received  the  full  force  of  the  fall  on  llie  faee.  1  saw  her  shortly 
afterwards,  in  a  state  of  imminent  uuffocation.  The  superior 
maxillary  boaes  were  detached,  and  hod  been  driven  back  into 
the  throat;  the  whole  face,  in  liict,  appearing  as  if  forced  in* 
wards.  Both  from  the  bJooil^,  and  from  the  obstruction  caused 
bv  the  pressure  of  the  bones  in  the  fauces,  breathing  was  very 
laborious,  and  wati  becoming  leas  and  less  possible  when  I  euw 
her. 


ExixaariES. 


Tbe  boBBi  were  dnvm  fanrvdB«  wad  cmO^ 
pUuv:   naMTTtaee  uC  the  ili^J«^«*«»  ww 
bukdigB,  aecurio^  the  upper  u>d  lover  jawi  Uigctlia'a 
fiKid  b«uig  ^ren  beCwccn  tlie  teeth. 

Great  nrelliag  and  eockyiouus  uf  tkc  face  AiOovrd ;  bat  tW 
indured  pairu  uniioJ  well  wilh  tlie  boon  from  wlikli  ihey  had 
been  AefMraled,  md  iKe  wnmui  faUy  recovered. 

T  luTe  twice  met  witli  this  accident,  boch  caws  occnrring  in  m 
elmUar  way. 


Cai^k  CLXXXIX,  —  Fntcture  nf  Epiphyn4  of  Betti  of 
Hamtru-s.  —  In  Jii&e,  \^T->h^  d  girl,  16  rear*  of  age*  wwm 
brtiuglit  to  me,  wKu  hatT  fallen  duwn  stain  the  ni^C  befone*  aad 
wH»  »aid  »1ie  liarl  wrenrlipc]  her  nhnuliter.  Sfie  oould  not  raise 
ttie  ami  willujut  great  iliffi^ultv,  and  tlien?  iraj«  niticb  teodenMea 
over  tlie  dL*)[oid  muitole.  The  «ha]>e  of  the  shoulder  waa 
Daturai,  the  head  uf  tlw  bune  being  evidently  in  \ia  place.  On 
sHzing  this  with  '>ne  hand,  bhiI  rolatinj;  ihp  humerus  wiib 
the  ullier,  ihe  fieud  of  ihc  bone  moved  with  the  ehafi,  and  no 
crepitus  \sAfi  felt' 

8he  vru>  fmniiTicd  by  a  number  nf  Hiirtreonfi.  nml  Mime 
thtmghi  it  lo  be  n  rupture  of  muscular  fibre;*  j  olhers,  fitmp!j-  4 
ilraln. 

In  tlm  coiin*e  <jf  llie  invesli^ition.  the  arm  vjtp  raided  up  to 
a  ri^fbt  Jm<r1e,  unt^  earned  aumewhat  backwnnls,  when,  lin  ruta- 
tii^n,  an  fjcx^a^ional  crepitus  could  be  di«linguished. 

ThiH  examiiiaiicjn  bein^  bnmn  with  dtfficLiltv^  it  waa  dere^ 
mined  to  i/tltenze  her,  wKi':h  her  piirenls  wmitd  not  eonsent  10 
till  the  followin^day.  The  ne*l  iliiy  the  tviie  pbiced  fiillv  under 
ether ;  and,  the  uiurwIfrH  being  rekxeil,  the  herul  r»f  tbe  bono  was 
projeeted  fitrwarilft,  iia  had  fjcen  done  the  day  before.  Tlie  epi- 
phyAiA  could  now  be  Aeiz<^l  wilh  ihe  finirerH;  and,  the  shaf^ 
bein*^  rolale<l.  It  moved  freely  wllliin  the  capsule,  independently 
of  the  re*t  of  the  Ixnie. 

A  [uul  wiis  placed  In  the  iixilln,  and  a  t^houlder-splint  ap- 
plied: the  arm  waa  confined  to  the  Hide,  and  supported  in  & 
flling.  She  canu'  to  the  }loMpit:d,  from  time  to  lime,  for  advice 
nnd  dreasing.  TJie  bone  umteil  very  rapidly,  »uid,  in  tiie  eourite 
of  a  Tow  wi^ckd,  ihc  uiotious  of  the  arm  were  entirely  restored. 


FRACTDRES. 


3^9 


This  case  is  r|uitc  inlerestinc  frtun  its  rarity^  °'^^^  from  the 
foct  of  the  obscurity  of  tlie  Ultt^osis  ;-  uo  ci-(?|nlu3  btin^  fell 
while  th<?  am  was  npplied  to  the  Btdc  and  the  hoad  of  tlie  hoUG 
dtawD  tightly  up  iuCo  the  Bucket  by  the  irritated  musclce. 
These,  bmn^  rc^bxed  by  cfbcr,  disL'Iorfcd  the  nature  cf  the  acci" 
dent. 


Case  CXC. — U)ittmltd  Fracture  of  tht  Ilamcru/s^  Bt- 
ttm~  Cure.  — A  iriuii,  55  years  of  age,  wru  brought  tu  iiic  by 
his  phy^iuhin,  in  the  Intler  part  of  May,  Id^l^^  with  no  unuiLiteJ 
fracture,  ^ituuted  about  (be  iniddlc  i)f  the  rtgl^t  buuienis*  Tlje 
fracture  Imd  birn  ciiu^ei.'d  pix  nmutha  before  by  a  cart  ronmng 
oTcr  t}ie  arm.  It  hod  beta  trcfited  in  the  usual  way,  by  epliDts ; 
but  tlie  L'udd  of  the  bone  hail  fuilt^d  to  unite,  and  the  limb  In 
couaequenije  wua  uficle&s :  the  fore-arm  mi.i  flejtcd  ou  tlic  itrai, 
and  the  elbow  was  more  or  le^e  etid\  There  waa  complete  flexi- 
bility of  the  nrm  at  the  seat  of  fracture,  so  that  I  had  great 
doubt  aa  to  the  auccias  of  any  operation. 

This  ease  beliig  an  ap[iropriate  cue,  I  determined  to  try  the 
seton.  The  fracture  waa  obliqUL'i  Lhu  lower  fragment  lying 
directly  anterior,  the  upper  pofalerior.  An  ijistruuieut  travcri^ing 
the  fiaaure,  between  the  t^\o  fractured  eud-"^,  wh?^  liable  therefore 
to  Hti'ike  upon  the  bundle  of  veseels  and  nerves  which  lay  directly 
agoindt  the  interuLd  line  of  fracture,  rendering  some  canlion 
neeestary  in  tbc  manugeiueut  uf  the  opemLion,  which  was  done 
as  fullows ;  — 

A  long  incision,  corresponding  to  the  line  of  fracture,  wai6 
mmle  directly  behind  it;  and,  by  di^aectiou,  luus^cular  fibre 
was  cxpofled,  Tbta  being  satisfactorily  usecrtaiacd  by  tlic  point 
of  tJie  finger,  and  the  vessel*  pulled  forward  out  of  the  way, 
the  ectun-nceJleT  threaded  with  a  akein  of  ailk^  was  forced  be- 
tween the  fractured  eitda  of  the  bone,  and  tiirough  the  muacic 
and  skin  of  the  opposite  eiJe-  A  free  rush  of  artcrud  blood 
followed  the  passage  of  tlie  instrument;  indii'.atlnv  diat  some 
arterial  braiteh,  of  eonsiderable  aize,  had  been  wounded.  A 
folJed  towel  was  now  placed  over  the  wound;  and  firm  cotu- 
prBiflJon  made,  by  means  of  a  roller,  from  tlie  baud  to  the 

4£ 


a3D 


EX  THEM  I  TIES. 


filiuuMer.      Tlio  pnticnt  v.-^e  pbiced  on  his  bnck  ir 
the  arm  ("Icvjitcd  on  a  pJlow  In  tho  bent   putJitRin. 

lie  pue*jf:J  n  preity  t'Onirortalle  iii;^hl,  nnd  hnd  no  bleeding- 
Thc  boTKlftpie  w.i8  reinoT<;d ;  but  the  doth,  whidi  ha<l  become 
saturntcd  with  b!ootl  nnd  dried,  thus  forming  a  cln&p  round  the 
limb,  -Aas  not  intcEt^^red  with,  ns  it  vrns  found  tltc  cimuhitioD  m 
the  nutin  veseel  was  well  pertbrmcil. 

All  the  dret'^in*re  were  removed  on  tlio  fourth  day :  the  arm 
nnd  fort^-arm  were  jduced  in  a  giittu-pcrclia  B[ilijit,  well  moulded 
to  fit  the  in^ido. 

No  i^on&littitioiial  irritntion  of  any  conP(^r(ucnce  followed  the 
opemtion,  or  nny  piiruleut  depoeit,  eueh  ns  I  hnve  frequently 
witncPBcd.  On  July  20th,  after  the  ecton  had  been  in  plnce 
thirty  tliivBj  tliere  being  some  indiention  of  this  ooeurroncc,  the 
aeton  wna  withdrawn.  The  wounde  at  once  rapidly  healed; 
nnd  on  the  SithT  an  exaniinulion  being  made,  the  bones  were 
found  firmly  united,  nnd  he  was  allowed  to  hiy  aside  liia  eplint^, 
and  ''o  nbout  with  a  ^lins*. 

Shortly  ulier  this,  im  attempt  huvirin;  been  mnde  to  overcome 
the  BtiflbesB  of  the  elbow,  which  had  remained  firm]y  tlexod 
einoe  the  treatment  for  the  accident,  the  mobility  at  the  seat  of 
fracture  wna  agnin  felt.  The  aplints  were  therefore  re-applied, 
when  union  again  became  firm  ;  and  it  was  deteniiined  to  make 
no  farther  attempts  until  the  lapse  of  time  should  have  insured 
the  huny  conEolidation  of  the  humerus.  This  p^^int  is  worthy  of 
notice,  as  I  have  twice  seen  a  fre*h  union  in  the  femur  destroyed 
by  atteraptfl  made  to  overcome  tlie  BiiilheBs  of  the  knee-joint. 

Case  CXCI. — Fracture  of  the  Longer  End  of  tht  Ra^ 
dius,  teith  othtr  FracUtrci.  Deat/i.  A.titopni/.  — 1851,  A 
man,  30  ytars  old,  was  brou^'hl  into  the  Hospital,  liaviog 
fallen  a  distanee  of  fortv  feet  tlirough  a  scuttle  to  the  floor. 
The  following  is  from  the  Hoepitid  records:  — 

"At  entrance,  at  6,  r.M,,  there  ia  fracture  of  the  right  ra- 
dius^  apparently  jual  above  the  joint.  There  is  great  deformity, 
eimidatiag  dislocation  of  the  wrist  backwards.  Crcpitua  dis- 
tinct. 

^Tlic  right  leg  is  shortened,  by  measurement,   ono  and   a 


FIUCTURES. 


331 


quarter  inchcii.  Ir  is  cvcvteJ,  with  ed^^e  of  foot  lj"iQg  flat  upon 
die  ti»(jle.  There  h  distinct  orojiitus  at  or  neur  tlio  cervix  fetno- 
rift.  'When  preswng  the  two  iliac  creste,  tliey  yield  sensihlvj 
and  give  a  feeling  of  indistinct  crepitus/'      He  dieii  nt  10,  p,m. 

At  the  siutopsy,  llie  following  wore  some  of  the  pathologioni 
nppearfmccs  eihihitod :  The  right  radius  was  fractured  trana- 
versely,  Imlf  an  inch  above  the  joints  with  a  comminuted  frac- 
ture cxirndinfr  inta  the  joint.  The  internal  lateral  liifament  wjib 
torn  BWiiy  frturt  its  attachmejitis  to  iha  ulna,  carrykg  u  bit  of 
the  bone  with  it. 

Tiie  right  feriuir  wiw  the  sent  of  n  commimitod  frnetnre 
lliroiji^')!  the  troclinnter ;  nnd  a  longitudinal  fracture  of  the  shaft 
of  the  bone  eKtonded  from  iia  cervix  downvvordd  fur  four  inchea. 
Neither  of  the^e  fmctures  coniraunicalod  with  the  capsular 
ligament. 

The  right  snero-ilinc  aynchondrosift  was  torn  asunder,  and  the 
bones  forming  it  fractur«l_  The  rnmtia  of  the  iachiiim  and 
pubea  was  fractnrefl.  The  lower  half  of  the  sacrum  and  os 
coceygis  were  t^omminiiled. 

Remnrh»,  — The  fracture  of  the  lower  eitremity  of  the  m- 
diiia  is  an  accident  of  peciilirtr  interest  to  i^nrgeona  from  the 
liability  to  deformity,  in  spite  of  the  best-direclod  treatment. 
The  variouH  apparatus  invented  by  distingu inched  eurgeona,  with 
the  ohjeet  of  preventing  this  deformity,  ^huw  the  imporinnee 
nitached  to  it-  From  simply  regarding  the  external  appenmnce« 
pre*iented  hy  this  fracture,  it  whh  formerly  supposetl  that  the 
bones  yielded  in  nr  oblique  direction  :  but  observation  of  pniho- 
logicnl  specimens  luia  fthow-n  that  it  u,  on  the  contrary,  almost 
always  transverse;  the  jvefadinr  dcfuriniiy  arising  not  so  much 
from  the  overla|>|nng  of  the  fragments,  as  from  the  direcliofi  of 
the  displacement  by  mn^cnhir  acfifin.  Dr,  Smith,  of  Dublin^ 
in  twenty  spefiniens  which  he  exmnined,  found  the  fracture  to 
bave  a  transverse  direction  in  eighteen.  In  the  present  instance, 
it  wna  tmusverae. 


Case  CXCIL  —  Fracture  of  Arm ,  with  Stihse/^nfnt  De- 
Joi'un'tif^  lii'^lnnifioit  tiif  Force  nfttr  Six  3ToulfiS.  —  The 
following  is  an  instithce  of  tlie  length  cf  lime  at  which  an  an- 


332 


EXTREUITIES. 


guW  deformity  from  friictui-c  may  be  remedied  m  a  vounr* 
perBon.  The  [latient  was  piiitly  under  uiy  charge,  and  pu'tly 
under  that  of  one  of  my  rjollenniiea.  A  boy,  16  years  of  age, 
enlerod  the  HoBpild  on  the  y«li  June,  18ii3,  who,  six  months 
before,  bnd  fractured  both  bones  of  tlxe  fore-nrni,  near  tlie 
middle*  by  a  faU.  Splints  were  applied  tioon  Eiftcr  lite  aceidont  ; 
find,  u'licn  tliey  were  removed,  &t  the  end  of  fi\o  weeks,  the 
fracture  bad  united,  but  lite  arm  was  crooked.  This  deform- 
ity liad  inorcaaed,  and  ibe  usefulneHs  of  the  arm  was  inipaired 
by  it. 

There  was   a  Inrge  callus   at  tbe  point  of  fmeture.      The 
deformity  was  of  two  kinds ;  consisting  of  &  partjid  fixed  pro- 
nation of  the  arm  below  tlio  fracmre,  nn<l  nn  angulnr  cutx'ature 
in   the  eenfia  oF  flexion-       Straight  BpUnta,  well   [ladded,  werai 
&|)plLed  on  the  flexor  and  exten^tor  surfaces  of  the  arm,  siud] 
firmly  secured  by  bandiigea. 

Tbe  use  of  these  splints,  variously  applied,  Wfts  contiuui 
for  one  month,  at  the  end  of  which  time  the  arm  was  a  vei^] 
little  straighter.  The  patient,  being  dissati^fled  with  tlie  elo' 
progress  of  the  cure,  although  it  waa  gradually  offefting  the] 
objeut,  on  the  10th  of  July  was  eiheriacd,  and  the  ami  for- 
cibly Btraigbtened.  The  ordinary  apoon-ehaped  epiiiii,  with  a 
ToUer  bandage,  was  tben  applied-  In  a  little  more  than  a  montl 
after  the  operation,  the  sbnpe  of  the  arm  was  found  to  be  noi 
mal^  nnd  the  fracture  quite  firm.  He  wad  discharged  from  thaj 
HoBpital,  with  onlera  to  continue  the  use  of  the  aplinis  for  sotnei 
time.  On  the  12th  of  September,  the  fractured  arm  was  ns 
strong  as  the  other,  nnd  perfeetly  straight. 


Fractl'Kes  of  the   Pateli^,  —  For  many  years,  I  u.^ed 

the  ordinary'  metbods  proposed  by  Sir  Aetley  Cooper,  Boyer, 
nnd  otbeTS,  for  the  treatment  of  fr-icturea  of  the  patella,  such  t\s 
mecliaciic^ak  contrivances  made  of  wood,  or  powerful  straps  placed 
aboTe  and  beloxv  the  fractured  ends,  which  were  approximated 
by  screws,  straps,  alnngs,  or  bandjigcs;  and  I  was  alway* 
struck  by  the  great  paia  and  sM'clling  prcwlueed  by  their  fip- 
plicttlion.  They  Bceaietl  to  ftcl  principally  on  the  akin,  even 
wlicn  applied  in  a  moderate  manner,  so  as  not  to  produce  in- 


FRACTUREa    OF   PATELLA. 


333 


jury  of  the  intejriimcnt.  If  thoy  hiul  nny  mode  of  ncting  on 
tlic  broken  boncf,  it  was  to  ilcprc^g  thdr  ed^cd,  itad  tljrow  the 
fraijtured  faoes  forwurdt*.  Tliie  idea  ho&  eince  been  verifi*id  by 
obeerving  one  or  two  epecimena  in  the  MLiseuiu  of  ihe  Boaton 
Society  for  Medical  Improvement,  coUeeteJ  by  tlie  didtin^iiflhed 
pathologist,  Dr-  J.  B.  S.  Jackatm.  Secii^g  the  I'eeulte  by  the 
old  metbod,  it  occurred  to  me  to  tniet  uhooet  entirely  to  posi- 
tion; the  only  aeceesory  means  einph*yefl  beir;^  a  broad  strip  uf 
adhtiiivc  plaster,  with  a  hole  in  tbc  centre  In-r^  onou^di  to 
receive  the  patella,  which  is  applied  after  tlic  inflaimuotory  eymp- 
toiDs  have  sub[jjdeiJ. 

My  plan  of  treatment  baa  been  this  :  Immediately  after  the 
accident,  the  patient  its  placed  on  a  bed,  bis  leg  miecd  on  an 
inclircJ  plane,  to  form  on  angle  of  about  45*  vk'itb  lus  body- 
A  cradle  is  now  placed  over  the  foot,  to  prevent  the  contact  of  the 
bed-clothes ;  ond  comprcaeea  are  placed  over  the  injured  |>nrt,  wet 
with  Bonie  cooling  lotion-  In  eaae  of  any  f^^reat  indatnmatory 
action,  leeches  are  opplial  ;  but  thia  has  very  rar'ely  been  necc?- 
Hary-  At  a  later  period,  when  pieaeure  can  be  borne  wilhout 
any  uneaaineae,  a  atrip  of  plaster,  arrnn^ed  na  almvoi  after  being 
well  warniedj  ia  nicely  adjusted  on  the  thigh  by  one  end,  Tlio 
upper  frognicnt  of  the  patella  ia  then  engap^l  in  tbc  opcnini;, 
slowly  dmnjijcd  down,  and  the  other  end  of  die  piaster  is  then 
made  to  adhere  to  the  front  part  of  the  leg.  Circular  atrapa 
may  be  used  if  ncceartary.  The  comfort  of  the  patient  m  im- 
meaaurably  f^CiU,  comfwired  with  the  tormenting  applications 
formerly  need;  and  the  succgbs  of  the  treatment  is  quito  aa 
good-  Stillr  it  \s<  eumewhat  doubtful,  wbetber,  in  moat  enaca, 
tbc  fraelure  would  not  do  quite  as  well,  placed  in  a  bnm  splint, 
gently  supported  by  bandagea  without  elevation.  In  fact,  I 
have  tried  thid  pliia  a  nnmber  uf  timea,  nnd  with  good  auo- 
cesa. 

The  late  Dr.  A.  A,  Gotdd,  t^  number  of  years  ftince,  at  the 
time  when  I  was  first  trying  the  method  by  poisillon,  reported 
to  the  Society  for  Me<lical  Improvement  the  case  of  a  patient 
whom  he  had  treated  by  keeping  the  limb  aua^jendo*!,  at  an 
nnglc  with  llie  body,  from  the  bedpoi^t,  without  bandages,  wbiclt 
wud  followed  widi  gratifying  success. 


During  tlie  year  1658,  himng  hn*]  n  numlK^r  of  caaes  tintler 
my  wire,  out  of  iJie  H4r»]>iial,  in  wliU;fi  I  was  Mc  to  fulltiw 
tlieir  i^rrjgreas,  I  was  soinewlmt  siriirk  at  the  viiriou*  peHcKis  aI 
whicb  |>:L[ienU  recovered  the  use  of  tbc  limb,  ndcr  the  aovideuL  ; 
null  fnuiii]  !t  much  lijnir^r,  in  mti^t  cust!^,  llinn  wju  generally 
0Lij)[iueieil.  In  order  to  nbuir  information  on  the  subject^  I  pro- 
p(t0Cil  ihe  questioD  ai  one  of  the  nieelmgs  of  the  Society  above 
men^oueil,  and  found  fmni  ibe  experience  of  other  medical  men, 
that  Fui]u<?  of  their  pntii-iil:*  hatt  recowrcHl  in  iibout  three  months  ; 
otb4^r«  rtiiuired  one  or  two  years  l)«fiire  tbe  siiflhess  was  luat, 
and  ]jower  of  flexion  ref^toreil :  one  eaj^e  wju?.  nientioiieil  in  whu'li 
t[ie  pjiver  uf  the  limb  never  rvturneUi  and  die  jmtteiit  wha 
oblijjwl  to  go  about  on  crutches.  The  recovery  of  the  free 
iDolioTk  of  tbe  liuib  did  not  ci)rrf;^|>*JTid  in  tlie^e  rases  irith  tlie 
completeness  of  the  union  of  tlie  se^tJiniteil  fragments:  some  of 
them  doing  remarkably  well  wltb  qnitc  a  luug  liguiucnloua 
union. 

I  propose  to  Illustrate  tbe  ftbove  nbserTaliona  by  a  nmnWr  of 
cases  wliich  liave  comu  under  my  care,  treated  by  lartuus 
methudtt, 

CaSb  CXC'lir.  —  Fnirlure  of  PuUlfit. -~  A  young  lady^ 
about  2>i  years  of  age,  while  barhing  in  tbe  Eea«  in  alteirjptmg 
to  lilb  u]>  a  cliiUI,  fdt  n  Mit]ihn  k[i;i|i  uboiit  tliG  Vnvp,  nnil  imme- 
diiite/y  lost  tbe  power  uf  supporting  herself,  8hr'  was  aH^isted 
out  of  ibe  water,  anti  tnkeii  home  ;  when  the  left  patella  vsbs 
found  to  have  l>eeii  broken,  and  the  fniginenis  sepunilefi  fnim 
one  to  two  Incliefl.  T  saw  her  a  few  boiLrr*  afterwanls.  She 
waa  i]iri:cLed  (o  be  pljK'ed  i>rk  her  baok.  the  le-;;  aiul  ihlgh  to  l>e 
idii^iitiy  devilled*  and  a  LMmpreai^,  wet  with  spirit  and  water,  ti» 
be  applieil  uver  the  joint.  Ueiiig  suinewbiit  dclirare  ami  dys- 
pe[Kic.  lier  food  was  ordered  to  he  careriilly  rcgulale*! ;  and,  to 
pjifclrdly  obviate  tbc  111  elTecte  of  confinement,  nhe  was  lnitbe*l 
over  oace  a.  day  with  warm  eult  water,  tblluwed  by  uiodernte  dry 
friction. 

After  tbe  first  or  second  day,  finding  no  undue  inflnmnintory 
action  aKiut  [lie  Joint,  anJ  even  feiu'ing  a  want  of  at^tidu,  tlie 
wet  applii.-JLt]<HJd  were  diM'outinued,  and  the  limb  plai^  in  a 
holluvr  aplhit,  more  fuUy  to  prevent  ilcxiuu. 


FRACTUnES   or  PATELLA. 


335 


Thi?  piLtient  was  confined  about  &ix  wecfcfl  bcfpre  tlic  union 
BecmcJ  to  be  auHicicntlj'  firm  tc  nJlow  her  to  get  up-  She  wna 
then  permitted  to  rise  ;  a  amdl  epiint  i>f  ;>;LUtu-pL3rcliit  boing 
phuHKl  nt  the  back  of  the  joint  to  give  it  support.  This  was 
removed  daily,  iind  gontlc  flcsion  given  to  it.  Finally,  at  the 
end  of  ucarlv  three  Tuonths,  she  was  able  to  bear  her  weight  OQ 
tlic  litub,  and  go  out  sLipporlcd  by  a.  cane  nnd  erutcb. 

About  citrhtcen  monlbjs  after  tbc  accident,  altliou^jh  cvory 
means  sueh  na  frictions,  iubrieftting  tbe  part  with  ointnenta,  and 
m  much  ticxion  as  could  be  nindc  withoiit  danger  of  brcnking 
the  intervening  li;;amcntDits  union,  hnd  been  ap]>licd,  ebc  woa 
still  unnbic  to  bond  her  Jcg  fartlier  tbun  at  a  right  angle.  The 
Bepnmtion  of  the  fragnicnta  wa&  from  a  quarter  to  haJf  an  incb. 
Once  during  this  period,  apparently  from  a.  peculiar  state  of  the 
constitution,  die  had  an  ntliick  of  eynoviCid  in  that  kiioc ;  tlie 
otlicr  knco-joiat  being,  at  the  ^auic  time,  a  Httle  tendcr- 

ThiB  accident,  it  should  be  observed,  occurred  in  a  lady  of 
very  dclicnte  constitution.  The  limb,  from  the  first,  was  un- 
restruincd  by  baudagea  ;  pretty  early  flc:iion  waa  used  ;  and  yet, 
at  the  end  of  a  year  and  a  hnJf,  the  limb  could  not  be  complete- 
ly bent-  The  treatment  above  deecribcil,  of  frictions  and  gentle 
flexion,  was  continued,  and,  two  yearj*  tiftcr  the  injury  was 
received,  ahe  entirely  recovered  the  uau  of  ber  limb. 


Case  CXCIV.  — Frrtctnre  of  Fatella.  —  At  the  same  time 
tliat  1  liad  the  preceding  oaae  under  my  care,  a  young  woman, 
about  25  yeara  old*  of  powcrfid  make,  acting  a^  son'ant  in  a 
friend's  famify,  was  brought  into  the  Hoapitnl,  and  eamc  under 
my  Dorc.  Having  fallen  the  day  before,  while  descending  the 
atnlra,  she  struck  her  knee,  and  produecd  a  lTJi<;ture  of  the  pa- 
tella. She  was  placed  on  a  fnictitrc-bcd,  the  lower  portion 
of  which  supyiortcd  the  injured  limb,  elevated  at  an  angle  of 
about  30".  Her  head  and  slioulders  were  also  slightly  clevnte<i 
in  the  same  way.  Cooling  appIicaLiona  were  placed  over  the 
fragroenta,  which  were  left  entirely  imrcstraincd  by  any  bandage. 
She  was  confiacd  by  Uie  accident  about  two  months  ;  and,  when 
she  left  the  Hospital,  the  fraelurcd  ends  were  scpamtcd  about 


half  on  inch. 


336 


EXTREMiriEa. 


T  saw  tliifl  pntient  a  nuTiil>er  of  H:jich  nfterwnnla.  At  the  onJ 
of  »]\  nuiiiLlif*  frotu  tlie  ncruSt^nt,  altlimigli  tlie  union  was  per* 
fectly  good,  and  all  the  a]>[iroprinte  meana  had  been  used  to  gain 
the  ufifi  iff  tlie  joint,  she  Btill  retjuired  a  very  iirm-laL't'J  bandage, 
tuippurled  IjUerally  ;  was  unahJe  in  bend  lln;  limb  so  «j  Ut  pick 
up  any  tiling  from  the  floor,  and  wus  obliged  to  wdk  wlih  ihe 
support  of  tt  cane- 


Cask  CXCV- — Frm:ture  of  Riffht  Puiella;   SabAequ&ni 

Fniuture  of  Iji{fl.  — A  iiion,  aged  33,  a  iitechanic,  fell,  .Fan.  7, 
t^triTf  on  tlie  ice,  and  fractured  his  rigbt  piLtellu  tranaverRelv  ; 
ihe  fingniculB  Inking  separated  about  un  inch,  lie  aixiW^reil  but 
Jittlc  piun  from  the  injury  when  brought  into  the  lIoapiLnh  lie 
Tvns  put  upon  the  iiii'lined  i raclu rc-hcd ,  and  treated  at  first  in 
the  &iiti\ii  loniiot^]'  as  tlii!  prcccdiug  aiA^a  :  {^tripa  of  adhesive  pljtu- 
tcr  being  u&cd  afler  the  iufljLUiinalioii  Imd  ^ub^idL-d.  He  was 
discbnTgi'd  well,  uu  March  22c!,  the  fragments  being  eeparated 
jibiint   a  llkjixl  of  an  inch. 

On  Nov.  22»  lHo8,  lie  wafl  again  brought  into  the  Hospital, 
having  bad  hii^  left  koce  atnick  by  an  iron  bar,  which  produced 
a  IranBvi^rse  fracture  of  the  putella ;  the  fragnientti  being  separ- 
ated about  tliree-tjiiarlers  of  an  inch.  Ili^  leg  wo^  jilaceJ  on  a 
Goodwin^a  »[jlint:,  and  much  elevated. 

Ou  Feb,  1,  1859,  tbtrc  wna  good  liganjeutoUH  union,  with 
sepanition  of  about  oiie-tliird  of  an  incli ;  and  he  vam  allowed  ti> 
get  up,  the  limb  being  supporteil  by  a  baudage.  On  February 
20th,  aunie  ehght  aepamtiou  of  the  jjugmcnts  was  found  to  Imve 
tiilten  place.  Do  March  1st,  no  further  ae^wiration  liiwl  occurred, 
the  tipace  between  tlic  friignients  being  about  half  an  inch. 

An  cjiiimjnation  of  the  other  limb  of  this  patient,  the  patella 
of  which  had  beeu  broken  nearly  two  yeara  bcfoit,  diacioacd  the 
fact,  that  the  fragmcnta  had  been  scpara(td  in  au  extraordinary 
manner  at  leoat  three  or  four  inches,  lie  six'\d  that,  on  leaving 
the  Hospital,  he  had  ussd  the  limb  witliout  any  precautions.  la 
conaequcnce»  the  fragments  gmUnally  became  separated,  and  lie 
finally  lost  the  power,  almost  entirely,  of  extending  the  limb  ; 
DO  that,  in  walking,  it  was  neceawiry  to  lift  the  leg  from  the 
ground,  and  give  it  ajerk  forw^iirda  by  a  sbghtly  lateral  motion. 


FKACTUttES   OP   PATKLLA. 


.^37 


Moreover,  if  extreme  cfire  wols  not  taken  in  miina^nr;  the  joint, 

by  walking-  n-itti  the  head  and  eliiiulilei'^  bent  turwariLn  so  as  lo 
throw  the  centre  of  gravity  rather  in  front  of  tlio  knee,  the 
joint  would  give  way,  And  throw  him  upon  the  ^fround. 

Case  CXCVI-  — March,  1859-  A  man,  30  years  of  af,^, 
conmdted  me  for  an  injury  of  the  lett  patella,  which,  he  said, 
had  heen  rractiired  twelve  years  before;  and  for  whitih  he  had 
hei^n  treated  at  the  Hospital  in  Dublin,  and  bad  a  guod  use  of 
the  limb  eiuce.  The  day  hetorc  I  eaw  hiiTLt  he  had  fallen,  and 
felt  Bi»mething;  ^vc  wnv  about  the  knee  ;  and  6upixi«ed  he  had 
met  with  the  same  accident  a  scound  time. 

1  found  what  appeared  to  be  at  first  a  vertical  fracture  of  the 
patella.  But.  on  more  cnrctul  ecrutiny^  what  aeonied  to  be 
a  fiasurc  in  the  bone  proved  to  be  made  by  a  projection  of  the 
outer  eondyle  of  the  femur  In  apposition  with  a  very  small  pa- 
tella of  tc^B  than  half  tbe  natural   aize- 

On  csamininp:  ihe  rif*ht  limb^  in  orrlcr  to  make  a  ('oin|>ariaon, 
I  found  not  the  fllightcs^t  tracca  of  any  patella.  Th«  joint,  in 
feet,  could  bo  fully  exjUored  ;  and  seemed  only  lo  be  covered  by 
skin,  fascia,  and  capsular  Jii^mcnt,  The  patient  naid  that  the 
motions  of  the  joint  were  [x?rfectly  ^ood ;  and  tiiat  the  only 
explanation  he  could  i^vva  was,  that,  when  a  {.^hildT  be  bad  an  cx- 
tengire  euppurating  sore  over  the  knee-joint,  following  emall-pojc . 

For  the  present  injury,  attributing  it  to  the  rupture  of  adhe- 
siond,  I  udvifled  him  not  to  conftnc  hinieelf,  but  to  have  a  knee- 
cap well  ndjuatcd,  to  attbrd  the  limb  eupport*  J£c  presented 
himedf,  some  dayi*  afterwai'd?,  with  thifl  appliance,  walkinj^  with 
cose,   and  only  cmbarraflued  on   mounting  a  ataircaee. 


Case  C^^CVU.  —  Fracture  f>/ rtitella.  — March  IG.  1«59, 
A  man.  a;;ed  40.  This  patii^nt  was  in  the  Mo^saehu^etta  Gen- 
eral Hoapital  four  years  bc»fore»  with  frnctiirc  of  both  thi^B, 
from  which  aecitkrt  he  completely  recovered.  To-day,  be  fell 
downstairs,  and  struck  directly  on  the  right  knee.  The  patella 
wo^  found  to  be  bmken  into  three  piecea,  with  but  little  wep- 
iiration  of  the  fni^ments  however.  He  was  immediately  placod 
in  bed,  with  hiB  limb  resting  on  on  inclined  plEinc. 

4^ 


flS8 


ESTKEMITIES. 


Diiiiii)^  Cte.  trcatiiic:'nt  nf  fiie  case,  there  was  fjut  Illtlc  pain,"' 
iilllnni^li  cuiissidenilile  eiriiaitiu  touk  place.  The  I'ecovery  whb 
excellent. 


Case  CXC\Ill.  —  FracUr^  of  Patella.  ~  ^^a.n'h  17, 
1850.  The  piitieril.  a  man  of  60  jcara,  fell  from  a  hnj-iuow, 
ami  titnick  h\s  k'fc  knee  tju  the  hum  tiui^r.  There  waa  a  fractiira 
of  the  iJiittlla,  witli  wry-  great  elfLisioii. 

lie  wija  placed  In  l>cd,  >vitL  lile  leg  i^ating  on  an  inclined 
j»lflne.     Tlje  case  went  on  to  a  favorahic  terminatiou. 

Case  CXCIX,  —  Ilupiare  of  the  Tendon  of  the  Qu^uln- 

ceps  Extenstir  FcmorU  Muscle,  just  at  its  Imrcrtian  into  the 
PattUa. — III  connection  with  fracture  of  the  patclU,  the  fol- 
lowing case  may  be  given.  It  was  treated  hy  poaitioa  about 
the  same  time  that  1  began  thnt  treatment  of  fractures  of  tlie 
patella,  and  ia  o\' ytvy  rare  occurrence. 

A  nuin  about  00  yenra  old^  aul^ject  to  rhcuuiailsnu  while 
sweeping  tlie  pavement  on  a  frozen  suiface,  slipped;  and,  la 
endeavoring  to  recover  himself,  felt  eometljiug  give  waj^  sihout 
tlie  knee-joint,  and  at  once  fell  to  the  grounJ.  When  brougbi 
into  the  lloapitTd,  A  woa  founJ  that  a  wiile  g^p  existed  hotiTcea 
Lhe  ijuadLiceira  tendon  and  the  patella,  tim  fikiu  hn'nv^  depressed 
at  that  point,  so  that  the  knce-jolnl  coulJ  be  completely  explored 
by  the  finger.  The  patient  was  jilaccd  on  ius  back  ;  and  the  leg 
elevated  at  an  angle  of  about  45°  from  the  bed,  and  supported  on 
an  inclined  pljtnc,  and  cooling  lotions  applied  to  it.  Much  swell-^ 
ing  and  effiisioji  into  tlic  joint  followed;  and,  :ia  no  advantiij^c? 
could  he  perceived  from  the  use  of  bandagcci,  tliey  were  laid 
uide.  Union  gradually  took  place  between  the  tendou  and 
patella;  anJ,  oftcr  a  treatment  of  a  number  of  months,  be 
finally  recovered  a  good  nae  of  the  limb. 

I  have  BCcn  three  or  four  instances  of  pcraonA  who,  having 
received  a  bloiv  just  below  the  patella,  faded  to  recover  the  tise 
of  the  leg.  On  a  very  careful  inspection,  a  transverse  crack,  or 
rupture,  was  dUtingiilshed,  partially  diviJ'ing  the  Bbrea  of  the 
lii^ainentuui  patcllic.  There  wjia  uo  otbcr  aj>|x.-arance  or  sym^i- 
loui  to  explain  the  Jota  of  power  over  tlie  leg.     These  patients 


FRACTTUUES* 


33y 


did  vrcll  aflcr  a  ronfincmt^nt  of  from  three  to  bIx  months  in  a 
hmn  epJint, 


Case  CC.  —  fracture  of  the  PelvU,  teith  Rnplure  of 
Bladder.  —  A  innn,  30  ycara  old,  died  on  liis  why  to  tlie  Hije- 
pital,  a   l>ank   of  citrtli   hurin^'  tjtUcn  on    liiiii   nn   hour  before. 

The  following  were  the  nppenriincee  presented  by  the  body ;  A 
fulness  WHS  obeefTcd  in  the  ri^ht  ilinc  region-  The  pcrinroum 
was  somewhat  fuller  than  nntund  to  the  right  of  the  medlnn  Hiie. 
The  left  eide  of  the  pelvis  appeared  drnwn  up»  60  that  its  api- 
noua  process  was  nbn^c  the  level  of  the  ri^ht  epinoufl  ]>roGe93> 
The  rlj(ht  lower  extremity  was,  by  mtftsureincnt,  onc-hii)f  nn 
inch  longer  thnu  the  IcfL  On  cxaiDiuAtion  uf  the  pelviif,  n 
fracture  was  deteeted  near  the  aympbysie  pubis ;  flido  one  through 
the  left  eacro-ilinc  syiichondrosiflH  By  riiiatinff  the  left  lower 
extremity,  tbc  Ictl  ilium  was  freciv  mov^nblc,  with  boiuc  crepitus 
attending  the  motion.  Powerful  fiexion  of  the  right  lower  eX' 
treiuity  produced  an  indistinct  crepitua  in  the  joint. 

A  enthetcr  wn?  pnasedj  with  aoroc  diflieullTi  through  the 
urethra ;  and  its  [xiint  ooutd  at  onec  be  dbtlnpjished  in  the  CAvi- 
ty  of  the  abdomen. 

Fermi^siou  being  obtained,  the  autopsy  was  made  tire  hours 
after  denih,  by  Dr,  F.  J.  BiituuteiLd*  then  house-aurgiiou  at  the 
Hospital,  who  drew  up  the  following  aocount  of  it ;  — 

*'  Oli  eultiu;;  into  the  pvritotieal  ravity,  it  {»  t'ouDi  to  be  entirely 
filled  with  blood.  Ilh  poflierior  wall  is  uovereil  wilh  a  durk-eolorcd 
eeokiymo^is,  aud  ij4  rnr^ed  by  m  large  efliiBinn  beneaih.  A  Minnll  li^r- 
uia  of  ihc  lirt«iie:<,  esliiriiJtl  la  lUe  iicnloiAcmn*  iibuut  llii:  aiic  of  dm 
ItilLe  fia;^i2rf  proLrtides  thmiii^h  the  mcmbrauUf  baek  of  llie  nghl  os 
pubi».  The  coufusbd  Btiii«  of  the  purts  beneath  the  pt>rironeiim  ren- 
der* u  rabiilft  eiaminntiiiQ  impossible.  The  btriod  has  unilermmerl 
dji:  perileoeal  cdvily,  nud  lullltrnEmI  iLu  JlJaeua  Jiud  p,«oaB  musclv:i. 

^'  The  blmldur  ia  ruptured  lo  the  extent  of  nn  inch  above  the  tri- 
angiilnr  li^^nmeni,  and  posierior  lo  the  iiymphysis  pul>i&.  The  flingno- 
n\A  uf  frticiuce  through  the  ^yuLpliyni^,  and  ihron^h  ihe  lef\  scicro-iliae 
ayaeliondrorsia  iji  found  lo  havo  l>eeu  eon~c^[,  The  IrogiDBats  of  iho 
latter  nro  sepapflltd  to  lUo  width  of  n.  fiafc»tr,  la  addiliou,  the  rigLi 
nreiatiulum  is  ero^^ed  by  ^^uv^end  frnemreA]  whidi  evieud  througb  die 
ischium  and  iliuui,  entirely  isolatiaj;  aevorrtl  pieces  uf  hone.     From 


UQ 


EXT&EMITIBS. 


tho  fundus  of  the  nccfAbuliim,  &  irinn^ular  pi«cfl  of  bane  has  be«n 
dr»wn  inwHrda,  am]  the  correi^poDdiiig  butI'wb  of  llie  hpftd  of  ihe 
&mur  a  cnisli^  lo  tlje  depth  of  one  or  Ino  liuee.    Ligameutuui  Ustv& 


Case  CCI.  —  Fracture  of  the  Nnch  of  (Ac  Thiyh-bone 
in   a    Genlhman  J^n^ty    Yearn  uf  Agt.     Recovtry^  —  The 

genilernan  who  wua  thr  t^uhjwt  nf  thia  case  wn«  n  |>ei>on  of  ihe 
most  energetic  clinriioitr ;  hi*  beuhh  had  never  been  abused  by 
any  excess,  and  he  had  always  lived  with  the  utmost  siiii* 
plioity-  Tlis  mind  wan  of  great  !^^tivily,  mid  he  hnd  ocpu- 
pied  many  positions  of  distineiion  and  Im^t  in  ibe  tiiale  aiul 
country. 

His  cnse  wji^i  parriculnrly  intercBting  to  myaelf  from  hi* 
having  been  braug)»t  into  profesftiunal  relatUmM  with  five  mem- 
hera  of  my  family,  diinng  n  period  nf  ninety  yenra. 

The  fi'Jirture  was  produced  hy  a  fall  from  hiu  cliuir,  Dec.  11, 
1861.  He  wn«  imflble  to  rUe,  and  was  placed  upon  n.  mat- 
treas,  on  the  floor,  in  which  poaiticm  I  saw  him  half  im  hour 
afterward. 

The  Jimbs  were  found  of  an  equal  lengthy  and  there  was  no 
Bversion  of  die  fool.  On  gentle  rotation  of  the  limb,  with  k 
finger  in  the  groin,  a  distinct  crepitus  was  observed.  The  tro^ 
chanter  rotntod  with  the  shaft  of  the  bone. 

About  eix  hours  after  tJic  ae(^ident,  a  fracture-bed,  wiEb  a 
triple  inclined  plane,  having  been  obtained,  he  wna  placed  upon 
it.  Before  thi*^  was  done,  it  was  found  ihat  the  foot  was  everted, 
and  the*  limb  ahoitened  lietween  one  and  t^vo  inches.  After 
being  kept  \\\  this  position  abuut  two  weeks,  he  be'gau  lo  be  un- 
easy; complstncd  of  aome  Eioreneits  of  the  back,  in  apite  of 
every  precaution  which  had  been  taken,  and  apoemodic  actions 
in  tlie  extremities  numifested  them^lvss-  He  was  then  moved 
to  a  new  bed,  which  I  had  coutrived  for  the  purpoae,  oonsistinj^ 
of  a  triple  inclined  plane,  placed  on  a  fiecoml  plane,  with  which. 
hy  a  rachet  movement,  the  patient  could  be  brought  up  into  & 
sitting  posture  without  di*tu.rbin<^  the  fracture,  and  the  pressure 
brought  more  on  the  tuberosity  of  the  iaehium  and  thighs.  By 
the  use  of  this  bed,  hia  condition  wae  nincli  improved :   and.  in 


FRA(7rUREfi, 


341 


the  course  of  the  winter,  he  recovered  the  ueo  of  the  limb,  with 
some  ehortcning  and  cvoreion- 

Dunng  the  trcaimcatf  he  onee  or  twice  fell  into  a  boiuho- 
lent  Btatc,  in  which  he  remained  two  or  three  daye^  the  pnUe 
bocomLDg  extremolv  slow  ;  and  fcora  were  entertnined  that  life 
would  ecaec  in  one  of  these  attncke.  On  iirimiiijj;  out  of  iheiUf 
however,  his  vitnliiy  was  gradually  restored. 

He  Jiverl  ahout  ii  year  uf^erwarda  :  and  finally  died  quietly 
without  any  luatked  Byinptciii£  of  diaeadc. 


Case  CCU.—Fiftcture  of  the  Uppey*  Part  of  tie  Shtfl 
and  ^^ck  of  the  0»  FeuiorU^  in  a  Lod^^  agtid  Eitfkty-eix. 
^o  Crepitus*  DGuth  in  one  Week.  Anfop/nf. — 1854,  Jan.  !>. 
This  pnlient)  ahoiit  a  week  before  her  death,  foil  in  her  room, 
striking  on  the  trochanter  of  the  nglil  tlii^rh-bone.  She  was 
UQflble  to  riee,  and  was  taken  up  and  placed  in  bed-  On  ck- 
nmination,  it  waa  found  that  the  rij^'ht  lower  cxtr«nuty  waa 
»hoHcued  nVjoat  an  inch,  and  the  foot  everted.  The  thigh  waa 
much  swollen.  No  crepitue  could  be  discovered  on  any  motion 
given  to  the  limb.  Sbe  was  |)liie<d  on  her  bat^k;  the  limb 
iupported  on  u  double  indined  plane,  mn<]e  of  |>illowg-  She 
complained  of  but  litUc  |>aiii  in  the  injured  part-  For  a  few 
days  she  did  wo)].  The  bowela  then  became  constipatedi  the 
puJse  failed  /rradtially,  and  she  died  on  the  ^ixth  day  from  the 
reception  of  the  injury,  a|)parently  trom  the  nliock  to  u  £y«tciu 
reduced  by  i^e. 

On  a  poat-m^Ttem  esacunation,  before  the  injured  parts  wero 
exposed,  an  attempt  wae  made  to  obtain  ci-epitua ;  but  none  was 
produced  by  the  ordinary  motions  of  the  limb.  By  extreme 
flexioAf  however,  uslnn;  at  the  ssmc  time  powerful  rotation,  a 
crepitus  could  be  did tiugui shell.  On  making  an  incision  over  the 
trochanter  d<jwn  the  tbi^h,  the  fat  and  musclej^  were  found  filled 
tviih  extravuHated  bloods  There  waa  a  commirmied  fracture  of 
the  ehaft  of  the  bone,  jual  bclcw  the  Iroehontor;  and  another 
fracture  cxtcndin^r  upwnrde  from  this  as  far  ae  the  edge  of  the 
aocket,  eeparatiu^'  the  neck  oi'  the  bone  from  the  trochanter. 
But  little  blood  wtu  ellused  into  tlie  cavity  of  tJie  joint. 

Tbifl  caae  le  worthv  of  remark  u»   ahowinjS'  how  extensive  a 


B49 


EXTREMITIES. 


fracture  mny  he ;   am!  yet,  fnnu  tlie  exIravii^Jtiian  tif  blood,  ni 
frcuji  otlier  causes,  one  of  tlK-  print-ipal  (Ii(igno»iiic  signji  of 
ture,  crepitus,  not  be  obtained. 


Case  CC^HL  — Fracturt^  of  ike  jVe-.-jfc  nf  Thhjh-bojte^  in 
Old  Ltidij  One  Hundred  Years  tvnd  Six  Montftn  old.  It 
ftersioH  of  Foot.  Dpnth  little  tfeei^  aftern^nrdfM 
Wnioti  of  Fracture.  Solid  Collection  in  R^f^t-utft.  —  Tli* 
old  l^ly  wlu>  w;i4  the  subject  of  ibiH  notice  died  Jaounry, 
1837,  lifter  a  long  life  of  uninternipled  ^ooil  health,  ngeJ  1' 
years  and  6  iiitmliia ;  her  ilt'atli  Wlii^  fiiiiilly  aroi-lemtcil  bv 
fiiicliin?  of  MiB  liip,  whiL'h  occiirreJ  u  few  weeks  previoiiBlyj 
For  n  year,  she  hud  lieen  subject  to  some  abeiraiiou  of  mim 
whidi  refjuireil  lier  lo  he  nonifwhat  reMmined  in  Iilt  inrulonx 
aiid»  fls  filie  ha<l  a  tojistaut  desire  lo  leave  the  hoii&e,  her  cloili* 
Avc^re  taken  from  her,  and  fihe  avjik  conliEied  oa  inut^h  ns  pnaslblc 
to  the  bt'il.  Three  weeks  Iwfore  her  Jewth,  while  lefb  by  hi 
self,  she  was  IhmjiI  by  the  [mrsona  in  the  nmrii  lx»h>vv,  to  get  oui 
of  her  bed  ;  ami,  while  walking  ai^ross  the  riHwn,  to  fiiJl  heavily 
on  the  lloor.  Upon  g<ung  into  her  chamber,  t*he  was  fouiii3  [in 
triite,  and  unable  tu  ride.  She  wqji  inuuediiitely  earned  to  bi 
bed,  iier  niedirul  sittendant  cidled,aml,  an  ejianunation  beii 
niade,  il  wns  discovered  tliat  a  fracture  had  tjikeu  placQ  throQi 
the  neck  of  the  ihij^'h-boae. 

There  was  but  little  ilisplaccjuent  of  the  fractured  parti^ 
limb   being  u  little  jihortened  and  the  foot  inverted;  and  it  wi 
detennintrJ,   ihcrtfore,   tijat    the   applieatiun    of  any  nppar^tiii 
fur  ennfiniug  the  limb  would  he  utinecefasary,  poeiiiun  only  bein; 
relied  u|>t)ii  for  the  union  of  the  bonftK      She  wiih  dirert&I  to   In 
upon  Iter  back;  and  a  pillow  wan  placed  under  the  thigh,  ao 
to  ktep  it  alighUy  Hexed  on  the   pelvia.      She  died  about   three 
weekd  after  the  ucciJenl ;   her  death  taking  jihiee  widiuut  dullFr- 
ing,  and  apparently  occasicmed  by  the  combined  effect*  of 
accalent.  Bind   the  etinfrnej  puaition  neceswrlly  attendant  on  \t. 
It  may  be  well  to  «ta[e  tliut  the  dcusen  of  the  old  lady  remain) 
perfect  to  the  hiet.      Her  hearing  wuh  ^■'ood,  mid  abe  was  abl 
to  read  the  pmnlleat  print  without  the  uau  of  gluHsea. 

The  hiidv  was  ejtaniioed  twelve  bour^  rtfier  Jciith,   and  pri 


FRACTUREB- 


343 


eented  the  fiillowing-  appearanres  i  Stnture  BTnn.ll,  abocit  Eve 
feet ;  very  little  emadulion.  On  ihe  lt»wer  part  of  tlie  tiaflrura 
wae  a  g&ngrenuua  apot,  two  m<iheri  iti  {llonictt^r,  occnsioncd  by 
the  long  preamire  on  that  part  frdtii  lier  conllnei]  position.  The 
left,  lower  oitremity  was  shortened  perlinps  a  quarter  cjf  nn 
inch,  nnd  the  toea  slightlj  turned  inwards.  Upon  oponLn«;^the 
heai]«  aboal  a  gilJ  of  serum  es('npe(l  from  the  cavity  of  the  dura 
jnaier.  This  inemhrane  wa*  strongly  adherent  throughout  to 
the  cnmiura,  requiring  llie  iise  tif  much  force  to  Heparate  il  fr<»m 
its  altachinenta.  The  Huperficird  vee^sels  of  the  hrain  were  much 
diriiendeil  with  MoihI  ;  it«  tiidi^Tanee  of  good  consiHteare,  nlfuring 
otherwise  uothirig  remark iifile.  All  the  t^uture^  of  the  cruiiium 
were  completely  ossified.  The  cartilnges  of  the  nba  were  not 
ossified,  as  is  usniillv  the  cn^e  ia  old  per^ouH,  and  were  eanily 
cut  thrtiugh  with   the  knife. 

Tiie  lungs  were  of  a  dark-blue  color  on  the  left  ttkle ;  at 
the  ^Liuiinit,  strongly  BcUu-rerit  to  (he  rihs ;  and,  ^t  xWu  point, 
a  conglomeration  of  small  semi-transparent  gramdutiouB  were 
found  embedded  in  the  siiLstnncc  of  the  hejdtliy  long.  These 
granulationa  were  scattered  throughout  the  lung;  but  lit  no 
point  wns  tlieix-  nny  iippearanee  of  tieatrices  or  tubendefi  in  a 
softened  Hiate.  The  edge?*  of  tiie  lower  lobe  of  tl»e  right  long 
presented  the  most  mnrkefl  appenrance  of  emphysema.  Tho 
heiu^  was  small;  its  cavities  filM  wtth  hhick,  iircoagolited 
blood-  The  free  edges  of  the  valves  of  the  aorta  were  not 
ossified:  wX  their  ba8es,  however,  and  at  that  part  of  the 
florta  opposed  to  their  eilgcs,  were  two  distinct  ossenus  rings. 
Patches  of  osseous  dE^posits,  some  of  them  an  inch  in  diameter, 
were  ecallorcd  at  iatcrvals  throughout  the  whole  cimrae  of  the 
aorta.  The  liver,  kidneys,  and  spleen  were  perfk.'tly  lnydthy, 
and  of  ilift  naturati  color  and  consistence.  The  stomach  was 
remarkahly  small, —  its  eitlibro  nhout  the  «aioe  ais  that  of  the 
duodenum,  from  which  externally  it  was  difficult  to  distinguish 
il,  —  ami  pre^'Cnted  much  the  n|ippnrnnei's  1  had  observed  about 
a  year  before  in  the  stomaeli  of  nn  old  lady  who  hiid  destroyed 
herself  by  starvation,  with  tliis  exception^  that,  in  the  latter 
cose,  the  mucous  cont  was  much  more  corrugsilod.  The  inte;^ 
tjnea  were  generally  of  amall  size  ;  at  some  points,  in  the  large 


344 


EXTSBXnTES, 


intestine**  not  Wing  macp  tlian  half  an  incli  in  diameter.  At 
tlie  levtum,  LowHver,  a  very  remai'kable  |ibenon»entiD  ^reAeTiLed 
iUdf- 

The  inteatiijp  w^s  liery  diliitod  iiitii  a  large  poucli,  completely 
Med  hy  li  liall  of  liurdeiied  fecaJ  matter,  wLicL,  occupj^Iiig  ttte 
wLoIe  cavity  of  the  pelvis*  forced  tlie  bladder  completely  out  of 
its  naJund  Hitujillun;  bulotv,  thiA  nuiss  was  Tound  prea^ing 
down  ojk  the  jicrluLcuin,  and  «Ii<^hlJy  ddutlng  the  Anu^.  From 
nil  appeiirnuceft  tbii^  ball  niuat  hute  been  for  a  lon^^  period 
In  tlic  situation  in  which  it  waa  discovci'od.  as  ohe  bad  cuoi- 
plained  of  no  6uffering,  nnd  the  bowels  had  been  peiHcctly 
regular  up  to  tbf  duy  of  her  JeatL.  Tbe  nialter  evacmited  of 
court»c  passed  down  at  the  eide£  of  the  obstruction. 

Tbe  bljidder  was  large  ;  ite  mucous  coat  somewhat  reddened, 
find  ratbcr  softer  than  natund.  The  utenis  whs  about  ilia 
eice  of  a  hozel-Dut ;  and,  on  cutting  into  it,  a  email  quantity  of 
pus,  apparently  of  recent  formation,  escaped  from  its  cjnity- 
Nolbing  remarkable  was  observed  about  the  ovaries,  eid(er  aa  1x> 
size  or  consistence.  Upon  examination  of  die  hip.  It  wa^  found 
that  a  fracture  had  taken  place  at  that  part  in  a  very  remark* 
able  luarmer.  In  tbe  fir&t  place,  a  fracture  citeniled  frfJin  the 
trocbanter  transversely  throiigh  the  neck  of  the  oe  femoria ; 
In  the  aecood  place,  tlie  trocluuiter  m^jor  vva«  completely  sepai 
nted  fronj  tbe  body  of  tbe  bone.  The  difiplacemeiit  of  the  fr 
lured  portions,  however,  was  very  slight ;  tbey  being  interlock* 
by  Irregular  aerrations,  although  freely  movable  on  each  others 
The  troclianlcr  minor  was  nearly  split  through.  There  appeai 
to  be  no  attempt  nl  uuiou* 

The  reinarkiiljle  fenturea  of  this  case  are ;    First,  the  invi 
fiioii  of  the  foot ;  second,  the  want  of  ossification  about  the  ril 
which  would  naturally  he  expected  In  a  person  of  wiicb  advantii 
age;   third,   the  small  aiic  of  tbe  stomach;    fuurtb,   thu   yreai 
maaa  of  hardened   feces  in   the  rectum,  allowing,  ncverthelessj 
tbe  regular  passage  of  matter  at  the  shies,  so  tliat,  previous 
death,   nothing  of  the  klud  was  suspected.      A  case  in  which 
Birailar  c-oUectlon  took  place  ie  given  in  one  of  the  numbers  oj 
the  "London  Medical  ijasctte/'    The  patient  was  a  Inly  eev*! 
cniy  years  of  age,  who  had  auffercd  for  some  time  with  most 


FfiACTURES. 


345 


csf^rucmlinrr  paina  in  the  lower  pnrt  of  the  roctum-  These 
p)UnB  were  periodical,  utid  similar  m  their  character  tii  the 
beariD^'-down  paias  of  labor-  An  examination  being  finally 
made,  it  was  found  that  a  large  masB  of  hardcued  feoen,  of  the 
size  of  the  hciu\  of  a  l"ull-gr<>^^n  fa?tU8,  \ra.s  preasing  down  upon 
the  perinicum  ;  tfie  nnuB  bein^  distended  to  tlie  siae  of  a  erown- 
piece.  Thitt  masflwofl  broken  down  with  the  bnndloof  n  apoon, 
and  the  sidferirigfl  of  the  patient  immediately  relieved  on  the 
rcnuival  of  tlxc  obatruction.  Nothing  of  the  kind  Jiad  been 
soapected,  ae  tbo  patient  liad  always  enjoyed  n  re^Iar  state 
of  bowels,  I  have  met  with  a  similar  instance  in  the  case  of  on 
insane  pereon,  alao  in  the  case  of  a  fracture  of  the  neck  tif  the 
thigh-bone  in  an  old  gentleman,  hereaRcr  to  be  related  ;  in  both 
iitstflncee  requirinf^  a  prolonged  opei'ation  ^vith  the  ecoop  which 
aceompaniea  lithotomy  inRtrumenteT  for  removal- 

The  inversion  was  caused  by  the  aerr^Ltions  heeoniiDg  inter- 
locked; the  blow  breakin^r  rhe  bone,  and  at  the  same  time  giv- 
ing It  a  Iwidt  inwards,  in  which  position  it  waa  retsuned,  aa  above 
deacribedn  In  conclusion,  it  may  be  observed  that  the  bones 
were  not  more  brittle  tlian  is  ordinarily  found  in  persona  of 
forty  or  fifty  yearti  of  age, 

I  have  in  my  posse^aion  a  apecimen  of  intrii-C4ipsuIar  frnc- 
ture  of  the  neck  of  the  femur,  with  inversion  of  the  foot,  oc- 
curring in  a  lady  ninety-three  yeara  old.  It  was  |>resented  to 
me  by  tbc  venei"able  Br-  Alden,  of  Randolph^  under  whose  care 
the  patient  was. 


Case  CCIV.  —  Intra- oapeular  FmciurB  of  the  Cer^'ix 
FetnorU.  I^a(/i/ro?n  Intestiiial  Strangulation, — Dec-ltt50, 
A  gentleman,  83  yeara  of  age,  fell  upon  a  carpeted  floor,  striking 
the  right  trochanter.  Wlien  taken  up,  he  was  foimJ  to  be  suf- 
fering severe  pain  :  tlie  foot  was  everted,  and  the  limb  shortened 
half  ati  inch.  He  was  placed  on  a  triple  inclined  plane  fracture* 
bed;  the  foot  being  supported  by  means  of  piUows,  and  pro- 
tected by  a  cradle-  At  the  end  of  seven  weeks,  he  was  able  to 
move  the  log  witliout  pain,  and  the  foot  was  not  disposed 
to  evert. 

On  Jan.  30,  185 1>  he  was  seized  with  a  pain  in  tlie  epiga^ 

44 


■-      A    JjAcMic   aa*   al   ovoe    9*ra,   filling   trmarvrrstAj 

^  ibt  aeck  «^  iW  bow.     TW  p^ie,  kwcra-*  «cr«  &i3k- 

mfidej  ;  wad  k  *u  «mI«-  afcr  c&ito  «f  ferofctc  nvcabuB 

E  wic*   thai   Ac7  partiifir  mM^J       A  yrtiw  ^  At 

.  al  ifae  bftdc  pan  of  the  ca/nx^  wtmitimri  catire. 

wMV,  ont  iBto  BDo^er ;  mod  ■■  aUtimal  sbortncaa  ^  tbc  Gmb, 
fFMa  the  panZal  drajrinz-np  of  the  ^^ft  of  ibe  hooe  bv  moscD- 

Id  di«  foUovinv  caj«.  the  piUienl  walked  $oake  ^ftsnoe  after 
ft  compkie  fnclnre  of  ibe  Deck  of  the  thigb-bmie  widun  tbe 
capmUr  llgamenl.  He  oerer  wonld  ^abmit  to  tay  fljaUaiatic 
treUmeni,  ocrt  tbiDldo^  bu  hip  lfft>kpD.  sikI  never  reconved  tbe 
tuc  of  tbe  limb.  He  died  two  vear^  and  a  half  aftemid^,  with 
a  cerel*ral  attack,  attendant  on  a  ?uppre?i4ion  of  arine.  Tbe 
fa*e  ha^  Ijten  fulk  described  bv  Dr.  J.  C-  Warren,  under 
wh'rt^  i-are  be  at  first  was,  in  the  American  e^lition  of  Cooper 
on  "  DL-bfcation^  and  Fractures,"  and  is  acoompanied  with  & 
w^jiidcut.      For  tbe  la^t  vear  of  hi?  life,  he  wa*  uikder  mv  care- 


('\>-K  CCV. —  FrnHnr'^  "f  tfi'.  Cf-rr/jr  of  thp  Oi  Femoris^, 
v.iihin  th*:  (J 'pnul'ir  Liffftrnpiit :  irtfh  n  partly  O^seouSy  and 
parity   C"rtilftffinouti  Union.      Locomoti'jH  ofier  Injury. — 


FRAtTURES. 


347 


"The  patient  was  a  gentleman  af  ediimition  nnd  ttileots.  Ha 
studied  medicine  in  tlie  early  part  of  hU  life,  but  ntterwards  left 
it  for  anotlier  profession,  A  conslhution  nniuridlj  wesk,  end 
impaired  by  diseasQ,  ^ndnally  gave  way  ;  ho  thai,  at  sisty,  he 
had  IJie  nppearjince  of  decrepitude.  He  liowever  continued  to 
go  out  and  attend  to  ^ome  business,  till  he  renehed  tlie  age  of 
BGrenty,  when  he  met  with  &  peculiar  accident- 

"  Being  a  member  of  the  Massachusetts  Senate,  he  waa  in  the 
fWt  of  ascending  the  titeps  of  the  State  House,  for  the  purpose 
of  taking  his  neuul  seat  with  that  ho^ly,  wLc&  he  fell,  and  struck 
on  the  Jeft  [trochanter.  On  arising,  be  found  himeelf  quite 
lame,  though  able  to  t^tanJ  and  walk-  In  this  condition  he 
went  up  the  atepe,  and  entered  the  House,  where  he  remained 
an  hour  and  a  half,  and  made  two  or  three  speeches  ;  during  the 
last  of  which  he  was  obliged  Co  sit  down,  leai'ing  it  unliniahed, 
A  carriage  being  called  for,  he  was  sent  home,  and  I  was  re- 
quested to  Visit  him. 

"I  found  him  in  his  parlor,  eitting  on  a  gofa,  with  his  feet  on 
tEie  Hoor,  as  if  nothing  had  hLippencd.  He  descnbed  the  acci- 
dentf  and  I  directly  eame  to  the  coDcIusiou  that  he  must  have 
fractured  the  ncek  of  the  tiiigb-bone. 

''On  examining  the  injured  limb,  I  found  no  appearance  of 
distortion,  deformity,  or  any  other  change.  It  was  of  exactly 
the  same  length  as  before  iho  accident  (having  been  rendered 
half  an  inch  shorter  than  the  other  by  an  injury  o\'  the  knee, 
received  at  an  early  period  of  life).  It  had  the  same  direction 
with  the  other-  He  could  stand  on  it,  but  not  walk  without 
euffering.  Tliere  was  no  appeai'nnee  of  any  detached  fragments 
of  bone  about  the  articulation  :  the  troiilianter  was  |>erfectly 
sound,  and  in  its  plaee.  There  was,  at  that  time,  no  tender- 
neas  in  the  groin,  nor  any  inequahty.  The  passive  movemeniB 
which  I  employed  produced  no  pain,  with  the  exception  of  strong 
rotation  outwards,  and  strong  flexion  of  the  thigh  upon  the 
pelvia.  These  movements  produced  some  degree  of  pain,  but 
not  very  coneiderablo.      There  was  no  crepitus.** 


Po^t-moriem  ExaminQttQn  of  Ike  Seat  of  Injury.  — "The 
muscles  about  the  thigh  were  thin  and  wasted  t  the  capsular 


lii^menl  wns  tLIclic'ried,  but  regtilai'  un  the  outfiide.  On  cnltutg 
inti)  tilt  articulation,  ihiTc  v^na  nn  ijjij>(?ai~ance  of  recout  indam- 
mAtioD  ;  the  neck  of  the  thigli-buiie  wns  Absorbed ;  just  mt  the 
cJgc  of  the  nrticuJar  fiurfnce  wa»  n  alighl  vWtng  of  tlie  bone. 
acai'relj  \i&ilj]e  in  the  t-ye,  hut  perfectly  aeiisible  to  the  toudi, 
which  jjidiuiteJ  tliG  sG-dt  of  the  fmctiu-e.  AVhi^n  Uie  uttenijtt  wm 
made  tn  niovi;  the  shaft  tif  the  htioe  upon  the  head,  t^o  lut^tiou 
hct^veen  ihem  cuuld  lie  perceived-  A  terticaJ  fiectiou  through 
the  liCiiJ  nwl  neck  of  the  Ixme  u~ne  then  inude :  the  plucc  of  the 
fnicturc  wuH  thu8  faiind  to  be  nidJeatcd  by  &  wliltt:  Line  running 
acroae  the  neck  of  the  hone^  Jind  liaviny^  ihc  thicknefls  ot'  the 
thiitieth  of  an  inch.  lu  onu  of  the  fractured  eecdtins,  m* 
motion  could  [>e  pnidiiceJ  between  tJie  head  aud  neck  uf  the 
hone  ;  ill  tfie  other,  dliirht  motion  exiBted.  The  preparation  ]& 
m  the  IVarren  Miidcuin." 


DISLOCATIONS. 

Dialocaliuiifl  are  neitrly  as  hjipcirUint  to  tlie  surgeon  as  fn*c~ 
tares,  I  do  not  jjropoae  to  go  into  any  detailed  description 
with  regard  la  th<?m,  but  only  to  make  a  few  reiuaika  on  cer^ 
tain  piiiiita  which  have  seeuied  to  me  to  be  of  apecirJ  impor- 
tance. 

As  a  general  rule,  dislocations  are  rarely  prcH^ut-ed  bv  n  direct 
blow  on  the  joint.  AVIiere  they  occur  from  ibis  canae,  tliey  are 
lieimllj  accompanied  with  a  fracture. 

I  have  never  seen,  nor  do  I  know  of,  a  coee  of  eimple  die* 
location  cf  ihc  hip-joint  produced  m  tliis  way.  Dislocations  of 
the  dhoulder-juint  nrt:  deMTihed  bv  aiilhnrK  as  trdting  place  cither 
by  fflJla  on  the  elbow  or  hand,  or  from  a  din:ci  blow  on  iLc  ahoul- 
dcr.  Mr.  Brj'ant,  in  Cooper's  "Surreal  Djclionary,"  fttales, 
that,  "in  thjity-one  {Hit  of  thirty-four  ca*efi,  llie  eauec  of  the  in- 
JU17  wHfl  a  direct/all  upon  the  ahoulder,  either  forwards,  back- 
wards, or  outwanJy.  Tn  two  iiisUni^es  ordy  of  dislocation 
downwards,  and  in  one  of  dialueation  downwards  and  forwArds, 
WM  the  hone  displaced  by  a.  fall  upon  the  eitendcd  arm," 
M.  Malgaigne  says,  on  the  contrary  (p.  462  of  his  work  on 
I}idlocati(jnH),    eiieaking  of  cne  of   the   niobt   common   dlslo- 


DlSLOOATlO^a, 


349 


h 


cations,  —  the  one  urwier  the  coracold  proccee,  —  as  foUowa  : 
*'  FinrtJIy,  in  very  rare  cases,  tlie  sub-coracoid  dislocation  ifi  llie 
effect  of  a.  direct  How  on  the  Bhoukler,  the  arm  not  hcin^  raised. 
RicUemnd  uppesire  to  have  ohaorved  one  ease  in  a  quarrvman, 
who,  HurprUed  by  n  caviog-m  of  earth,  atriick  the  exteriml  part 
of  the  shoulder  against  a  pillar  of  a  gallery ;  bttt  we  ehdl  see 
that  the^e  aorta  of  faUa  produce  particularly  incomplete  dielo- 
catioas.  and  especially  iufra-coracoid  dialocations ;  and  perlinjie 
that  of  Hichcriind  bi-longa  to  one  or  the  other  of  these  two 
cat^oTiea.^' 

The  error,  probably,  which  has  ariflen,  in  apeaking  of  these 
diBlocations  induced  by  a  blow  on  the  shoulder,  U  in  not  stating 
whether  the  arm  is  applied  to  the  side,  or  raised  at  an  angle 
from  it.  In  the  former  poaitioM,  it  would  seem  almost  impos- 
fliblc,  by  a  blow  from  above»  to  drive  the  head  of  the  bone  down 
below  the  socket.  In  almost  every  caee  where  I  have  seen  dia- 
loeiitiona  occur  from  &  f^ll  on  the  shoulder,  the  arm  lyiug  at  the 
side.  —  aa  in  persons  who  fall,  like  the  intoxicated,  without  an 
effort  to  save  themselvcti,  —  a  crepitua  was  found  to  accompany 
the  replacement  of  tho  head  of  the  bone,  which  was  easily  dis- 
placed i\g\\]j\  ofter  reduction,  as  if  the  aupport  from  the  front 
part  of  the  socket  had  been  broken  away.  In  one  case  of  dis- 
location, under  the  clavicle  in  iront  of  the  coracoiJ  process, 
which  is  said  by  Malgaigne  to  be  produced  by  a  blow  on  the 
shoulder,  tiie  man  vvaa  jammed  between  two  heavy  ft'eight-cars, 
which  doubled  him  up,  as  it  were,  dislocated  Ida  shoulder  for- 
wards, fractured  the  collar-bone  in  three  or  four  places*  and 
fraclnred  his  ribs,  driving  ihciu  into  liis  lunge.  The  head  of 
the  bone  was  replaced  before  I  aaw  him ;  but,  learning  the  way 
in  which  the  accident  was  received,  I  made  investigation  to  sec 
if  crepitus  was  present,  and  found  it,  but  not  very  marked, 

DislocaUons  of  the  elbow-joint  usually  result,  so  far  aa  1 
have  obscrvedi  from  falls  on  the  hand,  or  violent  twi<]ts  of  the 
ibre-arm,  blows  on  the  back  of  tlic  elbow-joint  producing  frac- 
turea>  or  fractures  accompanied  with  dislocatioUi 

Dii^Iocation  of  the  knee-joint,  unless  It  ifl  a  compound  one, 
I  have  rarely  seen.  Of  diepliw:euienl  of  the  semilunar  cnrti- 
lagea  of  the  knee-juint,  I  have  seen  a  uumber  of  lustatioesp 


350 


ESTREMITlEa, 


They  havH  fK^currpil  from  a  twiat  of  the  limli^  or  from  cAtclimg 
the  foot  In  the  I'arpei :  sLiid  I  Iulv*;  always  replaced  lh<?in  by 
fleeing  die  thigh  on  the  body,  the  leg  an  the  Uiigh  ;  iben, 
by  giving  tx  latt^ral  or  jerking  motion  to  the  joint,  and  auddeoljr 
strajghtening  it»   the  i^artihtge  has  gone  into  plcce- 

In  difllocationa  of  the  outer  end  of  the  elnviele.  I  hnve  not 
vrltncfidot]  much  mi(^esH  In  the  treatment,  nor  much  ultimate 
weakness  of  the  arm  by  lie  rerniiuhig  out  of  place,  nUhoiigh  its 
tou  free  pky  may  hf.  h  soiirtre  of  (lisromfort.  Dr.  FuIls,  of 
Baj«L  Boi^ton.  has  suggested  a  nuidi]i<^tion  of  Bartlelt's  appAi^ 
tud  furr  broken  claviele,  nj&  a,  reniedy  for  thin  aocidi:iit,  which  is 
etfecteil  by  nn  additional  aboulder-^trap  over  the  injured  shoul- 
der. 

I  would  mention  here  the  firllowiDg  ayinptom,  which  is  vexy 
frequent  after  recovery  from  dislocations  of  the  ahoulder-joiat ; 
and.  in  fact»  other  accidents  in  which  the  deltoid  muaric  is  in- 
volved. It  ia  the  want  of  power  in  raisin^^  the  anil  above  A 
certain  angle,  wliich  so  frequently  fellows,  I  Imve  often  seen 
patients  many  months,  and  sometimea  years,  after  a  difli^catioDi 
who,  Imving  recovered  all  the  other  motions,  ore  unable  to  raise 
die  arm  beyond  an  angle  of  Ay  or  50°.  In  cases  of  strjuniug 
of  the  .shuulder,  produced,  for  instance,  by  a  per-^on  swinging 
Limaeif  off  from  u  whmf  to  a  aliip,  I  have  ubaervet!  this  sviup- 
toni  after  a  period  of  two  yeiua  froui  the  time  of  the  accident, 
attended  with  much  pala»  Li  tjvo  inHtances*  it  was  cured  bj 
keeping  the  limb  at  rest  two  or  three  monthe.  In  the  eori 
part  of  1S(JG,  a  lady  considled  me  for  this  reason^  who,  sixteen 
years  before,  was  tluxiwn  out  of  a  slcigh»  and  struck  tlie  upper 
part  of  her  shoulder  on  the  curbstone.  She  could  elevate  the 
arm  to  about  45°.  It  could  be  rotated  freely  inward?,  to  any 
extent,  but  scarcely  any  oiitwiu'ds.  On  llie  hack  part  of  the 
head  of  the  bone,  I  discovered  an  osseous  Iamp<  which  ap- 
peared to  be  the  greater  tubercle  knocked  backward. 

"Tliis/^  by  the  way,  Malgiiigiic  says-  "is  often  broken  when 
the  head  of  the  bono  is  driven  forwards  under  die  clavicle  by 
a  direct  blow/'  Lately,  this  lady,  while  exerting;  herself  in 
packlag  a  trunk,  felt  soinclhing  give  way  about  the  dehi^id 
muscle,  followed  by  an  ecchymosis  ;   showing,  that,  even  oiler 


DISLOCATIONS, 


351 


this  Upae  of  time,  the  injury  to  its  fibrea  h&d  DOt  been  re- 
paired, 

Tq  following  tlie  wardi;  nf  Lisfranc,  la  P&iiSt  I  nutinnl  a 
mrmber  of  fswea  of  injiinfs  of  tbe  slioiikler-jomt,  which  he  con- 
siderLHl  utiomnloue,  und  whicli  were  supposed  to  be  p^rtin!  dia- 
locations  of  the  shoulder.  These  parientfl  hnd  all  rereued  tbeir 
injuries  by  a  blow  upon  the  joint  itself:  the  head  of  the  humerus 
seemed  to  l>e  displaced  slightly  forward,  or  sn  if  itn  the  edge  of 
the  glenoid  cavity.  It  could  be  easily  replaced  by  a  slight 
effort,  but  wns  at  once  dlspkced  when  abnndoned  fo  itself. 

iNime  time  afterwards,  I  observed,  in  the  *'  Mediro-t 'hirurgical 
Review,''  a  drawing  of  a  ca^ie  w^iiii-b  had  been  oonsidi^rej  one  of 
partkl  di>t]ueation,  but  ia  which  it  wr^  ahuvrn  that  the  front  part 
of  ihe  RoelvCi  hwd  bec*n  broken  off;  thns  allowing  a  flight  dia- 
plaeemenL  of  the  Lead  of  tlie  humeruB  fi^rward,  and  ending  in 
the  formation  of  a  new  Hucket  a  little  in  front  of  the  old 
<ine. 

About  this  time,  a  sailor  was  brought  into  the  MassachudGttB 
Heueral  Hiti^pital,  who  liad  fallen  fi-nm  the  mast  of  a  ship,  and 
had  reeeived  fatal  injuriea.  Among  others,  there  whs  apparently 
A  pivlinl  diglocaiion  of  tbe  fthonldnr.  On  eicjifninanon,  a  dia- 
tinot  eeebymoflifl  wna  found  on  the  external  aspect  of  tlio  joint ; 
nnd  the  front  part  of  the  socket  had  been  broken  off,  ao  that  die 
bend  of  the  humerus  lay  pnrtiidly  below  the  coraeoid  proccas, 

T>iiriny  severid  yeatfl  in  pniccioe,  before  I  fully  nndei^tood 
the  nature  of  the  lesion,  I  obnerved  eHses  of  dUlocation  of  the 
shoulder,  in  which,  afler  reduction  by  the  usual  methods,  tLe 
bone  iahowed  an  unusual  tendency  to  return  to  its  former  aiate 
of  displaecmenl-  In  these  easea,  I  found,  on  a  stnet  examiiia- 
tion  of  llie  patient,  that  the  injury  had  licen  inflicted!  by  u  blow 
upon  the  joint  itself.  Latterly,  1  have  orcajiioually  met  with 
eases  of  recent  dislocation  which  have  been  brought  into  the 
HoapitaJ  oti  account  of  the  supposed  fiiilurc  to  effei^t  rediic^tion, 
but  in  which  the  real  difficulty  hjy,  not  in  replacing  the  bnnc  in 
its  socket  (which  wna  very  easily  eHTectcd),  but  in  retaining  ic 
there  after  the  removal  of  the  nrlifi<!ial  supports-  I  Buppo&e 
these  eases  to  he  fractures  of  the  edge  of  the  soclfet,  or  it*  ear- 
Uliginous  ring,  bv  a  blow  nn  the  shoulder.      It  is  dirtieult. 


howercTt  to  prove  this  by  anatomical  icTefltigntiotit  onr  oppor- 
tunities to  do  eo  bemg  rorc. 

This  joct  ia  one  pf  coneidcrable  pmcticat  importance.  Whea 
B  p&tient  cornea  under  our  oof  ice,  with  a  recent  di^locatiOD  of  tht 
BliouliIer-ji>int»  he  mar  be  iiskeiJ  iu  what  manner  the  injurr  was 
recf-iycd.  If  by  a  blow  on  the  shoulder*  a  bruised  epot  will 
gencrfilly  be  fLiund ;  and,  if  ^n  ecchymoeia  alao  appears  within  a 
ahort  time,  either  m  ^ODt  of  the  joint  or  along  the  eide  of  the 
arm,  the  dia^osb  of  a  fracture  nuty  ahoost  certaialy  Le  mode. 
If.  on  the  contrary,  the  patient  has  received  the  blow  on  the  hand 
or  elbow,  with  the  arm  iit  the  same  lirac  more  or  Ie«#  extended 
from  the  thora.\,  we  may  expect  to  find  a  simple  djatocatioo  ;  or, 
If  there  has  been  great  violence,  we  may  pt>93ibly  find  it  com- 
plicated with  fraeture  of  tlic  neek  of  the  humerus.  Impacted 
iVacturc  of  the  head  of  the  humerus,  occurrtag  from  a  blow  on 
the  shoulder,  is  the  only  injury  likely  to  be  misUiken  for  the  *>- 
called  partial  dislocation  juat  noticed.  Malg^ai^e  mentioDs  a 
dia]jlat:cmcnt  of  the  tendon  of  the  Lod^  head  of  the  bicepa.  as 
giving  the  appearance  of  partial  didocation- 

The  moat  important  part  of  tlie  treatment  of  dislocation 
of  the  elmulder,  with  tracture  of  the  socket,  consists  in  retain- 
ing die  bone  in  poeilioti  after  it  has  been  roduocd.  This  object 
ia  well  attained  by  the  uee  of  Foxs  apparatus  for  fractured 
clavicle  ;  ihc  wedge-ahaped  pnd  in  the  axilla  preventing  the  re- 
production of  the  dialocfltion.  In  old  caaeSf  witli  eonipleto 
displacement,  considerable  force  ia  oflon  required  to  break  up 
adhesions,  which  arc  generally  more  tenacious  than  in  cases  of 
old  simple  dii^tocation ;  prohably  on  account  of  tfic  additional 
inflammalory  aclion  conaequcnt  upon  tlie  fracture  of  the  eocket. 
Greater  care,  and  a  lon^'cr  jvcrsistence  in  the  uac  of  mechanical 
means,  arc  also  ncccdsary  to  retain  the  head  of  the  bone  in  iu 
place  while  the  new  socket  h  in  process  of  formation.  In  fact* 
1  hjLVG  Been  the  head  of  the  bone  displaced  by  a  slight  pressure 
with  the  thutiih  while  bciu^  examined  after  reduction,  the  arm 
being  at  the  lime  firmly  bandaged  to  the  body.  In  old  dislo- 
eatione,  an  entire  loss  of  muscoiar  power  might  olao  allow  of 
this. 

I  have  had  Eu  treat  several  coses  of  dislocntion  of  the  ehouJ- 


i 


■ 


DISLOCATIONS, 


353 


der,  with  fHiCtureofthe  nwk  of  the  humerua.  In  two  mHtances 
in  whioh  I  was  called  while  the  muscles  were  fltill  i-elajced,  and 
before  the  patient  hod  rec4)vered  irom  the  dcprci^isin^  influence 
of  the  aliock^  it  was  found  jiodsible  ti>  effect  reduction  by  making 
ejtton^ion  of  the  shaft  of  thti  bone,  at  (he  same  time  working 
llic  Beparated  lieati  into  iU  socket  by  tirra  preeeuro  with  the 
thumbs-  In  cnse  reduction  cannot  be  thus  oftk^ted,  it  id  6lill  a 
qneation  whether  the  shaft  of  tJic  hone  should  bo  carried  b^ck 
mto  the  old  socket,  ao  as  thus  to  niiike  at  ouce  the  hi^^t  [inurti- 
cable  Joint;  or  wlicther  it  should  be  placed  in  apposition  with 
the  head,  aud  nn  attempt  made  at  reduction  after"  such  a  lapse 
of  time  an  may  be  thought  suthciept  for  the  union  of  the  frag- 
ments to  take  placo.  The  latter  ui(3tho<I  waa  tried  with  eu<^(7Ges, 
by  D^.  Jolin  C  Warren,  on  a  young  man,  whose  caste  he  re- 
p!>rted  in  the  "Boston  Medical  and  Surjifical  Journal'^  for  1828. 
Immediate  reduction  having  been  attempted  ia  vain,  fi-acture- 
opimmlus  was  applied-  After  seven  weeks,  extension  was  made 
with  pulleys,  and  the  dif^locatioD  re^iiiced.  This  coac  is  quoted 
by  MaljTitijrne,  who  con^i'Iere  the  precedent  worthy  to  be  fol- 
lowed in  similar*  casos^  I  also  atlcnipted  the  Bome  treatment  in 
a  CJ19C  wliich  oecurrod  nearly  twenty  years  ago  ^  but,  in  tlie 
attempt  to  Ijrcak  up  the  adhesions  whioh  bad  formed  during 
the  six  or  eight  weeks  that  had  olapaoii,  the  C4dlu9  gave  way, 
and  tJic  fracture  was  rcprodaccd.  The  broken  end  of  the  bone 
was  then  placed  in  the  glenoid  cn^nly,  and  the  patient  recovered 
w^itb  n  veiy  useful  arm.  Tn  anotiier  ciise  whieh  came  under  my 
tiotieCf  the  arm  had  been  paralysed  by  truitlet^a  attempts  at  reduc- 
tion, I  saw  the  patient,  in  consultation  with  other  eurgeone,  at 
the  end  of  seven  weeks,  when  it  was  dt'cidcd  to  leave  ti»c  broken 
end  of  the  bono  in  the  socket.  I  afterwards  loarnod  that  the 
pnmlyais  gradually  passed  off,  and  that  the  patient  recovered 
the  use  of  the  arm- 
Dislocation  of  the  hip-joint,  so  far  as  my  own  observation 
t,  may  take  place  upon  almost  any  part  of  the  pelvis  in  tiie 
imediatc  neighborhood  of  the  acetabuhim.  During  an  at- 
tempt at  reduction,  made  under  ether,  I  have  seen  almost  every 
kind  of  disphiccmcni  imitated.     !□  the  course  cf  my  practice, 

I  have  hod  three  cases  of  dialocations  downwards  and  back- 
us 


wardii ;  anp  nf  llipm  in  n  hrty  of  itbi  venrs  of  age,  the  ynijng»t 
|»iitJL'i]l  in  nhiHU  I  Uave.  I'ver  Been  (JJ^Kic^ihon  of  ihe  licnd  of 
the  JemLir.  I  have  mi^t  with  a  di^lt^calion  of  one  chi^h  into  tlw 
funimen  ovale,  the  i^thi^r  llii^ih  belii^  dislocated  upwiinld  :tt  llie 
same  time,  with  iiicumpU-te  fmctuie  uf  the  nei'k  of  ihe  bime; 
the  fractureil  |inrtliiji»  Hcjmratiiig  ju*t  ne  tJie  head  IiaJ  beeo 
ri^Fitori^d  to  Its  place  in   the  j^o<;keI. 

1  hiLvc  ouly  oai^  Heen  ii  difiluculion  of  thu  hip  in  the  femalei 
—  a  |i!i(i(-i]t  wImi  Cjttiit  into  tlje  llus|iit:il  under  Dr.  Cubol,  who 
reilnetil  it :  ami  I  believe  that  there  is  hut  one  Budi  i[ij^raDf?e  re- 
conled  in  tiie  work  £»f  Sir  Aj*tle_Y  Cooper  on  tliia  diiljjtt't.  TTie 
ravil^'  of  l\\\»  dishrcjition  in  women  in  n  fitcL  of  ij:rea.t  iiiqwrtanDe 
in  (listinfTiiMhing  between  iVacinreA,  and  dia[iUcenieiit«  uf  tlie 
head  nf  the  tlii^'h-boiie. 

It  \s  well  kmiwn  as  one  of  the  iliagiioatic  niaiks  of  Iracture 
of  the  neck  of  the  femur,  that  the  foot  ia  turned  ou[iV7U'c3«t  and 
the  lunl)  shortened.  In  dislocation  on  the  dorsum  ilii,  tlie  limb 
\s  Uirntu]  iiiwan1j4.  with  a  like  :fliorIeni:i^r,  As  an  exreptioti 
to  tiie  rule  in  fructare  of  the  nec^k  of  the  tiiigh-boae,  aud  us  n 
^Kitnt  of*  reseniblaiire  to  dinhiciition  ii[ion  the  dorsum  ilii.  I  would 
refer  to  two  easiyt  ahvady  given  of  iiiveisicm  of  the  foot  in  frac- 
ture of  the  cervix  feinorls  in  old  wmnen.  I  have  aUo  cibaerv^, 
in  the  courae  of  the  reduction  of  a  didlocatton  on  the  dorsum,  the 
toes  heconie  everleii ;  the  hend  of  the  Tmm'  tjikiiiir  a  i^itsition  m 
front,  go  ufi  to  pre>%nt  zaor^t  uf  the  ap^H^arance^  uaualJy  given  hy 
a  fracture  of  the  neck  of  the  hone. 

Tlie  iifle  of  ether  hiia  nuide  a  very  gi-eiit  ehnnge  in  the  prac- 
tice pursueil  in  the  treiilnient  c»f  dislonirioas  of  the  hip.  whidi 
can  now  be  very  Jreijnently  ledni^ei)  l>y  manual  ii'tfli^lance  uiJv, 
thua  enabling  ha,  in  many  cases,  to  dti4j»enaG  entirely  with  pul- 
leys; and,  by  flueceA*4ive  movemeiilh  of  floxion,  abiluetion,  and 
rotation,  to  rec^ture  the  head  L>f  tlie  bone  to  'ii6  liocket  with  r^ 
maikiible  facility- 

Caae  CCVL  —  DUioc'dion  iif  fits  Skoulder^oird  of  ci^ht 
weths'  standing.  Ueductinn,  — February,  18G4.  A  woman, 
4!3  yearfl  of  age  and  in  fair  hesihb,  wjis  taken,  afier  the  delivery 
of  a  healthy   diild,   with  severe  puerperal  convulsions,   lasting 


i 


WflLOCATIOKS. 


355 


P 


twenty-four  lioure.  Diirin^f  thlfl  time,  ahe  wns  corTmually 
throwing;  bewGil'  violently  iibout  in  the  bed,  unless  restrained 
by  nttetidants.  After  she  had  recovered  from  the  conv-uUiona, 
it  WAB  found  that  tlvi  left  sUoulder-jiMnt  wns  muub  awollen  nnd 
bruiseJ  on  its  outur  side,  with  an  ecchyiuoaia  nintiing  iViww 
upon  both  the  outer  and  inner  eidea  of  the  ami.  The  arm  wna 
useleBB*  At  the  end  ofsiic  weeks,  the  swelling  havint^  subaiderl, 
it  wEia  discovered  that  a  dislocation  existed,  Attemjita  were 
made,  by  niuiLual  exteni^ion,  to  reduce  it,  during  whti^h  taore  or 
lea«  crepitae  could  be  diettn^uiehed. 

From  the  liifltory  of  the  case,  —  that  is,  from  the  fact  of  there 
having  been  groat  tiwclJing,  attended  by  cochymosi^,  —  I  sus- 
pected that  a  fracture  must  Lave  existed  in  nildition  to  the 
dislocation - 

The  head  of  the  bone  could  he  felt  in  the  asillu,  and,  with 
the  neck,  seemed  to  be  a  little  enlarged,  PulleyB  were  a|^[Jlicd, 
after  ibe  patient  was  tborou^'hly  etherized;  nnd,  llie  adhesions 
having  been  rupturcKl  by  forcible  rotation  of  the  limb,  after 
strong  extension,  nn  attempt  was  made  to  carrv  the  head  into 
itfl  place-  Much  evepitus  was  felt ;  but  the  effort  to  restore  the 
bone  to  iiti  normal  situation  failed.  The  [lulicvs  wore  sigain  ap- 
plied^ nnd  powerful  rotatory  motion  given  to  the  buraems,  so  as 
Id  carry  the  bent  arm  through  threc-<iuartere  uf  a  circle.  The 
knee  was  now  plneed  in  the  axilla;  and,  the  pulleys  being  re- 
lajied,  ibo  bead  of  the  Ijone  was  j>rit>d  into  place-  The  arm  was 
tbea  confined  to  the  body  by  a  bandnge.  On  n  slight  pressure 
being  made  upon  the  bead  of  the  bone  with  the  fingers,  it  slipped 
partiiilU"  out  of  the  aoekpt ;  and  thia  continued  to  recur  when- 
over  thtj  bone  was  re".luc;cd,  until  it  waa  prevented  by  placing 
a  bu-ge  pad  in  the  axilla,  Thi^  arrangement  wus  adopted 
throughout  the  treatment,  ibat  is,  until  the  kpae  of  about  timr 
wcekfl,  when  it  waa  found  that  the  size  of  the  ]>ad  could  be 
«omewh&t  diminished.  Tike  patient  then  went  home,  with  divec- 
tions  to  continue  the  use  of  the  apparatus  until  no  farther  dispo- 
sition to  displacement  should  exiat. 

October,  l?*b4.  —  Thia  patient  consulted  me  again,  now  seven 
months  since  the  reduction  uf  the  dislocation.  4Sbe  said  that, 
ouee  or  twice  attcr  she  relurued  home,  tlie  bcuic  had  slipped 


.^56 


EXTREMinRfl, 


otit  of  pliioe,  Init  liad  Ucfii  etu^Ily  rediireil ;  and  slit?  thoiig'ht  thai 
it  w»8  nut  yet  ill  IIh  jiroper  ikWiJuh,  as  nhe  could  uuL  make  all 
the  UMial  nuivenients  uf  llu:  limb.  On  ciaiiiiiialioD»  I  fuuiid  Uje 
bhi>iildi-r  nciirly  us  plump  aind  round  ns  tlie  iftbcr,  aail>  in  fnt-t, 
a  Ihdt^  luurc  jiroiJiinent,  \'mm  the  liubit  of  cuETjking  It  elevated 
during  tbe  Ittng  couive  of  biLuda^iiig  to  wliich  it  biid  been  fu1>- 
jected.  The  wliuk  Itiiib  looketl  h^fultliy,  luid  ihc  u^^c  of  it  wof 
good,  with  the  (rice^ition  of  tlie  rnotioiia  kA'  tievation  »nd  »b- 
diiction,  wliicb  vie  often  tiee  iriiiJitiied  fur  a  ycur  or  luui-e  after 
a  simple  disjiliirement  of  the  booe,  or  even  when  die  muscles 
hjLve  been  injured  by  ii  suvere  atrjiiu,  "  ithuut  fluy  dijlucation. 
It  luigbt  bf  Mieutiont^J,  diat  no  uiollvn  iuiparled  Ui  the  head  t»f 
the  bone  could  repruduce  tiie  dialocatiGii,  aa  wjl3  die  case  but 
a  few   mondia  before. 


Ca&E  CCVn. —  Snb-coi-Qcoid  Dialocatiotin  probably  2n- 
campltit. — A  WgE,  powciful  youug  man,  who  BHid  that  be 
waa  but  Ifi  ye^Tv^  of  tij^e,  r^llhou-^^h  apjinrently  ueailj-  leii  yiam 
older,  presented  him*(elf  ut  the  Hospital  with  an  injury  M'bicb 
he  had  recniied  fifteen  days  before,  having  fallen  from  a  height 
upon  the  deck  u^  his  ship.  He  viiM*  uituble  to  uae  the  limb 
initch,  Liml  eoiilrl  jutL  rui^e  it.  lie  saiil  llierc  hud  been  but  little 
poiit  und  no  numbness,  nnd  that  the  blow  had  l>een  received  a 
little  below  the  most  prominent  part  nf  tlie  shoidder.  At  the 
point  indicated,  or  nither  a  little  hcluw  it^  wa^  a  slight  di^eol- 
oratlon.  On  the  inside  of  tlin  limb,  in  Its  loner  two^-diirdti,  >vii9 
an  e:itensive  eediymosta.  Under  the  aeromion,  tlie  bead  of  the 
bone  euidd  nut  he  felt,  and  the  roundness  of  the  shoulder  was 
lOBt.  Tbe  deltoid  mn^i'Ie,  liowever^  wiVA  not  on  a  stretchi  ns 
IS  acen  in  caaes  of  ordinary  dij^locatiou.  On  elevadng  the  limb. 
and  exphiHu^  the  axilln,  the  heail  was  felt,  ultliou^li  mtlier  io- 
diatinetlyf  and  ns  if  eo\eicd  up  by  somu  plastic  inateriul.  It  biy 
directly  under  tbe  eoracoid  proctss.  The  patient  was  advised 
to  submit  to  an  attempt  iit  reduction,  and  w^is  told,  that*  if 
be  did  not,  the  use  of  the  limh  woidd  he  impaired  for  life;  but 
being  very  stupid,  a[id  suffering  no  pain,  he  declined  to  have  the 
trial  TiiaJe. 

This   case   appears   to  be    one   of   those   iu   \\\i\'A\   the   head 


DISLOCATIONS. 


357 


I 


of  the  bone  Bcome  to  hove  been  driven  agninet  the  front  ^i^irt  ot' 
the  aouket,  breaking;  flwivy  ita  aupj^fjrts^  and  a\\o\v\u^  the  licaj 
to  rest  juel  in  front  of  its  naturnl  po&itit>n,  forming  there  a  new 
docket  nearly  on  llie  ed^e  of  the  oM  one.  Thia  injury  is  indi- 
cated, Srflt,  by  the  want  of  tcnsiou  of  the  dcltoitl,  w'hich  u^iiuHy 
e\idtfl  when  the  head  of  the  humerUB  i^  eaiight  unJcr  the  edge 
of  the  socket ;  aeeondly,  by  the  nuinbnees  met  with,  in  most 
cnsa^,  from  the  pressure  of  the  heiid  of  the  bone  upon  the 
oxillnry  nerveSf  w})erc  tlio  disloeation  ie  coin|>]cte;  and,  finally, 
by  the  j^reAt  eechymoeis  on  the  in^iide  of  the  limb,  occasioned 
by  the  niptured  veascU  iibout  the  injurad  soL^ket,  nnd  whiiih  we 
do  not  often  see,  so  fur  u^  my  exjieriencu  ^ogHt  in  L*aBe^  of  sim- 
ple diiiloentlon  of  the  shoulder.  An  attempt  at  reduction^  in  thia 
cnee,  tvould  ppoliably  have  i-eaulted  in  the  breakiu^'-U]*  of  the 
adhesions  which  hod  formed ;  thus  admittinfj  of  the  replacement 
of  the  bone  in  its  natural  position,  where,  however,  from  tlie 
want  of  support,  it  woo!d  require  the  aid  of  mcejianiea]  appli- 
ances to  retain  ic  until  a  new  socket  should  he  formed  about  it. 


Case  CCVJII.  —  Dislocation  of  the  Hend  of  the  Hftmenta 
Jbrwnrd,  icith  probahh  Frachirc  iff'  tfte  Suiket.  Jif^d'tcfi^n^ 
—  The  following  case  cxcmplilicB  two  fiicts.  The  first,  of  wbicsh 
I  have  befiire  given  one  or  two  instances,  is,  that  when  a  blow 
ifl  received  on  the  shoulder,  the  iirm  beln^  at  tlie  i^ide,  and  not 
extended,  produnn^  a  dUWatjon  of  the  humerus,  it  is  generally 
ncfompiinied  by  a  fraeture;  second,  when  a  patient  presents 
himself  with  a  doubtful  injury  to  the  arm,  tlie  necessity  of  ex- 
amining carefully  the  whule  upper  exti'emity- 

A  short,  powerful  Irii-hman,  about  5,'j  years  old,  apjjlieO  for 
advice  at  the  ilospitol.  Having  requested  the  ward-tender 
to  prepfire  the  patients  hefuroluind  for  examination,  as  there 
were  a  great  many  afipliuants,  his  shirt  was  removed-  I  iit  once 
perceived  an  unnatural  condition  of  the  shoulder;  and,  on  ex- 
amination, found  the  uau;d  signs  of  a  dislocjktion  forwards.  The 
padent  said  that  he  hiid  frdlen,  about  6ve  weeks  before,  striking 
on  an  ii*on  t^i-aliiig.  producing  a  severe  contusion,  followtnl  by  an 
ecchrmcais  on  the  out^tide  of  the  anu.  T  a&ked  hhn  if  he  had 
had  surgical  advice.      He  at  first  said  no,  but  afterwards  stuted 


us 


KE 


\y\e  act  uf  rutation,  imJe^  a  jKUt  oi  ic$  eu[>p<>ns 
heen  dettroyed^  Tbe  pulleys  were  ag^n  ftiljustcd,  the  baite 
retumod  to  iw  *ockct,  and  the  arm  secured  to  tbe  sitfe  hy  ■ 
banda^.      The  recovery  w^  good,  but  prolonged. 


Case  CCIX.  —  Cite  o/ Dialoeation  of  the  ShoutJer  back- 
^tjoriff,  from  yfuftcular  Contraction,  Jt^duction^  — This  dis- 
locntiort  i«  one  t»K  great  raritv.  Sir  Astlcv  Cooper  gives  two 
CMEA  aa  having  owurre<!  in  his  hospitftl  practice  In  the  coarse  of 
thirty  yenrs  ;  whith,  however,  he  speaks  of  a*  being  diBloeAtionA 
on  the  (|j)r<«iim  of  the  ecapula-  M,  Mdgaigne  has  ci^llecTnl 
twenty-nmc  cases,  eight  oP  which  were  the  reault  of  consul* 
aionH,  !ike  tlic  present  euse.  Out  of  a  huntli'cd  aiifl  fifty-ninu 
eiiHCB  cj['  wapulo-humeral  luxation  recorded  at  the  MiikUcsex 
lldupitsil,  three  are  useirrncd  to  this  variety.  Thi^  case  is  the 
firnt  (if  a  Jisliicatioti  of  tlic  shoulder  backwjii'ds  that  I  have  seen 
at  flic   llospilnl.      M-  Malgaigne  Joi^cribes  the  dislocation  under 


tPlSLOCATIONS. 


3511 


the  licad  of  onticnrrls  and  fjnrkwdnls.  He  alao  speakfl  of  fl»e 
dilficiilty  of  retiiiuing  tlie  heiwl  oi'  the  l)one-  In  one  of  Sir 
Afltley  Coo|>er*a  cases,  it  wna  found  thnt  the  fliib-s[^a[)ulufia  luus- 
cle  wtiK  torn  nwny  frum  its  iii&ertioii  Into  tijc  siiialk-r  Uiljerusity 
of  the  humerus,  i^tA  that  tlic  piw-tmiii"  [imtfcies  *lrew  it  bM^kwanls 
fts  fiooti  iiti  replaced  in  ihe  ftocket. 

Tljc  Hubject  of  the  preaeat  c\iss  was  a.  man  ajred  40.  He 
enlfiTd  the  rro!*|ut«.],  fTiine  2il,  1860,  Before  he  removed  his 
cluthe^f  imding  the  elhovv  ap[i1JL*il  to  the  i^tde,  arid  nrjt  stLittding 
out  froLii  tlie  budvt  as  in  other  dishiciuionn  of  ifie  (ihouhlcr,  T 
doubtLil  lu  beiti^  i]ir4li>c;itJoo.  On  examinution,  tlie  following 
3p[iearance»  wan'  pre^i?ntyil :  — 

The  coraeoid  prnt'esa  of  the  sr^iipuln,  vrns  so  prominent  aa  to 
apppjir  at  first  like  the  head  of  llie  bont.  t)n  tlie  oiitakle  of 
thid,  the  g^lenoid  ciivily  wh^  f^een  empty  ;  the  acromion  [jrojei^ted. 
Behind  the  acromiun,  and  rair^ed  n  Utile  above  its  external 
angle,  wa«  tlie  head  of  the  binie,  firmly  fixed  In  ita  position. 
The  arm  aeenied  tti  lie  n  little  Ion<fpr  than  the  other;  but  it  \VJW 
diilieull  to  deoide  this  hy  measurement.  The  fore-arm  and  hand 
retained  their  movements  ;  the  arm  itself  eould  he  <^nrried  olf 
from  the  side  only  for  a  short  distance,  and  ita  anterior  nnd  poi^ 
terior  inovement^  were  very  limited. 

The  accident  had  occurred  fleven  weeks  hefore,  dnring  nti 
attack  of  coaviilsions,  follnu'ed  hv  an  apoplectic  state  ;  and, 
on  neeouEit  of  thif;  eritieiil  rondilion,  nttention  waa  not  g^ivcu  to 
the  state  oF  the  shonlder  until  some  time  afterward?.  It  was 
not  known  whether  he  received  nny  blow  on  his  nhonlder  during 
the  eoavnlsions  ;  hut  a  slight  ecehymosis  was  still  visible  at  the 
hend  <if  ihc'  elbow,  and  at  the  upper  and  anterinr  part  nf  the  arm. 

Tlie  patient  being  etherized,  the  arm  wfis  rotated  freely, 
to  hrenk  up  adhe*iionft ;  and,  the  scapula  being  fixed,  an  at- 
tempt wns  made  to  force  the  head  of  the  bone  into  ihe  socket, 
hy  cjirrying  the  elbftw  barkwards^  and  prying  the  head  ftir- 
wanla ;  hut  it  cGohl  not  he  stirred  from  its  situnlUm,  Thii 
movements  of  rotation  were  noiF  repeated,  followed  by  powijrfid 
estensian;  and,  on  a  repetition  of  the  aame  process  ns  hefore, 
the  head  was  detjiehcd  from  ita  positianf  iind  ra|tTaeed  in  th<* 
flocket.  Thia  wjis  verifiod  hy  an  examination  made  hy  nU  the 
gcutJeiiicn  preeent. 


aso 


Exmiiurnss. 


The  arm  could  now  be  carried  freely  in  every  direction.  The 
head  of  the  bone  wna  rjukc  iiiovuUic  Id  tbc  si>eket ;  and,  on 
being  aclzcd  witk  the  tingera,  could  be  co^ilj  displaecd  ciUier 
forwards  or  bitekwnrdai  Tiiis  accmcd  owing  jmrtly  to  die  entire 
loss  of  niuacular  power  tar  retaining  tbc  lieod  of  tlic  bone  in  lu 
place;  and,  posaiUy,  from  an  intlnmmatory  action,  or  the  teu> 
iog  aviay  of  ihc  altaclinitnts*  of  tlie  ^ub-scnpularifi  muscle,  which 
took  place  in  some  of  the  cftt^ea  recorded. 

TEie  pntient^s  arm  vrm  bandaged  to  liia  didct  and  a  Grm  \ya/d 
applied  bebind  tlic  head  of  the  bone  to  prevent  dieplace- 
ment. 

Kotwiih  Stan  ding  tbeee  precautiona,  in  the  course  of  tlie  night, 
the  bone  a^ain  became  diaplueed,  du  that  itwaa  ncectisary  on  the 
following  day  Ut  etherize  bini.  and  i"cplacc  it,  which  was  done  by 
one  of  my  collca*jLics  ;  my  tetm  of  ^^ervicc  hnvlng  expired  at  the 
HospitiiK  The  right  aim  wm  no:v-  confined  bchiinl  the  body 
for  eii^bt  days,  duiing  which  time  the  bead  of  the  bone  rc- 
Tnaincd  in  phu-e,  Ucing  then  brought  back  to  its  natural  pOAL- 
tion,  and  bandaged  firmly,  in  the  course  of  tlic  night  il  again 
bccnmc  displaced.  It  wns  then  replaeed,  and  the  arm  coutiued. 
ad  before,  behind  the  back ;  and  he  returned  home  on  the  I3th, 
promising  to  report  in  the  course  of  a  week. 

He  showed  hiiaaclf  once  or  twice  more  ai  the  HoapitoJ.  The 
liriii  relnliied  its  positioc  in  the  socket,  and  the  motiona  i>f  Uic 
arm  were  improved. 


Cast,  CC^.  ^- Dtslocrttion  of  Shoulder  of  three  Tii^rttAn' 
stindlng^  Ittdaction^  —  May  17,  1>!61,  a  acarnun  entered 
the  Hoapitali  with  a  dislocation  of  his  shoiddcr  of  three  naontlia* 
duration,  w^hich  had  taken  phicc  ris  follows  ;  — 

Wliilc  rounding  the  Cape  of  Ciood  Hope,  his  eihip  encountoi-ed 
a  heuvy  gale.  A  aca  struck  the  vesricl.  while  he  ^\as  on  deck, 
and  knocked  hira  violently  agninat  the  tail'rail.  lie  received 
tho  blow  on  his  nnn  just  ImjIow  the  ahouldcr.  The  nLptain  at- 
tempted to  reduce  the  dislocation,  btit  did  not  succeed;  and, 
since  then,  the  man  hsA  been  using  his  arm  as  much  aa  the 
limited  motion  would  allow. 

On  the  day  following  hia  entrance,  May  I^th,  the  patient  waa 


DISLOCATIONS. 


361 


^ 


plJjprizpd,  tin?  mllK^sinns  being  first  lirok^n  iip^  an  far  as  conlU 
be»  hy  roturion  of  ifie  humerus  j  aiiiJ,  nffrr  pitenaion  and  other 
inan<Eiivrea,  contlnnEi)  fur  linlf  an  hour,  the  head  of  the  bone 
WHS  reatore*!  to  its  normnl   punifion   under  the  iiuroinlon. 

Owirjj  elrher  to  (he  pnrlinl  fiUing-iip  of  the  old  eoirket,  or 
what  iipponrod  to  me  n.  loss  c»f  Bubslanefi  in  the  front  pnrt  of  it, 
the  heoil  «f  the  bore  wuuld  not  remain  in  place  without  eup- 
port.  A  pad  wns  therefun?  £ihu?e(l  in  the  axilla,  and  a  relenlive 
baodii^  rtpplied. 

On  the  lat  of  June,  the  bmda^e  wjia  removed,  and  alight 
molinr  of  the  arm  aJvi^ied.  He  gnineil  slowly  the  mnseiilar 
and  nervous  power,  owing  to  the  ItJog;  cime  ibat  the  limh  had 
been  (lieplaced  ;  but  was  auMeiently  well,  Juae  22d,  rnther  more 
than  five  weeks  nftcr  the  re*liiPtion,  to  leave  the  Huipital, 
having  a  pretty  goud  use  of  hia   Umb, 


Case  CCXL  —  Bt^locfilloji  of  Shoulder,  with  Probable. 
Prat^.titre  of  Gff'noid  Onvity. — June  IS,  18«5K  About  aix 
weeks  before,  while  this  patient,  a  man  of  35  yenra,  was  standing 
in  hU  atore,  he  wiw  aei^ed  with  giddineaa.  and  fell,  striking  upon 
hit(  left  shoulder.  For  two  weeks  after  the  nccident,  be  felt 
p;iin  and  a  aense  of  uneasiness  about  the  shoulder,  whieh  was 
examined  by  several  j>hysicmn8T  who  could  delect  nothing  ab- 
normal.  At  the  end  of  the  two  weeks,  as  he  waj  pulling  on  a 
rope  attached  to  a  limb  of  a  tree,  the  limb  sprang  back  ;  and 
the  rope,  catehing  in  h!a  arm,  gave  it  el  severe  twitch,  thereby 
dislocating  it-  Seveml  atrempta  had  been  made  to  reduce  it 
before  luA  entrance  int^i  the  HospitaK 

Oo  examination,  there  was  the  usual  prominence  of  the 
acromion;  and  the  bead  of  the  humerus  wan  feltunder  the  oora>- 
coid  process.  Kiiving  been  ethevizeti,  the  reduction  was  easily 
effected  ;  though,  with  slight  pressure,  tlie  bone  would  slip  back 
to  its  former  position. 

In  Ina  first  fitfl,  rbe  juttient  prohdiily  broke  o(F  the  nntorior 
edge  of  the  glenoid  ruvity-  This  would  exjiLiiu  lUe  trouble  be 
had  after  the  first  injnrVi  the  fragment  acting  as  a  foreign  body. 
By  means  of  a  bandage^  ihe  hciid  of  the  bune  was  ke|)t  in  its 
place  ;   and  patient  made  a  good  recovery.     It  may  be  remarked, 

44 


363 


EXTREMITIES. 


that,  in  these  cases  of  oJd  dislocation  of  the  shoulder,  the  ft 
tm-e  of  ttc  socket  ia  supposed  frum  the  miinuor  in  wliich  the 
atxiident  occurred.  Secondary  die  placemen  la  would  Cake  place, 
from  obvious  i-casous,  if  this  fi^cturc  wns  present.  In  a  recent 
mac  of  dialooation,  tJie  praotidcd  surgcoo  cjinuut  mletnke  carti^ 
IngLUOUB  for  bony  crepitus. 


Case  CUXII-  —  Lateral   Dialocation    of  ik&   Sfbotc 
Thia  Qccidcut  u  c^ccaaivclj  rare,  and  the  only  cjlso  of  cumplcte 
lateral  dislocation  tW  I  can  find  ie  one  described  and  tigurcd 

Nov*  23,  l*i63.     The  patient  wna  a  tall,  nniscular  mun  abo 
25  yeara  old,  and,  in  wrestling  witb  nnoiher  man  of  about 
own   fltren^th,   vrns   thiown   violently   down,    hid    nrm    comin 
UJkd(^r  him,     Ou  rir^in^,  tlic  arm  wns  powerlcaa,  and  lie  ^apposed 
tbnt  the  joint  lutd  been  tractured.      Ho  was  brought  to 
bonac  in  a  state  of  groat  eufforing.      Supposing  that   it  was 
case  of  a  common  dialocittion  of  the  elbg^v,  I  felt  for  the  p 
jection  of  the  olecranon  throug;h  the  alothcs,  but  could  not  diati 
guiah  it.    Xcitficr  was  crepitus  produced  by  aitcmpta  at  rotntio 
The  clothes  being  removed,  with  some  diiHculty,   as   the  ni 
was  in  great  pain,  the  condition  of  tbc  limb  could  be   observed 
The  fore-arm  wae  very  eligfitly  tlcxcd  on  the  ixm,  but  less 
than  in  tlic  div^locibtion  buckwnrd«  and  was  not  eo  much  lax 
The  back  part  of  the  elbow  waa  completely  Hattcned,  and  no 
of  the  proceaaes  of  the  bones  which  enter  into  the  joint  we 
anywhere  prominent.      The  breadth  of  the  elbow  was  about  one- 
third  greater  than  natural.     By  manipulation,  the  arueulating 
process  of  the  radius,  the  olecranon  and  the  internal  condyle  of 
the  humerus  could  be  distinguished  in  the  maaa  i  but  the  who 
anatomical  condition  of  the  parts  was  of  the   most   perplcxiu 
nature.      By  cxtcueion,  HeAion.  and  rotation,  after  two  eftbrla 
tlie  articuloi'  surfaces  were  restored  to  their  natural  posili 
The  cose  did  well. 

Case  CCXIIIp  —  Fracture  of  the  Arm  just  above  the  Cot 
d'/hsy  ofKuen  w*ee^a*  standotg^,  imitating  Dinhcalian  of  tl 
Fore-arm  backwarde.  —  18C6,     I  have  lately  had  flu  oppoi 


DISLOCATIONS. 


363 


ntty  of  ggeing  Q  ca-*e  of  the  above  deaoription  in  the  practioe  of 
Dr.  Ciibot,  one  of  my  collengues  nt  the  Hoppitnl,  and,  witli  W\s 
permieaion,  give  it  to  show  tlio  deceptive  flppearoncos  which  mny 
be  prod  need  fifter  a  frfloUire. 

The  patient,  a  child  of  six  years,  was  thrown  down  by  a  boy, 
and  sustained  what  the  surgeon  in  attendance  confiiJered.  and 
which  undoubtedly  wasj  a  fracture  of  the  humerus  just  aJjove 
the  condyles. 

Seven  weeks  after,  the  inflnniniatiofi  and  swelling  having  sub- 
sidcdT  he  eiitere<t  the  flo^pitul  to  have  what,  on  a  cureory  exarai- 
nacion,  seemed  Co  be  a  di^lcxiAtion  of  the  fore-arm  backwards 
reduced- 

A  more  careful  inapeetion  woe  made  on  the  next  day,  with 
the  following  result :  On  the  front  of  the  arm,  there  wns  a  sli^lit 
ecchymottis ;  the  fore-arm  (Xjuld  be  flexed  lo  about  a  rif^ht  angle  ; 
and,  just  in  front  of  the  joint,  the  lower  end  of  the  shat^  of  the 
hnmei-ua  projected,  not  sharp  or  roughs  as  described  in  rcconf; 
fnictm-e,  nor  ao  broad  Jia  we  ordinarily  meet  in  dialocation.  On 
the  inner  aide  of  liii:^  portion  of  the  hunierua  wna  a  rounded 
process,  which  felt  very  much  liko  the  inner  condvie.  On 
the  ouUide  of  the  elbow,  the  hend  of  the  radiua  coald  be  felt 
behind  the  humerus.  By  carefid  manipulation  just  above  it,  the 
outer  condyle  was  found,  upon  which  it  moved  freely.  Tlie 
olecranon  could  be  easily  distingiiisbcdf  displaced  backwards, 
and  on  lis  inner  side  it  |>ortion  of  bone  was  felt- 
Flexion  waa  ^uod  lo  only  a  limited  dep'ce,  and  there  was  no 
lateral  motion,  hut  the  arm  could  be  com|>lctely  extended;  (he 
two  latter  points  conatitutin^^  tlie  chief  difference  between  frac- 
ture aad  dislocntitm  of  the  elbovv. 

The  diagnosis  made  was  that  of  fracture  of  the  humerus  just 
ahove  the  condyles  ;  llic  upper  frn<jincnt  being  forced  di^svn  in 
front  of  the  elbow-joiut,  and  the  lower  fragment  carried  up 
behind  tlie  shaft  of  the  humerue,  to  whicli  it  had  become 
nttached.  Under  ether,  after  a  moderate  amount  of  force  had 
been  usee],  the  motions  of  the  arm  were  somewhat  improved. 

The  appearances  hitve  been  given  in  detail,  from  (he  fact,  that 
tlic  diflereniiid  diagnoaia  between  fracture  and  dislocation  is  gen- 
erally made  when  the  injury  ia  recent,  and  before  the  process  of 


repair  lins  been  ect  up.  Af\er  tlie  bf^nes  hitTe  iinitcfl.  In  «  fnuv 
ture  iienr  tijiiiuti  witli  scjiiil-  dinpliiccment,  it  is  otlcn  v€rv  iIilH- 
cult,  anil  bometlmea  iiiipusriibk',  to  dacide  vt^telher  we   have  tu 

deal  with  £Lu  unreduced  dlslocallon,  or  a  fracture  witlt  tlm  bouea 
liULtcd  at  an  ^ncrlc. 


Ca&E  CCXIA'">  —  BiiWntiftn  of  both  TJntjhg:  one,  tukt 
the  I^oramcit  Ora/e;  iks  v/hert  on  tits  Dorfinm  &/"  ihc  liifim, 
with  Frttctiim  nf  the  Cervix  J^sruorifi,  JiffhicCion, — The 
putienl  was  brought  intu  the  MjiM^iichu^etts  Oenentl  Iloj^ptud, 
Laving  been  cmolied  hy  the  ^ivln^-way  of  ji  wooden  hi>ijjte  which 
he  WHS  eii^^ai^-d  in  jnoving,  bt^ln^  8lru<^k  iipi>n  the  back  a^  Ik 
was  mnkiii^'  an  atteiii[it  to  cf*cape,  Tlie  rl^lit  leg  first  attnu^tcd 
attention.  The  thigh  wria  fixed,  «li<jhlly  rtexed  on  llic  biHly, 
iitiuiding  off  from  it;  tiji^  tiiei^  pojntin;^  ni^rly  forward,  die  liuib 
apparently  elon^^utcJ,  A  deep  holhiw  voja  felt  in  tlie  re^on 
of  the  trochanter,  »hidt  hjLd  it^tsLi'di^uppcured.  The  man  being 
etljtni^ed,  [iml  the  imllt^vfl  ailjuslcdT  a  ^Trnduidly  inrreajst-d  furce 
wrta  applied  to  cKtcnd  the  linili.  A  aheel  u;ia  |ihu'i^)  nndur  the 
upptT  pjirt  of  it ;  and  an  nssistiint,  Bt^inding  on  the  tiiUo,  dii-ectcd 
to  lift  the  linib.  A  sli^lii  rotation  W[H  then  mmie  to  diM^ngngc 
the  heiid  of  the  liune,  untl  it  ^^  enl  into  its  plucs  without  U4iy 
pereeptible  noise  or  fiotlou  of  the  mnacles, 

The  ri<.dit  Iliiih  l>eing  ]>'plaee<l,  it  \v«3  now  perceiveil  tliwt  the 
left  lindi  nuh  distorted,  and  presented  all  the  mgns  of  £l  di^lo- 
catinn  upon  the  dor^^uin  ilii_  It  was  firndy  iiKe<l,  shiiriKoed,  the 
toes  inverteil,  and  resting  upon  the  upfK-r  jiart  of  the  other  foot- 
The  troehiinfiir  wua  proinincnr,  and  [Iniwn  np  from  its  place  to 
within  iibiiLit  three  indke?^  of  the  t^rent  of  the  iJiuui.  Oa  iiiakJno 
an  efTurt  to  move  the  liuib,  an  indiHtinct,  htit  very  deddiHl, 
crepitus  vraa  perceii'etL 

The  pnlleys  hein^  adjusted,  nnd  ether  administered,  the  limb 
was  slowly  and  with  nitieh  difficulty  dra^vo  down  ;  n  relight  rota- 
tory moiiun  being  given  to  it,  when  ihi^  heud  Wii.s  on  a  le\eJ  with 
the  socket.  It  went  into  its  plure  with  a  lend  enick,  which  was 
\i&in]  by  all  the  aj^ai^tHnts.  The  limh  now  nppeared,  at  tir»E,  to 
have  regained  its  natuiiil  condition-  A-'*  the  etfect  of  the  ether 
upon  the  muaculur   syalcni    suL^ded,   the    limb   jrratlnally    eon- 


4 


DISLOCATIONS. 


3fi5 


Imcled,  t\nd  the  foot  became  slighily  everteil.  An  e^cftminntiun 
now  being  made,  by  relating  the  limb,  and  [ilncing  the  iingcr  on 
the  trooha.ntcr,  it  wna  porfectly  evident  it>  nil  present,  ihiii  thei*e 
WAS  a  frn-cture  of  the  thigli-bone  pastsin^  thrjugh  the  trochanter. 
The  two  limbft  were  tlietetbre  confined;  the  riglit  one  by  a 
weight  attached  to  it,  and  o  crndle  placed  over  it.  To  the  left» 
Deeauk'a  splint,  an  uaed  at  tlie  Hospital,  was  applied.  In  ad- 
<1iiion  to  the  above  injuries,  two  or  three  ribs  on  the  left  side 
were  fractured. 

The  best  explanation  of  the  appearances  offered  by  the  left 
litnh  IS  this :  The  violent  crnahin^  force  dislocated  the  femur, 
At  tfte  same  time  breaking  the  neck  of  the  bone.  Tiie  Beparatii>n 
of  the  parts  was  not,  however,  sufficient  to  prevent  thoin  from 
bcinj^  repliiced  ;  but  the  Bigns  of  complete  fracture  of  the  neulc 
of  the  lemur  were  at  once  prtxluced,  on  the  bone  bein^'  reinmed 
to  ltd  socket. 

The  eubeequent  history  of  this  case  i»  not  wichaut  infereet. 
The  fiuficnti  from  the  time  of  his  ndini^dion,  hnd  com|»1nined  of 
hiri  chest,  where  his  fibe  were  broken.  One  night,  flome  weeka 
after  onlmnce,  great  difficulty  of  breathing  oarae  on  j  and,  upon 
ciamining  the  chcril,  it  was  discovered  that  a  congestion  of  the 
poi^teriur  part  of  both  Jungs  had  taken  place,  Kuch  as  Uas  before 
been  observed  at  the  Plo^pital  in  patients  wlio  for  a  long  period 
of  time  hiive  been  confined  on  the  back  without  movement,  after 
cerions  in  juries  to  the  lower  limbs.  From  tliis  atiection  he 
very  gradually  recovered. 

At  the  etid  of  two  months,  he  left  the  Hospital  well.  Tlie 
motion  of  the  right  limb  wiw  natural.  The  left  leg  was  a  little 
shorLened.  The  motions  of  tlte  hip-Joint  were  limited  ;  on  ex- 
nminafion,  the  trochanter  was  found  irreguhir  at  the  point  of 
fnicttire.  As  it  hiul  been  thought  possible  that  (he  heml  of  the 
femur  might  have  been  left  on  the  dorsum  of  the  ilium  when 
the  complete  fracture  of  tlie  linih  took  place,  search  was  made 
for  it ;  but  it  could  not  be  found  tliere. 


Case  CCXV,  —  Ca^e  of  Dislocation  on  Dorsum  Jiitt  tBith 
2*robiible  Fr(xr*.lure  of  the  Socket.  Hsducticti.  Fre^neni 
Rtcufrence  of  the  Dialocation,  —  A  man  was  bronght  into 


366 


EXTKEMJTIES. 


the  Iloepital  witli  a  dislocatrim  on  tliG  dorsum  Oii,  ^rhTch  was 
Ciiuecd  by  a  \vn;:;on  peeing  over  hiiu,  the  limb  being   at   &  ri^^hl 
angle  with  the   body.       Ether  -wns   pfivoiij  the   pullcya   applied, 
Aud   the  dijslocation  reduced.     On  rniJ^in^  ihc  limb  sJi^itly,  to 
eKamine  it,    It   at  once   elipped   out   of  plncc,   and    was   ngiun 
reJuee*.!,      This  cxpcrJtricnt  was  once  or  twice  repeated,  with  ihe 
same  result.      Dr-  S,  D.  Townsciid,  who  bhw  the   man,  verified 
the   laet.      Slight,  thoufjh  not  very   nmrked,   ercpitiie   attended 
the   mi>vcraenta  of  the  joint.      From  icar  of  displncemcnt.  and 
with  the  idea  of  a  fraeturo  of  the  edge  of  the  upper  and  back 
part   uf  the   eolylmd   cavity,   the  limb   of  the   patient  was   kept 
rigidly   eonfined  in  Dcsnult'e  nppnmtua,   and   hi<^   desire   Il>  re- 
turn home  resisted.      The  prceautiona  taken  in  this  tmsc  wcic 
flftervjifd  Ghown  to  be  not  without  reason.     About  three  wecka 
after  the  aceideut,  durin;;  my  absence  from  town,  the  patient  ^ot 
oiit  of  bed,  and,  while  re*?tin<;  on  tlic  injured  !imb»  ottemptwi  to 
tnrn  around,  thus  giving  n  slight  twist  to  iho  hi|>-joinC,      The 
bune  immed[jilcly  slipped  from  its  eoi.'kct.      This  accident  after- 
word, ill  the  couree  of  the   next  week,  recurred   n   number   of 
times  from  simple  motions  mndc  by  the  pntient  while  in  bed.     It 
was  then  determined  to  put  on  u  permanent  qilint.  and  nilow  it 
to  remain  for  several  months*      Thid  had  the  desired  ettect,  and 
the  patient  was  seen  by  me  some  months  nfter  leaving  the  lloe- 
pitid  :   the  joint  was  then  slowly  i^egnining  its  inobihty. 

During  the  treatment,  the  patient  was  very  desirous  to  return 
to  his  home,  but  waa  persuaded  not  to.  Hud  he  done  so,  and 
had  the  difiloeotion  been  reproduced  (ae  it  was  very  likely  to 
have  been),  it  might  easily  have  been  urged  that  the  dielocution 
Lad  never  been  redueed. 


Case  CCXVL — -Dislocation  of  the  fHp-jOiiit,  wiffi  other 
JiiJHricfi.  —  December,  1851»  A  man,  about  -DU  yeara  old,  was 
Liiried  under  a  bank  of  enrth ;  and,  on  being  dug  out,  was 
brought,  about  four  hours  after  the  necident,  to  the  Hospital, 

On  examiuation,  Jt  was  found  that  he  wjis  laboring  under  a 
fihght  concussion  <d'  the  brnin  ;  that  the  right  hip  was  dish>cated, 
tfic  limb  being  inverted,  and  shortened  twt>  and  a  half  inches. 
Tlie  left  testicle  had  been  torn  out  from  the  scrotum,  aud  hung 


fluepcnded  by  the  epermfttic  cord.  It  wna  covBrcd  wilh  grnve!^ 
and  the  cxtcrnaL  tunic  svtis  bo  di^  from  exposure  as  to  crucklc  like 
fmrcbmcnt.  Aci  the  vc^acld  £tiiJ  continued  lo  pulaaCe.  I  dotor- 
mincd  to  make  cfibrta  to  j)reflorvc  it.  It  was  ikereftire  icjupora- 
rily  tnvclofKtJ  ia  a  cfxoprwa,  wet  with  warm  water ;  nlier  which 
the  paticot  waa  pkct-d  antler  the  full  influence  of  chloric  ether, 
with  a.  view  to  the  reduction  of  the  clislocation.  The  furce  of 
the  pulleys  bcin^^  applied,  although  a  [rarfact  state  of  tolE(Sfl,tion 
from  the  cfTcet  of  the  anrr^thctic  a^at  eccmcd  to  cicUt,  it  re- 
quired continued  effort,  for  ten  or  fifteeti  minutes,  before  the 
the  muscica  concerned  in  the  dialocatiou  began  to  yieJd.  The 
limb  vraa  gradually  brought  down ;  and,  when  the  liead  of  the 
bone  came  opposite  the  socket,  upon  n  sliglit  rotntory  niovc- 
iDcnt,  h  alippcil  in  with  a  di^^tmct  rcp^i^.  On  mciving  the  limb 
al\cr  the  reductmti,  nn  uncommonly  hxid  cartLluginous  ercpitiH 
could  be  heard  ;  and  thia  ayinptom,  in  a  modified  fonn,  con- 
tinued for  five  or  six  weeka  after  the  necidcnt,  cvcn'when  he  waa 
eutftcicntly  recovered  to  wnJk  aljoiit  the  ward. 

Attention  wne  nest  ^^vcn  to  the  tealicJc-  The  acrotum  having 
strongly  eonlractcd,  it  vfaa  found  to  be  a  matter  of  some  diffi- 
culty to  return  it,  but  it  v/ne  finally  effected  by  seizing  the  scro- 
tum with  the  fingers,  aad  then  forcibly  crowding  in  the  tcaticle 
through  the  wound  with  the  thumbs,  confining  it  thua  until  two 
or  three  fiuturea  were  made  in  the  integuments. 

The  patient,  when  last  seen,  two  inonrh^  after  the  accident* 
was  recovcrmg  the  ufie  of  the  injured  limb.  The  wound  in  the 
flcrotuiu  had  iiealcd  well,  and  the  teaticlc  aeeined  to  have  aufiercd 
but  little  from  the  expoanrc  it  had  beeu  euhjeeted  to. 

The  application  of  the  c^ttcnding  forcc^  mode  from  the  aukle, 
was  found  more  convenient  tlian  by  the  ordinary  method  from 
the  lower  part  of  the  thigh.  No  subseijuent  inconvenience  was 
experienced  by  the  patient  In  the  kuec-joinC.  He  had  some  pain 
and  awelling  in  the  ankle-joint  for  a  number  of  days  after  the 
injury;  but  whether  it  resulted  from  the  accident,  which  was 
a  complicated  one,  or  was  in  any  way  connected  with  the  man* 
Dor  in  which  the  e:itendii]g  force  was  applied,  it  was  impoa- 
aiblc  to  determine. 


f 


366 


EXTREMITIES - 


Case  CCXVIT.  —  Dislocation  on  the  Dtirftnnt  Hit,  nf 
iw^nti/~thre€  dayt'  standi/iff.  JiedacCwu.  ^\  iiian  3fi  ywirs 
old,  of  etrun^  miipicular  dcvelupmcntr  was  AttcmptiDg  to  raise 
unkftlier  who  wtis  lyjng  hctuha  a.  niUroad  trsick.  Ou  makmg  die 
elTiirt,  he  fi^ll ;  the  weijj;Jit  uf  (lie  liJted  man  coming  aj^niinst  Lis 
pelvis  ami  Itft  Uiigh.  He  was  uniiUIe  to  n^e,  anil  was  taken  to 
a  neigl  I  boring  liiiiise,  wliere  Wis  hijf  wiia  exaaiinetl.  Tin?  injury 
wjifl  sujipustHl  Uy  be  it  ti-prtiin.  IIo  remained  m  bed  fur  twenly- 
tlir«t  d'AVn;  atid»  as  the  limb  dtil  not  recuver,  he  wiin  ixihist^}  to 
go  to  die  Ho»|)lt;il,  Doing  «n,  he  wjilkeil  a  mile  nm)  a  qunrter 
to  the  niilrfKui  station-  He  ciime  hy  the  tniin  to  Boston,  ami 
entered  thtj  Uoajjital,  Miircli  13^  18(52.  On  mitking  an  exaitii- 
nution,  I  at  once  perceived  that  the  limb  was  not  in  its  natund 
poallimi ;  and  that  the  Hymji1orii8  or  a.  cliHlocattion  upon  ibe  dorw 
«um  ilii  existf'il.  The  limb  wa^*  shortened  about  two  iiichea ; 
the  trochanter  being  about  that  distance  rearer  lo  the  cnwi  of 
the  ilium  than  tliiit  of  the  opposite  side,  and  the  toes  invei'led, 
bnt  not  lyini;  aeroHS  tlio  infttL*p  of  the  other  foot;  there  being 
thia  peeuliarily,  timt  tJie  legs  stood  off  from  tiie  tingh,  Furiuing 
an  angle  with  it,  and  giving  hini  n  kn[H.'l(-km?ed  appearttnt-e. 
The  w\iii]ii  limh  wii8  much  more  ntdvnble  than  I  hrtve  genemtl/ 
oh»4erved  in  a  case  of  dislocation.  Tliia  may  gioR^ibly  have  ariseii 
from  tbe  elfoTts  whieb  he  bad  maJe  to  produce  Tiiotion,  under 
ibe  impresfiiiiEi  tlntt  it  was  only  a  sprain.  On  turning  him  on 
bi«  faee,  the  natca  of  the  injured  Me  a[i|>e>ired  mnch  broailer 
and  roumW  than  on  tlie  other  aide;  and,  where  tlie  hollow 
usually  exists  behind  the  truchanter,  an  elevation  was  per- 
ceiveil,  whi<:li  on  exiimlniiLion  iippearwl  to  be  the  bead  of  tfao 
hona,  which  rot^iied  when  die  iicoessury  movementa  were  given 
to  the  femur. 

The  patient  wnB  etherized  to  the  point  of  total  relaxation  of 
^e  museleSf  and  pnllevH  were  np^lJedr  and  the  limb  drawn  down 
to  the  same  length  as  the  other.  An  attempt  was  now  made  to 
turn  the  head  of  the  hone  into  its  av>cket ;  hut  although,  at  tlio 
efforts  at  rotation,  a  tearing  sound  was  heard,  as  if  strong  adhe^ 
sions  were  [)eing  broken  up,  yet  the  bone  could  not  l>c  forecd 
into  its  socket.  An  oflbrl  w;ia  then  made  to  reduee  it  by  Dr. 
Seid'a  metlntd.      This  also  failed  ;   the  only  effect  being  to  cariy 


DISLOCATION'S. 


369 


I 


tlie  liead  oF  llie  bone  around  the  aocket,  atiil  Indite  it  in  tlie  fom- 
mcEi  t>valL^.  Fri3m  tbia  prjgiti<)n,  it  wsis  casUy  brou;jlit  back  tu 
its  original  gitusicion  on  the  dorsum.  The  pulle}^^  were  now  re- 
adjusted, and  the  Jlinb  ap;:Lin  bmughc  slow]}'  down*  eo  as  to  bring 
the  heM<l  oppo.ajte  (Ke  acetabulum ;  anil,  the  pulleye  bem[*  ro- 
kiGil,  a  siidUen  twist  nnd  lilt  waa  ^iven  to  the  bnne,  which 
went  into  its  proper  piaffe  with  n  jcrlc:.  The  limb  at  Gret, 
after  the  reduction,  huA  rather  an  iinnatnral  ajipearnuce,  bijiniT 
aeemiTijfly  louj^er  than  the  other,  so  that  1  thou^'bt  that  poapibly 
it  mi^ht  have  again  slipped  under  the  socket  i  but,  on  moving 
it,  I  found  those  free  motions  whi(?h  can  tinly  be  pivon  by  a  bone 
in  its  natural  position.  The  apparent  length  of  the  limb  arose 
from  It  deviation  of  the  peLvie,  it  having  been  three  weeka  in  a 
strain cd  position. 


» 


Case  CCXVJII.  —  Diihcation  o/ the  Hip  npon  Dorsum 
Ilii.  —  June  16,  \^^\^.  The  patient,  a  stout  man  of  23  years, 
while  standin;;  on  tho  inn.4;  <»f  a  milroad,  was  struck  fi'Oni  bc- 
himl  in  the  pelvi<;  iv^don  by  a  frei^^lil-L-ar,  thrown  down  Ujiua 
the  track,  and  dra^r^etl  eonie  distance.  On  examination,  the 
dislocation  was  evident ;  the  right  ler^  being  shorten&i  two  and 
a  half  inches,  drawn  up  and  thmwn  over  the  left,  tlie  foot  in- 
verted, and  the  head  of  the  femur  easily  Uiatin^ished  on  the 
dorsum  ilii. 

The  dislocaticn  was  readily  reduced  by  tlie  '*  flexion  method," 
and  the  patient  made  a  rapid  recovery. 


Ca8E  CCXIX.  — Perineal  DUtocation  of  H!p-jotJtt^  with 
JSver^icn  of  Foot,  —  A  tnan,  35  years  of  a^'e,  while  etiindiug 
neurly  erect,  was   knocked   down   by   the   cnving-in   of  a   bkiiik 

of  earth,  and  was  seen  by  nie  two  hours  ailerwnrds.  He  was 
thrown  forward  on  his  left  kneCj  with  the  thi^'h  much  ilcxcd 
on  the  pelvis.  Did  not  know  what  the  position  of  the  foot 
was  at  the  time  of  the  accident. 

The  left  thi<>h  was  found  to  be  Hexed  on  the  pelvis,  at  an 
angle  of  about  70*,  firmly  fixed,  and  about  tw'o  and  a  half 
inclies  shorter  than  the  other.      The  foot  was  everted.      Near 

47 


370 


EXTK>:UlTlEft. 


the  luWr  hchu  was  ft  projection.     'Hiere  was  coDsUemble  awd!- 
in^  iilioEit  llie  hijt- 

TEie  pnticnC  lieiog  eilierizeil,  eiten^don  waa  mmle  bv  pullevB, 
«t  fiTPt  iu  tlie  a£L«  of  the  fhigfi,  anfl  the  limh  roiaied,  but  with- 
out eflt<?t_  Extemiitin  being  ajriun  made,  i\i&  knee  was  J** 
prewedf  unJ  the  upper  enil  of  the  boDe  lifted  forwanU  lo  th< 
socket.  Thi*  ninntriivre  brou^hc  the  iip|>er  end  of  the  boue 
forward  upon  ihe  |>elTb  alMive  the  M>eket,  und  st niigbteneil  tbe 
thigh,  the  friot  being  evened  nnd  ihe  limb  ehorieneil. 

Strong  exteiWon  was  next  mnde  in  the  axU  of  ilie  bo<1v,  tli« 
tliigh  roratwl  inwiinl';,  and,  nftpr  ^hpping  h_v  the  aocki^t  many 
times,  ibe  bend  of  ibe  femur  hnji[i|ic>d  into  Uf<  pinee.  Atler  some 
eccli^tnosu  nnd  Hwelling,  the  eo^e  lerDiiiiated  favorably. 


Case  CCXX,  —  Ghlofttd'on  on  f/ic  Dorsum  of  the  Xixum. 
lipdiicttim,  —  An  intonWte^l  mnn  wjva  brtmght  into  the  Hos- 
pital, in  the  firei  week  of  pTime,  lJ*r>tl,  hnving  been  caught  nnder 
a  ti'sin  of  can  backing  into  ihe  ^tntion-hoiise.  The  tiL^hi  femur 
lay  ner<j^  the  opposite  tliigh,  6o  thnt  the  iatemd  part  of  The 
light  Vnee  touehcd  the  let^  patelk ;  the  teg  waa  u  litt}e  bi?Tit 
upon  the  ihifrli,  and  llie  r>ot,  eliglitly  inverted,  rested  on  the  in- 
step of  die  other.  Tlie  trofhimteT  was  feJt  a  liide  above  rhe 
neetsbulum;  and  the  head  of  the  bone,  a  little  above  atid  b^ 
hind  it,  WQS  indistinetK'  felt  undiT  the  muscles.  The  thigh  vr^tA 
immovably  £icd,  so  thnt  it  could  be  seized  near  the  knee-joint, 
find  the  patient  almost  turned  over  by  it,  without  prodiiuing  any 
motion  of  the  limb. 

Having  fully  etherized  the  ninn,  I  first  attempted  to  redaee 
the  dislocation,  by  Heid'e  uietbud  j  viz.,  by  strongly  Hexing  the 
thigh,  and  making  the  knee  describe  a  segment  of  a  circle  over 
the  nbilomen,  thus  sweeping  the  hend  of  the  hone  partially 
around  the  socket.  The  wJit  of  the  dislocation  was  altered,  but 
tlie  head  of  the  bone  waa  not  reduced.  The  limb  was  now 
Heiied  gently  hy  the  ankle,  and  easily  drawn  down,  till,  when 
opposite  the  flockei,  n  noiao  was  heard  as  if  it  might  have  been 
reduced,  but  not  of  that  docidetl  character  to  satisfy  me  thnt  it 
vaa  80-  Every  person  about  thought  it  had  been  returned  to 
ita  place.  On  letting  the  limb  j^ro,  it  seemed  tii  have  the  natu- 
iol  directiop,  but  was  evidently  a  litde  shortened- 


DISLOCATIONS, 


371 


Tlie  Yimh  wm  then  agiin  eeizi^l  ;  anfl,  firing  drng^l  down, 
I  put  my  hand  Miinil  llie  tronhanCer,  giive  it  a  Jitlle  Wt't,  and  it 
went  St  once,  with  nn  ijniiiL4talcablR  report,  into  ita  ptnce.  Mo 
tion  iMJuld  now  he  given  to  the  limb,  in  every  poHrtible  direction, 
without  throwing  it  from  it^  fiitiuuion. 

Cask  CCXXT,  —  PerhtPftl  TtUli^cation  of  tlie  ITrp'joint. 
Rediiei ion .  "-^  \^h\ ^  A  yonnj^  miin^  nliout  20  years  of  nge, 
was  struck  on  tho  outside  of  ihe  Oiigh,  and  ihrown  down,  by 
a  huTidle  of  hay  whirh  fell  on  him  from  a.  loft.  On  hia  being 
taken  up,  it  wjw  df^tvivprpd  that  the  ri^ht  hip-joint  was  Jialo- 
Cdted  ;   and  I  wa^  rcfjiiested  by  his  phyaii.'ian  to  see  him. 

I  f[jund  the  patient  tying  on  his  bnek,  tii^  tliigh  etanding  out 
laterally  from  t}ie  trunV,  and  forming  a  Hghr  angle  with  it-  At 
the  spot  usually  opcnpif>d  by  tlm  tvot'hanter,  n  deep  hollow  cs- 
ibted.  The  heatl  of  the  hone  could  he  felt  on  the  aact^ading 
bmnch  of  tlie  i^hium,  and  inigfit  Jtt  first  eimily  have  lieen  inid- 
iftken  for  the  tuber  iscldr.  The  patient  wonld  not  allow  any 
examination  to  be  made  until  he  had  hern  plaeed  under  the 
indueuce  of  ether,  , 

Aftpr  the  patient  was  etherired,  the  pulleys  were  adjusted,  and, 
on  the  first  etiijrt  at  fraction,  the  head  of  the  hone  slipped  aronnd 
tha  socket,  produeing  llie  appearnnoe  of  a  dislocation  into  the 
ifiL-hiatie  notoh.  The  f-kree  of  the  pulleys  was  then  intrreased^ 
and  the  head  of  the  bone  Wiw  quickly  bronght  over,  and  went 
Into  its  pla(!e  with  a  dirttinet  repnrt.  On  the  removal  of  the 
extending  power,  the  limb  was  found  CO  have  recovered  its 
proper  length  nnd  motions. 


A  few  years  before  the  above,  I  had  the  following  case :  A 
gentleman,  RO  years  of  aire,  fell  from  tl^e  third  story  of  his  store, 
alighting  on  his  knees  among  some  bales  of  goods.  The  effect 
was  to  produoe  a  dispbicement  of  the  right  thigh,  nttended  by 
phenomena  like  those  observed  in  the  preceding  instance.  The 
patient  was  etherized,  and  the  Kmb  replaced  by  manual  forte, 
without  the  aid  of  pulleys,  the  eystem  being  deprctjeed  at  the 
time  by  the  accident. 


372 


EXTREMITIES, 


CiSE   CCX-Xn. -^  Appearance   of  n   DUloerrtion    of  U 

Hip-joint^  after  nf^arhj  forty  yeare.  —  This  cnse  ia  odc  of  ui 
commcn)  interest.     The  subject  of  it  wna  a  gentleman,  ahoiit  31 
yenra  of  age,  who,  in  the  latter  part  of  the  year  1^21.  npjilicil 
to  Dr»  J,  C.  WDrrtii  on  account  of  an  injury  to   hia   hip-jyinl, 
wliich,  ho  6tntc<J,  had  been  injured  twelve  wceka  before  in   tl 
following'   nimincr.      He  wne  riiling  a  spirited  horse,  when    tJie 
animal  suddenly  reared  and  tell  ba<;kwari:i5  upon  hinif  the  weightj 
of  the  horce  being  reeciied  on  the  left  thi^^h ;  the  patient  havinj 
fallen  on  lila  backt  aa  he  aaid*  a  liutc  inclined  to  the  leli  «id< 
On  attempting  to  rise,  be  found  himself  crippled. 

After  It  careful  examination  of  the  caae,   it  woH  declared 
be   n  dislocation,  and  the  patient  was   not  encouraged  to  ho] 
much  from  an  operation.     lit  peraiHtcd,  however,  in  having 
attempt  at  reduction  mode;   aud^  after  n   consultation  witli   tb 
other  niedieul  ol^cers  of  the  Massachusetts  General   lloapital, 
WHS  a[^ed  that  tWis  should  be  done.      The  eflbrt  failed,  oflcr  all 
tlic  ordinary  means  had  been  resorted  to*     About  a  week  iifter-^j 
wards,  the  patient  appUcil   to  another  surgeon,  who  gave  ns^f 
opinion  aimilar  to  tbnt  given  by  Dr,  Warren,  and  mndc  another 
attempt  at   reduction,   but  without  Bupeess,       Finally,   he  w 
induced  to  apply  to  a  proJcssed  bone-setter,  who  mitde  a  thii 
attempt,  with  the  eamc  rcfjult.     Immediately  after  the  accident* 
he  had,  it  seems,  called  in  two  practitioners  in  the  neighborhood 
who   made  attempts  at  reduction,  and  supposed  they  had  sm 
eeeded  in  replacing  the  bone- 
About  a   year   subsequently,   cnntrnry  to  the  advice  of  Ds, 
Wnrren,   a  euit   for  malpractice  was   brought,   by   the  patienti' 
against  the  two  surgeuna  who  were  onginally  called  to  the  case. 
After  one  or  two  triala,  the  suLt  wna  withdrawn,  the  jury  having 
disagreed,  priueipally  on  aceount  of  a  eondict  of  surgical  tesi 
mony. 

In  September,  1858,  1  received  a  letter  from  Dr.  Greeleyj 
of  Ellsworth,  Me.,  the  physician  of  this  piaticnt,  stating  that 
was  at  the  point  of  death  j  that  his  friends  were  botli  willing 
and  desirous  to  have  the  coac  investigated,  and  tliat  he  himsi 
had  always  expressed  the  wish  thnt  this  should  be   done.      Ol 
the  receipt,  a  short  time  afler,  of  the  telegraphic  despatch 


DlSLOCATlOKd. 


373 


nouncing  his  death*  Dr.  IL  K.  Oliver,  at  my  request,  prf>ceeded 
to  Ellsworth  ;  antl,  nfter  taking  note  of  tlie  external  iipi)eflr;Lncefl 
of  the  hody,  separated  the  pelvis  and  the  upper  third  of  the 
thighs,  nnd,  by  permisflioa  of  hia  family  (it  being  imtHva/^ible 
to  make  a  &u.tiff]LCt(>ry  iiiveati'^'^atloii  on  the  spot),  brouglit  the 
portions  ihua  remove<l  to  Bojitou.  Here,  he  made  a  careful 
di^eection  of  the  eofc  paitSi  on  the  afPcctcd  sitlc;  and  fluba&- 
quenlly,  the^e  tissues  liaving  been  removed  by  niaceralioai  made 
a  thorough  eAamiutitloii  of  the  houy  atructurca. 

The  following  is  his  report  of  the  examination  of  the  body, 
the  diaaection,  &c* ;  — 

*'  T}i4>  bofh'n  Willi  miiaciilar  anil  adiponi^  ET.tAnes  well  iavelopeil*  WOB 
lying  on  JUq  bi^il^  ihi;  ^fioatderj^  iteiug  uli^litly  raiai^d.  The  loner  ex- 
trcniiliea  wero  od  a  liac  with  the  body ;  Lhe  heeU  boin^  together,  and 
on  tba  SEime  level.  The  hmbe  were  tliersPoro,  to  Lhe  cyoy  of  equal 
length.  Tlie  riwht  side  of  the  pehU  nppeflre<l  lo  be  aomewhAi  luwer 
than  the  icl\.  Tlie  light  foot  vnrltd  but  r^li^lillj  from  the  perpcoiljcu- 
}or ;  tbc  Icfl  lurucd  out  aL  tin  aa^h  of  2~i°  or  30^.  The  li:l\  kuuc  was 
raisedi  £o  that  tha  Lhigh  made  wiih  lUa  piano  af  tha  bed  aa  angle  of 
aliotiL  \a°.  The  rii;ht  kuue  Wiii^  raised  ro  tlie  IcvpI  of  ihe  left»  a 
dif^troDce  of  two  iachea  in  the  length  of  dit  tiuiba  was  noticeable.  It 
was  diEBcull,  on  account  of  the  ^eat  amonnt  of  adiposo  1ii^Q«,  to 
compjLiG  Iha  lenglb  of  Ilia  limbs  by  moiisuriag  from  the  auEcrior  su- 
ptrior  tjpinnu'*  processes  of  iJie  iila.  The  movemenlB  of  [be  left  thigh 
were  limited^  und  confined  exclusively  lo  flexion  and  cxteusioa;  no 
niolLon  wlmlovor  being  perfcivod  in  attempts  at  ubdiit^tioa  and  adcliio- 
lion.  KxEenMOTi  uf  the  leg  wha  impo^sihle,  ^ven  aller  iliinKion  of  the 
tetidnim  of  iha  Hi^xur  musi.-lea  uf  llie  thigh-  Tli^re  wim  iimsequeuily 
A  pcrmniieat  fiexioa  of  iho  ihigh  upon  iho  body,  and  of  the  leg  upon 
the  Ibigh.  On  Itie  uppur  and  inner  part  of  tEic  thigh,  a  large,  hanl 
mnfifl  coulJ  be  fi>lt,  not  eKLSting  in  the  correqpoadioj^  lotraliiy  on  the 
ri^bt  aide.  Tiiis  waa  ^ubsequeiidy  Touud  to  be  iha  new  bcinj  scckel. 
The  body  being  turned  ovefi  the  flalnesA  of  (he  lef^  hip,  a9  compared 
M'ilh  lb*  right,  was  very  markt-d.  On  emminalion,  a.  hard,  round- 
ed body^  BubMH|uen[ly  fuund  to  he  tho  irochaaicr  major,  wa^  felt 
lying  rather  Jeep  below  the  l«vel  of  the  trochanter  of  the  nght 
■ide. 

^*  Id  the  disseetion  of  Lite  leR  hip,  all  the  muaoks,  large  and  amnn, 
belonging  lo  this  region^  wuro  fl-nad^  hut  nolir-eably  h'^s  full  iu  sub- 
etUDce,  atid  oC  a  lesa  healthy  color,  thna  tho^e  of  the  ri^ht  side.     Tho 


374 


EXTREvrrrEa. 


cliimge  of  directTon  taken  by  ihemi  brougLt  tibout  hj  the  clkAagfi 
tlic  point  of  insctlioQ,  —  namely,  tlio  Iroi'liaiitor  mnjor  nud  the  up*^ 
per  purt  of  tbe  thigh-bone,  —  was  of  course  Jipparect,     The  gloteiu 
miuiiiiLis,  lit*  it  pH»sud  ovi^r  wlmt  rvmaiued  of  ihe  acetubulum  to  renck 
ilfl  poiut  or  iu=«riioa,  was  (irmly  bouod  down  to  ihe  li^fltnent  whk-li 
covoreif  tiie  cr^vity  by  Htraog  hhrotis  liemio.     The  obturator  cxteruiu 
appeHred  to  be  ivduc^d  to  a  I'l^w  tibrc^f  Hrisiag  from  tho  ramu^  of  iltft, 
uchium   and   pubea.      Tba   carlibii^IiiouQ,  nud,  apparcutly.  pari 
the  oflseouB,  rim  of  iho  ftcciftbaluin  was  nb?crbcc].     Sir«tch«d  <^^ 
what   rfmRiiii>il   of  Ibe  onvity  was  what  npponr^d   Co   be  n  part 
the  old  capsHlar  lignment^  Mitl  pHriUlly  Gtn-loaing  the  oeck  of  il 
d i, "t placed  buuQ.     Deuealb  ibia  Jigamutit,  and  filliitg  up  Ibe  {metabului 
WAd  a  dense  iiiJL»a  of  adipose  Btid  fibroua  li^uc.      Kacoinpivj^diiig  lh«' 
new   socket   waa   a   lough   fibrou*   hiyer,   whieh,   as   it   surrouoded 
ih^>  neck  of  thfF  bone,  na-iumod  hII  the  don^iiiy  nnd  strength  of  a  tru4 
capfluk,  with  pcrhnpfl   eveu  grt'fl*er  Ibiekutartn     No  Uhb  of  divisioul 
bctwcou  Iha  nc^v  ntid  tho  old  <:ap^uhir  lignmcot  juM  referred  to  could 
be  dfiteotpd.      Upon  dividing   the   CBpaulaj   b'gameot,    a  ligameulum 
terea  was  found,  dT^itjg  tbe  hetul  ftnuly  to   ibe  sotltet,  And  rei^iTing 
Iho    uutrieut  vcA^i^h  iLrou^li  a  iiotoh   in  lliu   same  relative   postliou, 
□amcly.  In  the  on(t?rior  part  of  the  cavity^  as  in  the  true  acetabubun. 
The  nrticular  eariilage  of  tbe  uew  socket  wa»  wanting  in  that  smooth^ 
shining   appeiirwiitu,    ebftracterwiiir  of  nrtieidHllug  Biirfac«  general- 
\j.     Thai  of  ibe  bead  of  the  bone  wa^  much  less  uneven.     Besides 
the  rouod  li^umenrf  a  few  small  fibrous  blinds  wera  seen  attacbiug 
ths  bend  of  thu  bone   to  the  sookel  anteriorly.     Upon  exuminatioa 
of  the  interior  of  [he  pelvi:^,  the  thyroid  foruiiien  wm  fouEid  lo  be 
ncarty  obHEcraied  by  the  rounded  biL9^  of  the  new  socket ;   but  it  still 
rc^taiDcd  ilB  iincjnbrauo  £trctehed  over  the  intruding  bony  eup^ 

"  Sinfe  niHCefHiion  of  the   soft  lisaiioa,  Ibe   following  points  ar« 
to  be  remarked  in  the  Iwiiiy  ^Irndures:  — 

'^An  ndvcDlitioua  soc^keL  for  the  head  of  the  [higb'bone  is  formed^ 
below,  and  a.  little  ia  advance  of  the  acelnbuliim  on  ifae  left  nid^ 
This  soetet  fiUfl  up  tho  greaier  portion  of  ibp  ihyroid  foramen,  and  il 
bounded  us  Ibllowft :  Superiorly,  by  ihe  body  i>f  the  pnbes  and  the  aco- 
tabulnm^  the  cavity  of  the  liUter  being  encrom^hcJ  upon  by  the  adrea* 
tiiioua  BO(?kec  [o  the  oEtout  of  one-half  of  hs  area  \  posteriorly,  by  Ibe 
body  of  iho  isL^hiuiu,  upon  wliidi  ilie  socket  rests  wiihont  leaving  any 
prkrt  of  the  ihyroid  foramou  viaible^  iufeficjHy,  by  the  rami  of  tlio 
iethium  ond  pubes^  leaving  no  port  of  the  foramen  visible  there  ; 
anteriorly,  by  an  irregular,  crcactnt-stiapci  portion  of  Iho  foramen, 


DlfiLOOATlONS. 


375 


one  and  three-quarter  iQches  iq  Icn^th^  by  qd  Average  brendlh  of 
onc-quartor  of  ua  inoh.  Tlio  nmjar  purt  of  the  soiket  is  at  ooe 
pflpe  ;  but  Ibertt  Jire  four  eepnrote  piefren  of  bene  of  diffi^rent  sikm, 
the  }aTg^t  of  wliidi  mut^urua  two  iocbes  in  leugtli  b^  an  uv«m<;e  of 
oDe  iD<:h  in  breodlb.  Tlic^e  looaa  pariioiifl  bciiis;  liUcd  in  Lbc  places 
where  Ihoy  opponr  lo  belong,  the  aockel  h&H  uti  average  oulaide  diam* 
ercr  of  three  iitrbe^i  and  n  depib  of  iwc  mdiea.  The  subBinnro  ofiEs 
padetus  is  quite  Arm,  but  irregular  *md  rough  externally,  ftod  aome- 
ivhftt  roii^^h  intornally-  Tlie  opeiiio;^  tbrough  wlikh  the  nutrient 
veftgela  pae^ed  rroiii  Ihe  inlerior  uf  [be  peh'i>f  into  the  CHVily  of  Ibe 
joint  is  «een  &t  the  nuierior  porEion  of  tbe  fundus  of  the  mx-ket. 

'*  Wbero  llitT  Bf>t-ki:t  if  uaitud  vi'iih  the  i^chinm  and  the  nxxnl  of 
the  iachjum  and  pLil^r^^  hcuy  niallor  hiiB  Lcou  depotilL'd  in  limilcd 
umount,  so  Ihut  a  liirrow  vxK'UiU  from  tbe  otd  nc-etiibuUim  pislcriorl)', 
round  lo  [be  lower  jwiriion  of  the  LTesccni-Mbupcd  opening  Hurt riorly  : 
but,  upuu  the  superior  aspcrl*  whoi-e  the  weight  of  ilie  body  vaa  lo 
be  mipperled)  the  interMil  LrcLwceu  the  socket  iiDd  (ho  adjoioio^  por- 
liou  of  the  p^lviM  i»  ^ulir^dy  tilled  up.  Tlerf,  in  fad,  14  «eeti  n  tirnif 
ntroDg  huliress,  ihrowu  ncrosa  frtiiu  tlie  budj  uf  the  puben  and  ihe 
ptibic  portion  of  the  ilium  downrtnrdu  and  outwards,  aprending  oyar 
the  wholo  superior  surfuc^e  of  ibe  eorket  quilc  to  ile  outer  od^.  Ou 
exumiDiug  the  iuEerior  of  the  old  aeetubulum,  Its  cavity,  nnlenorlyf 
is  seeu  to  be  pa]i!«idt'rid>1y  euLT0ii(:ljei1  upon  by  ihe  posterior  border 
of  ihfl  butlresa  just  deniTibcd ;  and,  poBlcriorly*  by  «  second  but- 
tress, much  emulJer  thiiu  the  ono  uiontionGdi  thrown  down  upon  1b« 
aocket  from  ihe  ponteiior  poninn  of  tbe  flrelobubim. 

'^  Tbe  heud  i>r  ihc  tell  femur  ts  uiurh  lurger  tlmu  j[s  fellow  of  tbe 
opposite  aidaf  uud  ir^  surfnec  quite  roii^b.  Its  ^renlcat  eircumlcrctic« 
is  tiis  itiehei.  From  the  hi/nd  of  Ihe  bene,  nloug  Ihe  ooek  aDterioHy 
flnd  superiorly,  \si  ihrown  a  ridge  of  bone  Eenrly  reu<;hmg  the  iroeban- 
l(-r  iniijur.  This  oihls  uiulerhilly  to  tbe  ciruun^rvrtucB  of  ibo  necV. 
which  is  itvQ  and  ona-ci^bth  lachort ;  that  of  the  ueck  of  the  opposite 
side  being  four  inehea. 

"  The  mom  caroful  prruliny  fails  to  defeet  ri^s  of  prt^vious  friwv 
lure  anywhere,  either  in  tbe  pelvis  or  in  the  ft^tuur." 


lie /iiarlit, —The  moBt  Importftiit  point  which  Dr.  Wnrrco 
was  caJIcd  upi>»  to  decide  in  tliia  case  wqh  whether  a  Jif*locatioD 
of  the  bone  e^Etsted  or  not.  Hb  opinion  was  thnt  a  Ublocntion  did 
exist.  The  dofcadant  in  the  amL,  liowover^  obtnineil  a  disngrec- 
mcDt  of  tLc  jury  by  the  teatimony  of  a  diatinguiaheJ  surgeoa. 


S?6 


EXTREMITIES. 


who  expre*i.He<!  a  de^Jd*'*!  fniinion  rhiit  there  wm  not  smd  never 
htui  W-n  a  iii.s|o<'aiiij|],  hut  Ouil  the  ori*;ln»l  injury  wae  a  fruc- 
ture  of  the  pelvia.  It  will  be  wen  that  no  signs  of  any  fnictupe 
having  occurred  arc  to  he  found  In  the  ^^^jectLneir*  but  iltat  lW 
inJEiry  wa«  wbai  Dr.  Warren  BUjiji^jsed  it  to  be, — a  simple 
dislocnlion. 

The  question  was  made  very  prominent  in  ihe  trial,  whether 
tlie  ejicciea  of  di^lucalion  of  llie  hip  whiuh  Dr.  Warreu  &upj>ofc<l 
this  to  he,  —  rHincly.  lIowIl^x-:i^]rl  and  baekwarrjs,  ntih  tlie  beud 
of  the  bone  lying  on  the  ischium,  near  the  le^aser  lAcbintic  noldi, 
—  ever  exiateil  ;  and  the  work  of  Sir  Astley  Coo|ter  was  hnui^ht 
forward  In  pruof  tliat  such  a  JIdlucatiuii.  although  [ni^ntioneU  hy 
•ome  authrtritic«i  could  not  take  j>lac«.  Dr.  Warren,  however, 
did  not  utider^lund  Sir  A^dey  to  Ji^ji^trt  that  this  ilisEoralioo 
couid  not  take  phiee.  Moreover,  lie  It^lt,  that  in  any  case  the 
evidenct?  of  hi^  own  iten^e:^  should  rather  be  his  guide  ;  uid,  na 
he  w<i»  aho  of  the  belief  tlijit  there  was  no  depression  at  any 
point  about  the  acctabuluin  in  whii'li  the  he^itl  of  the  boiie  could 
not,  cxeeptionally,  be  lodged,  he  [lersintcd  in  his  o|tinion  tbiit  the 
dmlocation  baekwarda  and  downM-ard^  wa;4  wilhin  tlie  boinidA  of 
poaaibilit^,  and  that  the  dij^Iocalion  in  <|ui;5tJon  wa^  of  tJiat 
deacriptii>n.  In  ihj^  belJrf,  he  hnd  the  nmatenanee  I'f  the  coii- 
milting  snr^eoQs  of  the  Ma^saelkusetta  General  Huspitat. 

Sir  Astley,  at  tliat  |)rnod,  did  not  acknowledge  die  exifiteniTB 
of  thia  apceies  of  dl^plaoeinual  of  the  hip-juint;  yet,  in  later 
editions  of  hia  work,  pnhliaheil  by  Draueby  Coo^ier,  one  or  two 
cases  arc  related  as  having  ajWrw^ard^  ocenrreil  U'i  him  :  and,  ill 
the  edition  of  Sir  A»tley  Cooper  on  Dif^l  oca  lions,  puhlisiied  \>y 
the  MdMUchuseltfi  Medical  Society,  two  eases  of  this  injury  nre 
dcacribcd,  the  Hpceijuena  of  vihieh  I  had  tlie  o|)[)ort unity  of  eee- 
ing  abroad  ;  one,  through  the  politeness  of  Mr.  Edward  Stanley, 
tlie  distinguished  aurgeon  of  ^t.  Bartlioloinew^H  Hospital ;  itud 
the  other,  by  the  kindneea  of  M.  Kobert,  in  Paris.  In  tlie 
latter  cnac,  the  dislocation  was  partial,  with  the  head  of  the  bone 
reeting  on  die  sockets  The  dislocacion  downwards  and  baek- 
■wnrda  w,  however,  at  the  precent  day,  Tery  fully  acknowledged, 
and  1  have  eecn  it  in  my  oivn  practice;  while  Mr.  Erichsen,  in 
the  la«C  edition  of  his  valuable  work,  has  placed  it  among  hte 


I>IS1*0CAT10K8. 


377 


four  forme  of  dielocalion ,  conBirlcrinrr  the  dielocntjon  upwnrde 
&nd  backwiinle  into  the  iecluatLc  notch  oa  dimply  n  Jitli^rcut  form 
of  ihe  dislocation  upwards  on  the  iJium, 

A  few  words  as  to  the  Teasoiu!  which  influenced  Dr-  Warfen 
in  his  deoieion  aa  to  the  kind  of  di^locAtjon  will  be  of  intci^ct^t 
here.  The  limb  wua  len^thenod  ;  the  diaplncement  waa  tliere- 
fore  downwards.  The  next  point  wiie  to  determine  whether  tins 
dl^plucemcnt  ks£  downward^  and  forwards  into  the  foramea 
ovale,  or  downwards  und  backwards  in  the  vicinity  of  the  Jcsser 
iachiatic  Dotch,  The  iachniilion  of  the  foot  ojid  leg  were  such 
as  to  suggest  to  Dr,  "Warren  tlie  poasibility  of  a  displace ment 
into  the  ibramen  ovale ;  but  the  phenomena  were  not  so  marked 
as  to  impress  thia  species  upon  his  mind  to  the  excluaion  of  the 
displacement  downwards  and  backwards,  since  he  was  of  the  opin- 
ion, that  the  position  assumed  by  tlic  liinl)  mi*;;hc  be  varied  by 
drcumstances,  being  inflcienced  by  the  de^jreo  and  direction  of 
the  dlidlocatintr  force,  as  well  as  by  the  subsequent  condition 
of  the  capsular  Ji^ment. 

In  this  condition  of  things,  the  head  of  the  bone  having  been 
diligently  sought  for  at  the  inner  and  upper  |MUt  of  the  thigh, 
and  not  detected  tliere,  but  a.  hard,  round  body  being  distinctlj 
felt  below  and  behind  Ihe  acetabulum,  the  head  of  the  bone  was 
thought  by  Dr-  Warren  and  his  confrdree  at  the  Hospital,  to 
be  lying  behind  and  upon  the  lower  part  of  tlie  body  of  the 
ischiuiu,  in  the  vicinity  of  the  lesser  isehiatic  notch. 

The  dislocation  as  it  now  appears  it  not  as  it  waa  described 
by  Dr.  Warren ;  but  the  socket  for  the  head  of  the  bone  lies 
almost  inuDcdmtely  under  the  old  acetabulum,  perhaps  a  little 
forward  of  it.  The  cause  of  the  deception,  it  will  be  surmised, 
,1hi  in  the  fact,  that  tJie  head  of  the  bone  found  its  resting-place 
tlmosC  immediately  under  the  aoetabuluni,  at  the  poeterior  part 
of  tlie  thyroid  foramen,  and  in  contact  with  the  body  of  the 
iichiuni.  Such  a  position  of  the  head  wotild  render  its  detectiou 
anteriorly  quite  diHicult^  even  in  very  thin  persone. 

The  specimen,  beautifully  prepared  by  Dr.  Oliver,  may  be  seen 
in  the  cubmet  of  the  Warren  Mu^um  of  Natural  History,  Its 
appearance  is  faithfully  represented  in  the  annexed  en^aving, 
oopied  from  a  photograph*     Above  the  advcntitii^ue  eoeket  lied 

48 


378 


£STREUlTiE9. 


Hi 


what  remaine  of  the  ncctabulum.  Anteriorly  ia  seen  the  cres- 
oenl-shaped  portion  of  the  thjrokl  fonimen,  mitl  fhe  twitch  iIp' 
scribetl  aa  admitting  the  nutrienl  veaeolfl  of  the  joinC.  The 
larger  butd-esa,  described  hy  Dr,  Oliver,  ie  perceived  above  tlie 
new  flocket,  and  nnterior  to  the  oeotahiilam.  The  change  in 
the  Appearance  of  the  head  of  the  ihifrh-bone  of  the  affected 
Bide  ]fl  very  faithfully  deliiien-lcd. 

The  flpeciraen,  OBide  from  the  interest  na  coDnccted  with  the 
trial,  is  exeeedinglj  inetrucHvo  in  several  re^pecte.  It  la  most 
curious  to  observe,  that,  in  the  depoeilioD  of  the  bony  milter 
in  the  fonnaticm  of  the  new  aoekel,  a.  distinct  interval  is  left 
for  the  entrance  of  the  nutrient  veescla. 

The  firm,  Hlrong  biittres3e&  which  nature  hsvB  provided  are 
found  just  at  the  points  where  tliey  are  needed  in  the  support 
of  the  btxly.  The  depth  of  the  new  aockei  is  quite  remarkable, 
and  will  explain  in  a  mea^uro  tlie  imposfiibility  of  abductintr  ^r 
acidulating  the  limb;  the  edges  coming  eo  far  forward  on,  and 
oncompoaeiag  ao  closely,  tlie  neck  of  the  thigh-bone,  elb  to  make 
any  such  action  impracticable. 


Case  CCXXUl.  —  DUlocation  of  the  Thi(fh  into  the  Fo- 
t^men  Ovale,  fieduction.  ^  In  the  early  part  of  May,  1859, 
I  wafl  called  to  see  a  man  who  Lad  received  an  injury  of  the  hip^ 


DISLOCATIONS. 


'did 


joint,  nho  other  injaritg,  hy  the  fiill  of  the  wnll  of  a  house. 
When  I  orrivL'd,  he  \v^  lvii>;i  on  his  bnck,  witl»  hia  Icil  leg 
flexed  on  tho  pelvii^,  untl  eimidin^  ofi'tVom  iho  uthor  at  an  angle 
of  nbont  45**.  A  slight  hollow  wiia  peruciTcd  nt  the  scat  of  tho 
trocJmntcr,  nnd  tho  foot  waa  slightly  everted.  Taking  hold  of 
tlic  nficctcd  bone,  I  found  it  in  a  great  degree  fixed  i  and,  tha 
foot  being  evorCcd,  I  &t  once  recognized  n  dialocatioii  into  tho 
fiti'itmen  ovjde  without  further  cxriminntiiMi,  kuowin;^  that  no 
other  injury  cuidd  lUVfiCiit  thc^c  evmptomj*,  unWa  it  were  a  frac- 
ture of  t};e  neck  of  the  thigli-bonc,  in  ^vhieh  case  there  would 
liftve  been  tt  (certain  decree  nl  niobjlitj  of  the  injnred  Umb- 
farther  exnmiiintioQ  also  wa8  imprncticiiblo,  the  patient  haviii;^ 
his  ciotlios  on,  lying  In  the  street,  and  inaliinfr  the  ^rretLtest  out- 
cry on  tho  elighteflt  attempt  to  determine  the  nature  of  tho  in- 
jury. In  addition  to  the  above  di.aloeatt£m,  ho  had  a  fracture  of 
(he  liiwer  eri<l  of  the  radius  of  the  loft  arm,  and  n  deep  cnt  on 
the  right  temple- 
He  WRS  plaoei^l  on  a  Hltert  and  conveved  to  the  Hospital, 
whero  I  almost  immediately  fullowed.  He  wns  etherizeil,  and 
the  dislocated  bone,  with  very  slight  manipulation,  slipped  into 
itfl  plaoe.  The  patient  vas  kept  in  bed  about  tlirco  weeks  by 
hia  other  injnriee,  bnt,  on  gcttini;  upon  his  foot,  rceovored  rap- 
idly. The  fractured  radius,  whieh  wos  much  displaced,  was 
ti'catCfl  with  the  splint  contrived  by  Dr.  Dond,  of  Philadelphia, 
for  that  injury,  which,  for  comfort  and  efficicney,  is  superior  to 
Qtiy  one  that  I  know  of  for  the  treatment  cf  this  troublebome 
ueeident. 


Cabe  CCXXrv.  —  Ditlocaiion  into  the  Foramen  Ovale  of 
yhur  veekif'  standing^  with  other  Injuries.  HeUuctiott.  — 
Oct.  !l,  18(jl.  A  younp  man,  lil  ycnra  of  age,  was  brought 
into  the  Hospital,  having,  twcnty-ecvon  days  before,  fallen  from 
the  forevord  of  a  ehxp,  while  at  sea;  strjkini;;  first  on  tho  roof 
of  the  cabin,  and  from  thenee  slipping  ofl^,  and  strikin;;  the  roil. 
By  the  first  blow,  the  hip  was  dialoeatcdj  and,  by  the  second, 
the  right  arm  was  broken  in  three  places,  vi^fi.,  tho  head  of  the 
humerus,  tho  oloeranon,  and  the  wrist.  Tho  bones  of  the  arm 
ha<l  united  when  be  entered  tlic  Hospital ;  the  joints  being  rigid. 


380 


EXTKEM1T1£S. 


anil  the  shnft  of  the  hunienifi  nkiicli  in  a[1viLn(.'6  of  the  lieml  <jf 
the  b(>ne.  The  pittiout  wa«  in  rather  a  feeble  *ityle,  and  hiul 
gone  through  mueh  AufTcHTig  at  eea;  for  Tour  days  af^^r  tJie 
injury  there  being  a  siippreflaion  of  urine.  Tfip  left,  tiiLgh  vaa 
out  of  ita  place,  the  knee  was  Lent,  the  shaft  of  the  feiuur  pro- 
jected forwards,  forming  an  obtuse  angle  with  tiie  body-  The 
toea  presented  almost  directly  forward*.  The  troehanter  was 
not  prominent,  as  on  the  opposite  side  ;  but  ihf  re  waa  no  hollow. 
At  the  upper  and  inner  part  of  the  thighi  a  prominence  could 
be  felt,  not  perceived  on  the  other  side ;  and  this  could  be  dis- 
tinctly felt  in  the  rectum,  and  was  undoubtedly  the  head  of  the 
bone. 

The  patient  being  fully  othorizod,  the  thigh  was  seized,  and 
cffoita  made  to  break  up  any  iidliesionft  winch  might  have  beeti 
formed^  by  making  motions  of  flexion  and  rotauon.  By  the*e 
manipulatioua^  the  head  of  the  bone  ^vas  dislodged  from  its 
position,  and  slipped  up  on  the  piibia,  but  would  not  enter 
the  socket-  On  further  eftbrta  being  made,  it  slipped  round 
under  the  eocket^  imd  finally  lodgi^d  on  the  dorsum  ilii.  In  (he 
course  of  the  reduction,  tlie  appearances  presented  by  nil  the 
diderent  dislocations  of  the  hip-joint  were  imitated.  The  pul- 
leys were  now  applied ;  nnd  the  limb  being  gradually  drawn 
down,  when  opposite  tlie  socket  a  movement  of  rotation  waa 
given  it,  and  it  slipped  in.  After  the  reduction,  a  rigidity  of 
the  muscles  on  the  part  of  the  thigh  still  gave  it  an  unnntural 
look,  as  if  it  might  be  ont  of  its  place ;  but  the  lef^iomtion  of 
an  equal  length  to  ilie  other,  and  the  free  motions  which  could 
only  take  plat^e  with  the  head  of  the  bone  in  the  socket,  diH[)elled 
any  doubts. 

The  feet  were  then  bound  together,  and  the  patient  was  put 
to  bed.  When  seen,  an  hour  after,  the  hml)  aj*ain  proje(?ted 
forwards,  aa  before  the  operation  ;  and  it  was  enid  that  it  Kad 
a^umed  that  position  after  some  struggles  made  by  the  patiect 
in  coming  out  from  the  effects  of  the  ether.  A  little  force,  being 
opplie^l  lo  it,  brought  it  down  to  a  flat  poeitjon  in  bed.  While 
under  the  ctl^er,  flexion  was  given  to  the  stiffened  joints  of  the 
upper  extremity. 

The  patient  complained  much  of  pain  in  the  upper  part  of  the 


DISLOCATION  B. 


381 


tliigh,  an(]  required  aixty  drops  of  clisir  of  opium  to  m&ke  biin 

fiJccpi 

Go  the  followiug  day,  there  wtis  a  suppre^aion  of  urino,  aa 
hod  occurrcfl  &ller  the  &ccidenti  He  gruducUl}'  but  compJotclj 
recovered  the  uac  of  all  bid  joinLa  iu  nbout  a  month  after  the 
reductiou. 

Case  CCXXV.  —  DidocaUon  of  Thtgh,  -with  Fructrtrt  of 
the  Acetabulum^  Death*  Aniopst/.  —  A  strong,  robust, 
though  mtoiapcrate  man,  36  years  of  age,  fell  from  a  nx^f, 
eCriking  on  hia  right  side,  and  waa  carried  to  the  Hoapital.  The 
tollowing  ia  the  report:  "On  entranee,  the  patient  lies  on 
the  injured  side.  When  placed  on  hia  back,  it  waa  found  that  the 
right  Ic^  wna  shortenctl,  the  knee  aemi-floscd,  and  the  foot  in- 
verted. The  patient  being  etherized,  the  thjgh  couhl  bo  Hexed 
at  a  ri^ht  jinglc  ^vjth  the  iibdomeu*  Crepitus  could  be  heard 
nbout  the  head  of  the  bone»  By  continued  exertion,  the  limb 
waa  extended  to  within  half  au  inch  of  the  length  of  tjic  aound 
limb,  and  Dcsault'a  apliut  applied." 

The  day  following,  the  patient  died  of  delirium  tremena.  At 
the  autopsy,  the  following  apppnrancea  were  presented:  There 
yas  li  great  cfIii»on  of  hlood  into  the  tiat^uts  nbout  the  ^at  of 
injury.  The  head  of  the  feiour  projected  a  ehort  distance  be- 
yond the  edge  of  the  great  sacro-iechiatic  notch,  haviag  fd- 
lowed  the  groove  left  by  the  dieplsiceinent  of  a  fractured  portion 
of  the  acetiibuijin  and  bone  behind.  The  latter  waa  about  an 
inch  and  iL  half  squnre,  and  three-qunrCera  of  an  inch  in  thick- 
ness at  the  ihiclieat  point*  The  fracture  alao  extended  through 
the  acetiLbuIum  and  the  bone.  The  head  of  the  femur  waa 
deeply  indented,  and  the  fragments  of  the  bone  and  cartilage 
were  separated. 


Case  CCXXVI.  —  Dulocaiion  of  the  IIip-jiAiU  back- 
wards^  and pro6tti/lij  dowitroa/tlff^  Reduction.  —  A  little  boy, 
aix  yeara  of  age,  waa  eitting  on  n  long  lieiivy  pi^-ce  of  limber,  ou 
March  18,  1800,  when  it  rolled,  throwing  him  down,  and  passed 
OTcr  him,  bruibi[)g  different  parts  of  his  body.  When  taken 
into  the  houee*  he  aeemed  ao  much  iiijui-ed  otherwise,  that  hia 


KXTKEUlTlEfi. 

mother  diil  not  pny  pirrticuliir  atCenliun  to  tlic  injury  of  the  hip- 
On  ihc  third  day  alter  the  neculcnt,  Dr,  S.  A.  Green,  iK^iitg 
calTvd  In,  iloteclcd  u  dir^luculiou  of  the  left  hip,  and  udvjeod  hia 
removal  to  the  Hospito-J. 

^^''hcn  I  firat  saw  the  boy,  he  wna  lying  on  the  ri^ht  side; 
the  Joft  thjf^h  bein^^  drawn  np  ntarlv  at  a  ri^fht  nn^le  with  ihc 
body,  and  placed  rather  iteroeo  the  opposite  limb,  ns  in  eorne 
cased  nf  hip-di&eaee.  On  lifting  hi«i,  and  lunkin^  hira  Etfin<t  on 
the  sound  limb,  iLt  the  same  time  dra^^'lng  down  the  di^pW'ctl 
ore  as  for  lu  it  would  ^,  the  {not  pointed  forwunld,  inetcud 
of  reatin^;  on  the  top  of  the  other  fotjt,  ne  in  disloealjjii  ud 
the  dorauin  ilii ;  tijc  pelvis  was  driipofcd  down  somewhat  by  the 
llinb,  and  llierc  was  g^at  tension  of  the  mu^lcis  running  frum 
the  femur  to  the  pelvis*  ae  ie  aometimes  seen  in  dieloeatiOD 
into  the  furamcn  ovale,  whioh  it  somewhat  rcfternbled  in  this 
respect ;  hut  one  •^>i  the  prinuipal  si^zne  ol^  that  dislocation,  the 
deprceaion  of  the  tro<*hniiter,  was  wauling.  Thu  di^loention,  in 
fact,  rceomblcJ  more  what  htis  usually  been  eulh'd  the  disloca- 
tion downwarda  and  backwartU,  in  wfijt^h  the  hi?nd  of  the  bono 
liea  a  little  behind  and  below  the  aookcti  I  totrk  pains  to  try  to 
obtnin  eome  measuremonte  aa  to  the  dift'ereneo  in  Icngili  of  the 
two  liiuba ;  but  found  this  inipmcticnble,  in  consequenec  of 
the  bent  position  of  the  thi^h  on  ihc  pelvia.  The  head  jf  the 
bone  eoidd  not  be  felt,  on  account  of  the  swelling  whieli  had 
taken  pinee  from  the  length  of  time  eince  the  displacement. 

The  ehild  bein^  etherized,  I  tiret  attempted  to  reduee  tho 
limb  hy  the  method  of  sweeping  the  tbigh  over  the  opposite 
limb  and  pelvis,  protiucing  a  rotation  of  the  bone.  Tlie  litnb 
waa  then  eeizcil  by  the  ankle,  njriidually  dm<;ged  down  into  u 
straight  poBihon,  and  then,  by  a  alight  rotation  outwarda,  the 
head  of  the  hone  clipped,  w^ilh  a  very  dlatinet  aouiid,  into  its 
socket,  ^lotion  could  now  be  maJc  of  it  easily  and  frcoly  in 
every  direelioup 


Case  CCXXY  11.  —  Fmct  a  re  of  Upj^r  P<trt  of  Thigh- 
bone^ imitatii/g  Dislocation  of  thf  Hipfoint.  —  A  powerful 
man,  aged  40,  a  seuumn,  entered  the  llocfpitalf  Juno  1-1,  1865, 
for  an  injury  of  tho  bip-joiatj  received  seventeen  months  be- 


PISLOCATlONfl. 


383 


r<ir«i  whidi  he  ^uppofleil  to  lie  n.  dir^locstLion.  "  IIi^  waa  guaH* 
ing  a  gavemment  warthou^  at  Alexandria,  Va-,  when  he 
diflcovered  tliree  ^eriUaa  in  tlie  third  atorj".  He  discharged  liis 
musket  at  one  of  them,  killing  him  inetantlj  ;  the  ^etoiid  took 
to  liis  hnela;  it  struggle  then  ensued  hetwecn  the  patient  apd 
the  thud  onu.  which  entled  lu  tlieir  grappUdg  each  other,  and 
both  rolling  down  u  hatchway,  landing  on  the  ground-tloor,  a 
diatttuce  of  eome  thirty-five  feet,  the  guerilla  underncathn  The 
latter  receivetl  two  fractured  legs,  Hud  a  eenleiice  of  fifteen 
years  In  the  Alhuny  Penitentiary*"  Tlte  seanistu  wna  carried  to 
a  hu.Hpi(jd,  and  etheriaed.  He  waa  aftcrwajxU  infomicd,  that 
hia  thigh  waa  dislocated,  but  had  been  reduced  ;  and,  at  the  end 
of  BIX  monlha,  was  disdinrged.  Ilia  leg-,  however,  never  aa- 
Bumed  its  original  length,  and  lie  hud  the  iJiipreflalon  tliat  the 
di«Wation   vkim   never  reduced. 

Upon  eKunination,  there  waa  found  shortening  of  one  inch* 
but  neither  inversion  nor  everaion.  He  could  walk ;  though, 
owing  to  the  shortening  and  stiffness  of  tiie  iilp-joint,  he  carried 
a  cane.  There  waa  an  irregular  [irojectiou  (bony)  bdiind  the 
trochanter  major.  Patient  was  stout,  robust,  and  in  cicellcnt 
hcidtli.  Upon  inveatiga(ion,  it  was  decided  that  the  head  uf  the 
tlijgh-bone  was  in  its  socket  j  and  that  the  shortening  was  due 
to  a  fnu'ture  received  at  the  time  of  the  fall,  the  precise  nature 
of  which  eouhl  not  be  ascertained,  Itc  was  again  examined  June 
21st,  under  tlic  iuflueuce  of  etlLcr,  in  the  preHcnce  of  all  the  via- 
ttln^  Aurgeous  of  ihe  Hospital.  It  woa  decided  that  tite  head 
of  (lie  femjr  wkh  in  it»  pro]>er  position,  and  the  shortening  was 
tlie  result  of  thp  old  fraclui'e. 

The  stiiTncss  of  the  linih,  ihe  projection  behind  tlie  socket, 
and  the  want  of  history  in  regard  to  the  fracture,  at  first  led  Ut 
the  suppoNitiiiii  that  the  patient^s  impre^r^ion  iv^  to  a  dislociUioa 
esisLing  might  be  a  true  one.  Under  ether,  however,  the  mo- 
tion of  every  kind  which  could  only  be  given  to  the  head  of  a 
bone  in  its  socket,  showed  tliat  die  a]jpearances  Wei's  caused  hv 
fracture,  whiitcver  the  original  injury  had  becii^  wliicli  possibly 
might,  fnim  the  italure  of  the  accident,  have  been  both  fi-actunj 
and  dialocution. 


384 


EXTHEMTTIEe. 


The  fullufving  is  a  Buznniary  oF  tte  dis]i>catianH  of  the  hip 
tnsatctl  in  i\\Q  Mar^ixhasetU  GcEieiul  Htiaplud,  Jrum  Dec^m* 
hev.  1821,  to  May,  1865:  — 


DDTAiiin  Ilii SS 

Forsmea  Ovale      ......        8 


S8 


89 


Of  tlieae,  36  occurred  in  mnles,  and  1  in  a  fciuaic-    In  19*  die 
puUcjB  ivere  used  ;   in  20,  no  pulleys-     Two  of  the  uaauixeoflrii] 

CMe«  were  complicated  uith  tVaciure. 


AMPUTATIONS. 

The  queelion  of  poiiita  of  election  for  the  performance  of  am- 
putation has  been  re-opened  within  the  past  few  ye»rfl>  and  the 
nile  of  practice  lunterially  changed  from  that  even  now  taught 
in  oome  of  the  a[jpruvcil  European  (e^t-books.  Tbe  old  rule  of 
amputating  the  leg  witliin  a  few  inchee  of  the  knee —  for  an  in- 
jury, perhaps,  of  tlie  ankle  —  hats  given  place^  in  thia  country  at 
Icaflt,  to  the  much  safer,  and  in  crery  reaped  better,  prnctiee  of 
saving  as  niuch  of  the  limb  as  possible.  This  reform  ifl  due 
almost  wholly  to  tiie  inveittion  of  tlie  improved  conical  docket^ 
no-vf  no  univi^r^ally  employed  iu  modern  artificial  liiuba,  iu  whicli 
the  weight  of  the  body  ie  eustaiiied  by  tlie  accurate  adjustment 
of  the  tapering  sides  of  the  etnmp  to  the  corresponding  cavity 
made  to  receive  it,  while  the  senaitive  cicatrix  i^  efiectually  rc- 
lieved  from  pressure. 

The  advantages  of  immediate  amputation  are  pcrhnpH  now 
more  fully  recognised  tlian  ever  before.  Even  during  the  pe- 
riod of  JcprctisioEi  or  sliock,  where  it  would  formerly  have  been 
thuiiyhl  uecenaury  to  wait  for  re-iictiun,  we  now  feel  justified,  in 
most  caaea,  in  proeeedlug  at  once  to  the  operation;  having 
learned  by  experience,  tlmt  the  inhahttion  of  cdier  ia  generollj 
attended  by  a  greater  and  more  rapid  reatoralior  of  the  vital 
forcea  tlian  tliat  which  followa  the  esihibition  of  alcoholic  sdmn- 
lantfl.  Cy  operating  at  thia  time,  many  patients  may  be  saved, 
who  would  otherwise  die  from  the  gradual  loaa  of  blood,  and 
from  the  ncrvoufl  irritation  dependent  upon  extensive  injury. 


AHPUTAT10X3. 


385 


The  kinds  of  operation  ■which  have  gcnornllv  been  preferred 
in  this  ^'iijinit^  arc  the  circular  for  limbs  with  a  single  bone,  and 
the  flop  for  the  fore-arm  and  le^.  The  opetntions  of  Syme  imd 
Pirogoff,  for  sr^ving  lu  niuch  as  possible  of  the  lower  extremity, 
and  oa  eubetitutea  for  fimputittion  in  the  leg,  arc  woU  worthy 
of  luloptien  in  suitable  cnsC€. 

Tlie  operation  by  daps  of  skin  alone  id  now  looked  upon  with 
great  favor.     I  have  often  [lerforrned  il  with  much  satii^faction. 

One  amputation  —  timl  at  the  hip-joint  —  may  bo  pai^iieularly 
mentioned,  on  necouat  of  ita  etriking  want  of  eucecBe.  Out  of 
twenty-three  operations  mentioned  by  Maclcod  ns  having  been 
pertbrrued  in  the  CnineaT  ull  proved  fatal ;  and,  during  the 
late  WOT  in  this  country,  the  euceceaful  casca  woro  very  few. 
It  has  been  thought  safer,  therefore,  to  leave  □  niaUf  with  a 
compound  comrainuted  fraciurc  high  up  in  the  thigh,  to  the 
clmneea  affordeil  by  nature,  rather  tban  to  perform  tJie  umpu- 
tatioo  now  under  consideration, 

I  have  had  an  opportunitj^  of  twice  performing  tliia  amputa- 
tion in  Boston,  One  t'ase  was  in  a  child  whose  limb  was  par- 
tially torn  oS  by  a  railroad  oeeident ;  tbc  other  was  for  a  largo 
tumor  of  the  femur,  which  reached  hi^h  up  into  the  groin.  The 
first  patient  died  at  the  end  of  a  fortnight,  without  evident 
cause,  when  apparently  in  a  fmr  way  of  rccoi'ery  ;  the  other 
recovered.  The  method  adopted  in  the  lost  ease  was  hy  making 
anterior  and  posterior  i[\i\is  of  integument;  tying  the  femoral 
artery  before  making  tlie  section  of  the  muscles. 

In  cosec^  of  rc-ainputation  for  diseased  stumps  of  the  legf  and 
for  tumi>rjd  high  up  on  the  ]eii;,  where  it  is  desirable  not  to  go 
above  the  knee,  I  have  had  the  following  experience  :  — 

The  tlcpa  of  akin  bein<^  made,  and  the  tibia  and  fibula  sawn 
tbrtnigh  ju3t  below  their  heads,  the  popliteal  artery  is  upt  to  be 
cut  ofi'  ut  its  division  into  the  antenur  and  |>odterior  tibiu] 
arteries*  At  the  same  time,  the  stump  almost  immediately  is 
retracted  by  the  muscles  into  the  [lopliteal  tipaee  ;  and  a  trouble- 
some hemorrhage  commences,  whidi  it  is  ditRcult  to  arrest  with 
the  patient  in  hie  ordinary  position  on  the  back,  and  embarrasa- 
inent  is  experienced  in  finding  the  vessels-  Much  blood  also  is 
u»ua]]y  lostf  if  the  surgeon  has  trusted  the  vessel  to  digital  com- 

la 


3S6 


E^TREMlTIBfl. 


presftion.  DMring  the  flpnng  of  18r>fi,  Imving  hnil  a  niim1>er  of 
tlictic  ernes  t[»  deul  wilh,  I  JoiinJ  ^<:ut  cuove[uence  i[i  (liming 
tlie  patient  at  once  over  cjd  \us  face,  in  whicli  position  llie  ves- 
sels were  eiieilv  sei^iited.  In  these  caaea,  the  simple  (laps  uf 
flkin  have  healed  luach  more  fnvorablj  tlmti  by  the  old  msihtu] 
of  iDLiBCiibr  £&pf<,  as  rccommeiKleU  by  Liaton.  For  imiputation 
of  the  thigh.  Dr.  John  Green,  formerly  of  Boston,  i\*tw  of  St. 
Loul^,  in  ihe  June.*  noiuher  vH  the  Boston  *'  MedLal  anil  Surgieal 
Juurual ''  for  lf^63,  has  gnen  nn  eAcelleut  r^^itm^  of  ibe  he*t 
melhuila  now  in  uae  for  making  n  good  «lump,  which  liave  been 
Buatained  by  hia  exi>erienpe  in  the  army  Juruig  the  Jate  war. 

On  account  of  the  ilani^LT  of  pyivnn;i  in  a]n]>utittiuas  at  the 
pz-eaent  day,  it  luis  been  projjofied  to  opcnite  at  the  joint,  as  le«e 
likely  to  be  followed  by  this  occurrence,  tlmu  where  the  bone  U 
diviiicd  in  ita  coutiuuity* 

LUfcanc'a,  Chopart's.  Pirogoff*fl,  and  Syme's  operation*,  I 
have  hail  occasion  to  pcri'orni.  In  elviL  practice,  howevetT  the 
nature  of  the  iiijurj"  for  whicli  aaij»ulatiun  is  peiTornied  ia  such, 
that  tile  opjiortnniiy  icr  these  opcrjitlon^?  is  comparatively  rare- 
They  are  peeuliialy  ajipjicahle  to  the  leaiuna  produced  by  fire- 
araiiH. 


Case  CCXXVllI.  —  Aitipniniion  of  ihe  Arm  above  the 
Slhow  for  OftJigeuital  Cancer  offht  F'o^t-ami.  Ditiih,  apf.r 
tfOo  years,  Ji-oni  Internal  Oanfrfr. — A  child,  11  nionllia 
old,  wafi  brought  to  tny  fiLU^gicEil  Lafirniai^  hy  !ta  pareiit^^,  on 
Sept.  9,  1843,  having  a  large  tumor  involving'  the  whyle  uf  the 
left  forc-ami.  At  birth,  (he  tuiiior  uas  about  the  size  of  an  eggi 
and  regularly  increased  with  tlie  growth  of  the  child- 

The  mother  waa  delicate,  but  none  of  the  funtily  hod  been 
affectetl  with  cancer.  The  child  was,  hi  other  resjiccts,  appar- 
ently in  iine  bealthi  The  ti[Luor  evidently  Avoa  earcinoinutoud- 
It  was  of  a  firm  coii^iatence,  flomewbat  irr^fgular  in  ita  outline, 
and  in  one  part  slightly  discolored.  Intniediate  amputation  waH 
advised. 

The  parents  did  not  bring  the  child  n^nin  uutd  the  7th  of 
October,  nearly  a  month  afterwarde.  The  tumor  wa*  then 
larger,  mid  had  Hoftened  at  the  diacolored  portion-  Atnput&- 
tioD  was  performed  above  the  elbow. 


AMPUTATIONS. 


397 


The  opcrnlion  waa  borne  well,  nnd  in  a  few  weeks  the  child 
recovered  perft'otly.  The  Euiuur,  bem^  cut  open,  was  found  to 
be  encepbalotd  cancer,  eoftening  having  commenced  in  it-  I  did 
not  henr  fi^oni  thia  cliild  Jtgain  until  the  month  of  June,  1S45, 
when  I  wne  culled  to  nltend  the  nuiopey  \  he  ha\-ing  died  under 
the  following  cirf^utnetonces.  He  had  been  in  full  hciilth  until 
throe  months  before,  when  a  phyeician  wna  cnUed  to  sec  him, 
Hnd  found  him  laborin*;  under  a  eli^ht  coufjh^  and  distress  in 
the  ri^ht  side  of  ihe  ulieet,  which  wiia  alighlly  enlarged.  The 
cou9;h  and  jtaln  gmduaily  increased ;  the  cheet  end  abdomen 
becoming  enormously  distended,  ae  if  from  an  internal  tumor- 
He  finally  died  in  ^eat  eufferinc^- 

Thc  cavitv  of  the  thorax  waa  occupied  by  an  enormouE  TnafB 
of  encephatoid  diseaae,  which  bad  token  the  place  of  the  lun^, 
eome  traces  of  which  were  found  in  the  back  part  of  the  chest. 
The  diseased  masjs  forced  thft  heart  over  to  tlie  left  eide  ;  it  dao 
projected  throiiirh  the  crura  of  the  diaphrarrm  into  the  abdomen. 
The  flubptance  of  the  left  lung  waa  etuddod  with  enccphaloid 
mo^^ea,  some  of  which  hung,  ae  it  were,  dependent  from  ila 
eurfncc.  The  heart  wqb  healthy.  The  Uvcr^  although  net  de- 
cidedly eancertjua,  Mvas  evidently  much  changed  in  elructure. 
The  kidneys,  fpicCQi  and  other  organs,  were  normal.  The 
etutnp  of  the  nrm  ampitt;itcd  was  in  a  healthy  condition,  na  well 
ne  the  axilla  of  that  eide.  The  o:ctroaiitica  of  the  nerves  were 
much  cnlariHxL 


Case  CCXXIX. — Amputation  at  ihs  Shottider-joiiit,  for 
Siippurafioii  af2er  a  Bttnt,  —  A  boy,  foui'  years  of  (lo^,  wne 
brought  into  the  IJoepjinl  in  the  middle  of  February,  lybU,  with 
his  entire  arm,  part  of  hia  face,  and  cheat,  burned  by  the  explo- 
eiod  of  a  buming-tiuid  lamp.  The  burn  of  the  face  and  cheat 
did  well  \  but  almost  the  whole  auffn.cc  of  tlic  arm  suppurated, 
and  for  a  long  time  it  waa  supposed  the  child  must  auceurab,  so 
profnee  was  the  discharge.  He  was  only  kept  aUvo  bv  the  use 
of  largo  quantities  of  stiumlanta,  taking  from  b\s.  to  eight  ounces 
of  brandy  tn  twenty-four  liouvi^,  Finaliy,  about  the  thiixl  week 
in  Morch,  the  arm  bcgiin  to  have  a  gangrenoua  p.ppearanee,  with 
patches  in  difTcrcnt  parta,  attended  by  hemorrhage  from  one  of 


36& 


ExxiiEwrriES. 


thpni.  yirhich  wna  arretted   by  tfie  percbloridc  of  iron-      He  had 
alB<>,  iLt  tliirt  lime,  beiuurrliugK  from  hia  nose. 

Aa  floou  ti6  the  cliilil  liad  raLlii?d  eufficieutly,  it  vna  proposed 
to  remove  the  arm,  tlie  Bti^nfU  from  which  was  hardJj  aupport- 
nhle  in  the  room.  Tlic  parentft,  who  were  of  tLe  nmsL  iji^norant 
flnd  d«;rnided  eort,  at  firat  declined  to  have  iiny  lliiDg  done,  hut 
finally  consented-  The  daily  dicHj^ing  of  tlie  wound  caused  the 
raost  violent  outcriea  from  tlic  patient^  on  uccouut  of  the  excels 
sivE  pnin. 

Thehiirn  extended  quite  up  to  the  ahoulder;  anilt  with  ihe 
exception  of  fl  ^mnll  dRp  of  wkiri  beliind,  there  wiia  uo  iutegu- 
menl  left  to  cover  the  wuund.  In  removing  tlie  liiub  at  the 
joint,  the  head  of  the  bone  was  found  to  be  so  incorponited  with 
the  capftule,  uml  attitcJied  to  it,  a*  well  as  ao  noftcncd  by  disease, 
that  the  knife  at  firat  cut  deeply  into  it.  The  vei^sL-ls  were  iui- 
Diediately  seized,  compressed,  uutl  tied,  ao  that  very  little  blood 
was  lopt.  A  couple  of  fluturea  brought  together  the  inegular 
edges  of  the  wound. 

The  irritation  caused  by  tlifi  limb  being  removed,  the  patient's 
pulae  rose  at  once.  He  almost  immedialely  began  to  take 
food,  reeovereil  his  appetite^  mul  very  aoon  h'ta  health. 

Some  time  afterwiinla,  lie  was  seized  with  attJioks  of  uocon- 
aeiousnes^i  lasting  at  first  for  a  short  time,  and  ultimately  filed 
witli  cerebral  ayraptoms. 


Case  CCXXX.  —  Amputation  at  the  Shmildtr-joint  Jitr 
Injitrif.  —  An  Irishiniin,  32  years  *if  age,  waa  hronglit  to  the 
HoMpitid  on  May  IG,  18p'>1  i  his  arm  having  been  drawn  in,  two 
hours  before,  between  the  cog-wLeela  of  [Kiwerful  uiacluncry 
used  for  pressing  heiiip.  The  limb  parsed  in  up  to  tlie  shoul- 
der. The  bonea  of  tlic  liniid  were  fmmd  to  he  cnished,  the  ra- 
dium and  ulna  not  broken^  tlie  lower  two-thirds  of  the  humerus 
comminuted;  and  an  opening  over  the  hnichial  artery,  tvro 
inches  below  the  axilla,  uElowed  the  finger  to  be  pajsbcd  in  and 
up  to  the  joint.  The  limb  wu^  removed  by  an  anterior  and  pos- 
terior flap.  Some  diffieulty  waa  exiJerienced  in  d Ian rtieulating 
the  hcatl  of  the  honieru^^,  from  the  fa^t,  that,  the  bone  being 
broken   below,   im   purchaj^e   could   be   liad   by  wliich   the  head 


AMPCTATIONB. 


389 


could  be  lifted  from  its  sockctn  A  powerfiil  pair  of  forceps  had 
been  provided  tor  thi^  purpose ;  but  the  diripiucomciit  wiia  cf- 
fcclcd  without  having  recourse  to  them.     Tiic  patient  did  wcll- 

Thio  wBfl  the  fii-st  case  of  ataputntion  at  ihc  sliouWer-joint 
occurring  at  the  KospitaL 

It  will  not  he  out  of  plncc  to  mention  here  a  contrivance 
which  I  bad  auhapqucntly  arranged  to  replace  in  &  dcg;reo  the 
amputnlcd  arm.  Finding  how  free  and  powerful  the  actions 
of  tlic  muftcica  were  npon  the  scopuJa.  I  bad  a  inrge  solid  leather 
cot  or  covering  made  to  fit  the  stump.  This  was  kept  in  pUco 
by  two  stmps  ;  one  passing  over  the  oppoeite  shouldnr,  the 
other  and  stmnger  one  round  under  tlic  opposite  osilla.  A 
strong  hook  waa  inserted  in  the  end  of  tlie  stunipp  With  this 
appendage,  the  lOfln  fleaurcd  me,  thnt,  after  eomc  months'  pmc- 
titc,  he  was  able  to  do  aa  good  n  diiy's  work  in  sawing  wood 
OB  he  formerly  eould  with  the  lost  arni< 


Case  CCX:XXI,  —  M^tUgnant  Tumor  of  the  Rirfht  Arm^ 
requiring  Amp^Uilioii  at  the  ia^houfdc^'-joint*  —  Thi a  patient 
WA0  a  tall,  thin  man,  30  years  of  ngo*  He  had  olwa^'a  been 
heiilthy  until  Aprd,  1^50,  when  he  had  Ui^^hm-gefl  of  hlnod 
from  the  kidneys,  unattcndeil  with  pain,  continuing  for  one  or 
two  weeks.  In  June,  the  tumor  nppenrcd  aa  a  email  hard  lump 
under  tbc  ekin  of  the  arm,  near  the  insertion  of  the  deltoid 
musclcn  This  grwlually  increased  until  it  nearly  encircled  the 
anuT  extending  under,  and  raising  up,  the  brachial  artery  and 
nerves.  The  motions  of  the  limb  were  not  much  affected  by  itfl 
pretipiire  until  the  winter  of  185U-51,  when  it  increased  rapidly, 
nnd  the  nctivo  portion  became  somewhat  painful.  Hie  phj'Hician 
coneidcrcd  the  cose  a  critical  one,  demanding  the  removal  of 
the  tumor  or  of  the  arm,  and  directed  him  lo  me.  After  a 
CRrefiil  examination  of  the  tumor,  wliioh  W!i6  r|uite  firm  nnd 
movable,  it  was  agreed  that  the  piitient  should  be  etherized, 
the  tumor  cut  into,  and,  if  found  to  poasctfa  the  efiarnetera  of  a 
mahgnant  groirth,  that  tbc  arm  should  be  removed  at  the 
ghouldcr- joint. 

The  operation  waa  done  on  the  15th  of  February,  l^bX  ;  and, 
when  the  tumor  was  incised,  it  was  found  to  ho  carcinomatous. 


I 


390  EXTREltlTIES. 

The  bleeding  from  it,  wiiii^h  was  qiiitn  free,  wne  therefor© 
stnndied  wiih  u  bil  of  Hjmn^,  :im]  die  removal  of  the  arm  pro- 
ceecle*!  witl*.  Tliis  waa  doue  by  an  anterior  not]  a  postcrinr 
flnp;  the  former  \niln^  ninde  from  without  iini'iinls  hv  menns  of 
a  ac!ili>el»  iti  uriler  to  hnve  a  more  regular  woHTid,  ami  the  better 
to  avoid  impinging  on  the  tumor-  The  suhdnvian  artery,  as  it 
pa^t^ea  over  the  first  rib,  was  so  effeetually  comprpsfied  by  Dr, 
H.  W.  WilliiLins  tliat  scarcely  any  blood  wiia  lost. 

On  Feb.  20lh,  iie  bad  a  discharge  of  bloody  urine,  after  ft 
severe  piiui  in  the  loins.  He  seemed  to  atEach  but  liltle  impor- 
Umi's  to  it ;  and,  lit  fact,  it  soon  ceased-      He  rapidiv  rppovered. 

The  tunmr  hml  a  litrdm^aius  apiJi'-anuKre,  and,  under  tlie  mi- 
croscopcj  showed  fibroua  tisauet  in  which,  after  much  investiga- 
tiou,  CEncer-cella  were  distinguished. 

Cass  CCXXXn>  —  iVecrosi*  of  Humerus.      AmpiUatton- 

—  The  patient  was  21  years  old.  Tliree  years  before,  after 
getting  wet,  he  wn*i  seized  with  an  inflanimalion  in  the  riciuity 
of  tlte  elbfJW-joiNt,  imd  supp^iRifion  ensiiEtl.  After  !i  time,  bone 
wftfl  dwcharged-  Other  jrarta  of  the  arm  were  flubaeqiiently 
attnoked,  and  iiiiicb  hone  remove<l.  In  the  course  of  the  dis- 
tant', tbt  r*bcinIder-joirit  and  the  elhow-ji>int  becume  ant-hylosed  ; 
leaving  the  hand  fiied  in  strong  rotation  over  the  pubes,  only  * 
Bliehl  lateral  aeiion  being  permitted  hy  the  movement  of  the 
scapula  on  tlie  Iwjdy.  Very  large  sequestni  Htill  remained  ;  and, 
from  the  [jofljtion  of  the  hand  and  los^i  of  use  of  the  joints,  it  was 
thought,  that,  even  if  uW  the  dead  bone  was  removed,  the  limb 
would  he  left  uselt**.  Anipntalion  was  therefore  de<;ided  on. 
Some  difticuhy  wiia  experienced  iti  fixing  on  the  point  for  re* 
moval.  If  the:  section  wu»  made  above  the  apertures  in  the 
bend  of  the  hnmeniH,  It  would  be  difficult  to  get  a  flap  fmm  the 
tn.'ide  on  account  of  the  size  of  the  new  bone,  w^ncli  wa«  foreed 
eloae  upon  the  ribs,  obliterating,  as  it  were,  tiie  axilla.  On 
eonankaiion^  it  wnt*  decideil  to  ntnpnlate  n  few  inches  below  the 
sbuulder,  removing  the  tiei:|ueHtrum  afterwards.  Thl^i  was  dune, 
and  a  large  piece  of  dead  hime  forcibly  cstracted.  The  nxillfirv 
artery,  from  the  confinetl  position  of  the  wound,  waa  aecured 
with  some  difficulty,  as  had  been  apprehended. 


AMPUTATIONS.  391 

The  patient  left  the  Hospitiil  about  four  weeks  after  the  operft- 
tiuD,  mudi  improved  io  beolthr  with  tlie  wound  m  a  hciUthy  con- 
dition. 

Case  CCSXXHI.  -^  Same's  Operation  on  a  Girl  afecfed 
icilh  Talipes  Varus  and  Spina  liifidn. — A  girl,  13  years 
old,  en1er<id  the  Hospital,  April  13,  13ii0,  on  account  of  con- 
gemtftl  talipes  varus  of  the  left  foot,  with  ulceration  below  the 
anklCf  Avhieh  had  c>:istcd  for  ^ix  years. 

She  hnd  iJso  a  Epiiiii  biliJiL  over  the  sacrum,  about  four 
inches  in  diiiuicter.  It  was  ductuntin^f,  eliialic,  jind  painful 
under  strong  pressure-  She  had  ineontinenee  of  urine,  nnd,  nc 
tiinee,  of  feces-  Her  mentnl  faculties  were  impaired.  There 
was  a  fetid  di'schar^  from  the  tilcer,  and  dead  bone  cculd  be 
felt  with  u  probe. 

Afjril  2Ut,  Syine^B  operation  wilh  performed  &t  the  ankfe^ 
Joint.  There  wns  more  ihnn  u^ual  suppitrniion  in  die  wound; 
and.  May  4tb,  free  hemorrhage  occurred,  which  wns  stopped 
wirh  difliculty.  SubsetjuentlyT  she  did  well,  and  was  dis- 
charged May  2lJth. 

Tiie  disease  in  thb  case  appears  to  Imvo  arisen  from  impaired 
nervous  energy,  probably  owing  to  the  tumor  implicating  the 
Gpinal  cord. 

Case  CCXXXTV. — Amputation  for  Caries  of  the  Bonea 
of  the  Foot.  Double  Talipts  Varttt,  Spina  Bifida. — A 
young  Lailv,  17  yenrs  of  ogSj  applied  to  me  for  advice  in  April, 
1849,  Slic  bad  w  fi]iina  bifida  over  tlie  last  lumbar  vertebra, 
which  in  infimoy  wns  about  iKe  tizo  of  a  bean.  At  the  time 
I  saw  her,  it  was  divided  by  a  deep  suIcub,  one  side  direftiy 
over  the  ?pine  ;  being  about  as  liirge  ns  n  mcdium-»ized  nppte, 
Bof\  and  Huctunling,  and  protected  by  a  thick,  tough  ekln.  The 
Other  side,  ibout  hnlf  ns  Inr^e  a»  the  first,  bulged  out  on  the 
right,  and  was  solid.  Tbis  tumor  ga\e  rise  to  no  abnormal 
eeneationa;  nor  did  it  interfere  with  the  moiion  of  tlie  lower 
eittrendties*  unless!  wiien  injured  by  n  bloWj  when  it  was  IbtloM-ed 
by  temporary  numbneHa- 

Soon  after  ghe  began  to  walk,  talipes  vEirus  of  the  left  foot 


392 


EXTREMlTlEa. 


npppftreil ;  nnij  bo  gi^nt  was  the  defordiity.  ihtit  slie  refiled  en- 
tirely iipun  the  outside  of  the  foot.  Tho  tViuiiim  utiil  pressure 
gave  rise  to  an  ulcar,  whldi  reMistcd  trentment,  anil  gruduall; 
tixtcmled  over  tlic  wliole  of  flit-  hldo  of  llie  foot,  Pruip  time  to 
time,  portions  of  bene  hod  been  didch&rgeil,  and  (iniJIy  ih&  llctle 
toe  BQpa.riLted  in  a  gjLi^trrenous  condition.  Necro^ied  bone  eoultl 
Btill  he  deteefed  throu^li  three  R^tuloua  opeiiingj^  in  tl^n  ulcer. 
After  a  long  nttnck  of  flicknees  in  \wr  eighth  year,  the  right  fool 
became  ileformcd  in  a  Biniilnr  manner  to  the  left. 

The  ]e(t  leg  wns  one  and  a  half  inches  shorter  ihtm  the  right, 
the  knee  tw<t  nnd  ri  half  itiehes  hiru^er  round.  The  shortening 
was  mu^rd  hy  the  los?^  of  pc^rtioiis  of  the  fibuhi  and  ttljju,  whidi 
were  dl^elinrged  through  iiHtuiaa  whose  cicatrioes  rem&ined. 
There  vrns  an  abseeas  over  the  external  malleolus  on  the  oul^ide 
of  the  riglit  foot. 

April  Tth.  She  was  etherized,  and  the  lefl  foot  amputAted. 
just  above  the  ankle,  hy  ihe  lateral^fliLp  method.  The  etlge^  of 
the  wound  were  brought  together  hy  a  single  suture  and  ndhe- 
flive  pla^ter.^  She  did  well ;  the  wound  uniting  partly  hy  first 
intention,  and  partly  hy  granulntinn. 

May  4th.  The  tendon  of  the  tibialis  antieus  and  the  tendo 
Achillis  of  the  riglit  leg  were  tlivided  ;  find,  n  few  days  snlwe- 
quenlly,  an  nppanitiw  wne  applied  to  siraighten  the  foot, 

June  .'50th.  8he  eonld  rest  her  weight  upon  the  wde  of  her 
Tight  foot,  though  it  was  not  entirely  straightened,  and  was 
atill  weak. 
which  restored  completely  the  power  of  walking- 


She  afterwards  had  an  artilicial  foot  for  the  left  leg. 


Case  CCXXXV.  —  Pn-Of/off^tt  AnipiUntion  at  AnHe-jotut 
for  Railroad  Accident.  tSlougklnfj.  lie-amputation.  Re~ 
cavnnj.  —  A  young  man,  about  20  yenra  old,  wns  brought  into 
the  Hospital  on  the  23d  of  June,  ISfif),  with  bis  fool  crushed  ; 
having,  the  night  hefore,  stepped  upon  the  top  of  &n  engine 
while  in  motion,  catclung  bi^  foot  in  tiie  machinery.  The 
phalanges  and  tnetatsu^nl  bones  were  comminuted,  the  integu- 
ment covering  them  destroyed,  and  the  skin  torn  npwanls  over 
the  flwtrntralus.  He  inj^isted  that  nothin^r  ahoulJ  Im?  removed  fhiit 
was  not  nhsolutely  crushed,  though  T  informed  him  of  the  daci' 


AMPUTATION'S, 


I 


»r  of  elon^hin^  of  tho  eoft  pnrta  in  ncciiknts  of  this  dGBcription 
whidi  vilftlity  diil  nfjt  appear  di^stroveJ  nt  the  time.      It  waa 
lecided,  thcivfore,  to  |>crforni  Pirogoft'^B  operation. 

An  incifiioD  wtxs  axade  in  front  of  tlie  internal  mnlleolua, 
CATTiod  under  the  foot,  (ind  terminated  rear  the  external  mal- 
leolue.  Tlie  iutcf'umcnts  of  tlie  heel  wei'c  then  diui^ected  a 
little  From  the  bones,  and  tho  inoietoa  carried  acroea  the 
■fi>ot  in  fronts  no  iw  to  expoac  the  joint.  The  Qstr:i^>'itlua  waa 
[dis!irtj'!idutcd ;  and,  in  dissecting  it  out,  in  order  to  get  at  the 
ffl  calcisi  care  was  taken  not  to  injure  tlic  poaterior  tibial  artery. 
The  08  cal^'is  was  then  eawn  through  obhquely^  and  tlic  foot 
xemoved.  The  intepiments  of  the  lower  part  of  the  le;*  cL»verIng 
he  joint  were  dJefiected  bnck  a.  liti(c  ;  and  the  external  and  in- 
;teruid  mnllculj,  together  with  the  nrticnlnr  ^urfaec  of  the  tibia, 
■ere  i-eniored  with  a  saw.  This  was  done  with  some  djffieul- 
flv,  owing  to  the  ^>riinary  ineisicme  having  been  made  in  front 
f  the  malleoli,  as  described  in  the  books;  whereas  it  would 
been  much  better  to  have  be*:un  farther  back,  wliieh 
liave  been  easily  done  without  endangering  the  vBs*ela 
that  Bupjdy  the  flop.  It  being  found  that  the  oe  cnlcis  Inter^ 
^red  Bomcwliat  with  the  easy  npproximntion  of  the  li|>B  of  the 
^ound,  a  flli(:e  was  removed  from  it.  The  enda  of  two  or  three 
tendons  which  projected  wera  cut  ofl'  with  aciasore,  aa  waa  also 

I  About  an  inch  of  the  plantar  nerve.  The  bone  ccmc  woll  into 
place,  and  the  edgca  of  the  wound  were  ftpproximatcd  by  a 
large  namber  of  euturea.  A  bro:id  atrip  of  adheaive  plaater 
waa  applied  so  aa  to  keep  the  bone  steady,  over  this  a  towel 
folded  itn;;thwitc,  and  tlic  whole  secured  in  a  hollow  padded 
flplint  to  eouiitcract  nny  rerriielion  of  the  inuaelod  of  the  cuif. 
He  was  ordered  a  lar^  opiate  nt  night,  and  alcpt  quite  well. 
The  next  day  he  cc»mplaincd  of  pain  from  tlie  prceaurc  of  tho 
eplinl,  which  was  then  removed. 

On  the  ^5tli  of  June,  the  weather  being  very  hot  ond  the 

smcU  of  the  dreasinga  quite  offensive,  they  were  removed,  with 

the    exception  of  the   a^lhej^ivc   plaeter ;    and  a  cotnprc^,   wet 

[with  a  weak  eolution  of  tlie  permanganate  of  potash,  was  applied. 

"cry  flhortly,  iia  I  had  fearetl,  a  elough  commenced  in  the  centre 

»f  the  wound  ;  and*  na  it  eeparatctl,  repeated  heroorrhngca  took 

00 


394 


EXTREBiUTtES. 


plftce,  finrtlij  followed  by  g-nngreiie  and  erypipolas  of  ilie  lower 
part  of  the  fitunip.  It  being  impodsible  to  amputate  the  limb  in 
that  condition,  tbe  tiapa  were  dcpumted,  atid  the  bteedinp;  reaeds 
found  and  tied-  The  limb  subsequently  required  amputation 
higlicr  ujj,  which  wqh  done  eomc  weeks  oflerwarde,  by  one  of 
my  eoilcQgiiee  (my  florvice  linving  expired),  when  the  patient 
wad  in  a  proper  condition  to  support  it;   and  be  did  well. 

The  operation  of  Piro^off  at  first  guve  every  indication  of 
eucccea ;  but,  as  we  arc  continually  ob&orvin;;  in  roiln^mU  acci- 
dents, the  injury  to  the  muscles,  veBseU,  and  nervee,  wae  much 
more  extensive  than  would  at  first  be  auppoeed,  and  neee^aitnted 
the  SLibeequent  amputation  of  the  leg. 

Case  CCXXXVI.  —  Rt'an}piilat.lon  of  Lt^g,  Recovery. 
—  Mnrrh  22,  18fi(l,  a  man  4fi  years  old  ciiterei.1  the  FToHpital  for 
painful  atuinp  of  right  leg  :  twenty-eight  years  before,  when  at 
eea,  whaling,  b!f^  right  foot  waa  torn  oil'  at  the  ankle*  by  being 
caught  in  a  coil  of  rope  which  was  "nintiiiig  out"  witli  ip'eat 
rapidity.  A  few  days  after  tlie  injury,  the  leg  was  amputated 
juat  above  the  ankle-  The  patient  stated  tliat  no  flaps  were 
made,  but  that  the  l!mh  was  cut  *'  square  off/^  The  slump  wan 
long  in  bealin^i  and  afierwanla  there  was  much  pain  of  a  neu- 
ralgic chnractex  in  it.  For  tlie  tliree  monthe  previojs  to  his 
coming  tu  the  IIoBjiital,  he  feulFered  from  an  indolent  ulcer  on 
tlie   end  of  tlic  >tuinp. 

March  S4tb.  The  patient  being  ethmzcil,  re-ampul  ration 
was  performed,  by  flaps;  a  long  [Ulterior  and  short  posterior 
one,  chiefly  of  bkm,  being  taken.  Tliere  wns  much  veuoua 
oozing  after  the  vesaela  were  tied,  which,  however,  subsided 
after  the  stump  had  been  expo&ed  to  the  air  for  two  hours.  The 
flaps  were  then  brought  togellier  with  seven  sutures,  Jind  cold 
water-ilreatfin^ja  applied  wilh  a  nu>dera(ely  firu^  bandage-  On 
examination  of  tlie  amputated  portion,  the  poaterior  tibial  nerve 
was  found  to  be  bullxius  nt  ita  exti'einity  ;  and  from  it  numerous 
nervouB  filaments  were  distributed  to  the  end  of  the  bone.  The 
flaps  united  almost  by  first  intention,  and  in  three  weeks  the 
patient  was  discharged  well. 


AMPUTATIONS. 


395 


Case  CCXXX.VI1. 'imputafion  cf  Lvg,  h\gh  up,  ^cilh 

Cutaneous  Flups^ — A[irit  ii^  186G,  a  man  aged  46  entered 
the  Hospital  wirli  a  large  ulcer  of  a  cancerous  appes.rH.Tice  en- 
tirely encircling  rhe  lower  part  of  tho  rifrht,  leg.  Its  edgea  were 
cflllous  and  elevated.  It  begsin  three  yeairj^  before,  end  he  had 
done  DO  work  uince.  Tbe  kj^t  six  ntontha,  he  had  been  unnble 
to  walk  on  the  leg,  whirli  was  bent  to  a  right  angle  with  the 
tbigh. 

Amputation  being  decided  upon,  the  question  was,  at  what 
point  this  should  be  done.  There  was  imegumeni  enough  for 
a  long  stump;  but  tfiis  was  objectionable  on  account  of  the 
fle::ced  positii>n  of  the  knee.  It  was  iheivjlbre  determined  to 
divide  the  bones  just  below  the  head  of  the  tibia,  as  making  a 
better  t^tump  than  the  cotidvlen  of  iLe  femur  bj  the  knee-joint 
operation - 

The  popliteal  artery,  being  divided  just  after  its  bifurcation, 
retracted,  and  the  stump,  at  the  same  time,  was  powerfully 
drawn  backwards  by  the  flexor  muscles  still  attached  to  it. 
This  stjito  of  things  rendered  it  very  difficult  to  get  at  the  ves- 
sels; but,  by  turning  the  patient  on  his  face  and  dissecting  up 
the  tissues,  they  were  finally  reached  and  IJed. 

In  the  present  instance,  two  flaps  were  made  of  skin  alone, 
instead  of  employing  Liston*s  method,  the  diTision  of  the  miis- 
cles  being  made  by  a  circular  cut.  The  two  arteries,  lying  in 
contact  just  after  the  division,  were  now  easily  seen,  and  tied  at 
the  hack  of  the  wound. 

This  amputation,  with  two  flaps  of  skin  and  a  circular  cut  in 
the  muscles^  is  the  most  satisfactory  one,  in  this  situa^ioni  that 
I  have  ever  done.  An  amputation,  lower  down,  performed 
recently  in  the  same  way,  has  also  resulted  better  than  usual. 

The  ulcer,  on  microscopic  examination,  proved  to  be  epithe- 
lial cancer.  The  bones,  though  perhaps  a  little  enlarged,  were 
not  implicated  in  the  disease,  Tbe  patient  did  remarkably  wellj 
the  flaps  healing  almost  by  the  first  intention. 


Case  CCS^SJiYJIl.  —  Ambulation  of  the  Thigh  at  the 
JjOKer  Third^  for  Disectse  of  the  Knee-joint  of  eighteen 
years^  standing.  — The  following  case  of  disease  of  the  knee- 


■AW 


BXTHBMlTIEe. 


joint  la  ore  of  those  bo  freqncntlv  mot  with,  more  parti<^ii]arly 
in  womeDi  where  the  pnticnt  ia  kept  under  trealrnent  lor  many 
years.  Vkith  alternate  iiiipro\cuicnt  and  r^Lip^ee  ;  the  di^endc 
ultimntelj  requiring  an  nperalioCi  On  in^pcetion  of  the  joint, 
the  Eurgeoa  is  eurpriped  at  the  great  extent  of  disease,  anj 
that  the  operation  has  been  ao  long  deferred. 

A  woman,  42  years  of  age,  mneh  emaciated,  and  of  a  very 
livid  complexion,  enmc  under  mj  cflrc  in  the  Hoppital,  in 
ApriJ,  1^0-5,  Eighteen  years  before,  she  had  fallen  down  ataira, 
Btriking  upon  the  right  knee,  ■which  became  swollen,  and  eon- 
fined  her  to  lier  hcil  fur  five  or  six  wccka,  8inee  then,  she  had 
scarcely  ever  piidscd  a  year  without  having  an  attack  of  InKam- 
matioD  in  the  Julnt,  coniimng  her  to  the  hou^.  In  April,  18l!4, 
it  became  more  inffamed  than  usual;  and  an  iibecesa  formed, 
whieh  pointetl   in   the  popliteal  space- 

The  limb  was  aomcwhat  flexed,  and  the  tibia  slightly  dislo- 
cated haekwarda  upon  the  iemur,  and  the  patella  apparently 
fixed  to  the  outer  condyle.  The  husband  of  the  patient  wished 
her,  ae  alic  said,  to  submit  to  treatment  tor  several  months 
more  before  baling  any  operation  performed  ;  but  she  preierrcd 
to  wait  no  longer.  The  question  of  excision  was  considered^ 
but  not  urged*  on  account  of  the  slate  of  her  general  health; 
and  siie  decided  the  innttcr  by  declaring  for  an  amputation. 
This  was  done  by  the  circular  method,  with  the  losa  of  but  a 
fctt"  drops  of  blood  ;  compression  being  made  by  a  tourniquet 
in^'cntcd  by  Juhn  Whitton,  the  ingenious  ward-tender  at  the 
Hospital,  which  compressed  the  artery  only,  without  interfering 
with  the  Tenous  circulation-  The  wound  was  closed  with  two 
sutures;  and  the  only  dressing  used  was  a  compress,  wet  with  u 
weak  solution  of  peminnganate  of  potaah,  with  the  view  of  pro- 
venting  infection  of  the  wound  by  Hospital  gangrene,  which 
was  prevalent  at  the  time-  The  shock  of  the  operation  pro- 
duced considerable  exliatistion ;  but.  by  the  use  of  stimulants 
for  several  iioura,  she  recovered  from  her  dcpresflcd  conditioni 

The  case  terminated  favorably  in  a  few  weeks* 

An  examination  of  the  joint  showed  llie  tibia  displaced  back- 
wards upon  the  condyles  of  the  femur,  the  cartilages  completely 
destroyed,  and  the  epiphyses  of  the  bones  cxteoaivcly  carioua. 


AHnruxvoa>~$. 


tbe  pt^Jkead  Fpare  ;  and  i^  pat«Ila  in^  finnlT  fii«d  to 


Case  CCXXXIX.  —  Comp<m$^  /Vm^wv  i»to  fie  JTm*^ 


ThL* 


fint 


by 


me  %i  b,  F,M, 


Ixri^ 


compound  cownnmnteJ  fj«etuie  of  tbe  koec-joiui  la 
B  half  before,  from  the  flake  of  an  aadtor  filing  upon  fam.  A 
wound  exifled  oo  eadi  aide  of  tlie  joint,  ao  i^At  iIm  ia^cr  omU 
be  parsed  &om  <nM  iide  to  dte  otber,  encomitcri^  tbe  t^afca^ 
fr^menta  of  bvoe.  Tbe  injured  part  wia  quite  iii^<tt«ible  to 
tbo  examuiation.  There  was  a  moderate  but  eon$i«iit  6i>w  of 
blood  from  the  wounds.  Tbe  pul^  waf  I^O,  trre^riilar,  feeUe; 
patient  A  little  flightr.  Stimulantg  were  given  ercrr  fitteen 
mioutee  for  two  boure,  but  witb  do  imptMrement  in  tbe  pnlee; 
tho  dischar^  CFf  bJood  gradually  iDcrea^inf:  from  tbe  woumU. 
Under  tbeee  cireumBUneee,  the  que^ion  vrhicb  pre*ented  it&df 
was,  wbetber  to  proceed  1o  imineduitc  ainputatioti,  IVom  fear  of 
tbe  paticrnt  loEing  hie  rfiaoee  bv  hemorrba^,  or  to  apply  a  tour- 
niquet, and  wsiit  for  nn  iniprovemeDt  ia  tbe  ^vmptoioa. 

On  con»uItaLion  with  tny  colJea^e^  at  tbe  Ho&pitaJ»  tbe  laller 
course  was  decided  upon.  On  tbe  following  tQoming,  (be  ap- 
pcarancee  were  much  the  same;  puJsc  120-  The  leakxpf^  of 
ven^^'Ufl  blood  continued.  On  further  consullalion ,  it  waa 
thouv^ht  unsafe  to  defer  ]ong;cr  tbe  removal  of  the  uijvircd  pait. 
He  wne  lhcref>re  etherized,  and  the  nntputation  f>erforrae<U 
The  atae  tcrminsitod  favorably.  GencmJIy  gpeakiDg,  en^es  of 
Urn  doecription  have  done  well  after  immediate  amputation, 
Bince  the  Introdiiction  of  etber.  The  want  of  vitality  in  the 
preeenl  cbsct  however,  seemed  hardly  to  justify  it*  even  with 
the  adaistaocc  of  this  asent- 


Case  CCXL, — Amputatwn  of  Thigh  for  2^tcrc*ia, — 
Mr.  F.,  28  years  of  a^,  applied  to  mc  in  February,  lJ5t>l,  on 
nccouot  of  a  necrodd  of  the  femur,  for  which  he  requested  to 
have  an  amputation  performed-     When  be  woa  fitlccu  yeara  old* 


398 


EXTBEMITIEB. 


he  received  a  ahock  la  the  lirab  hy  jumping  froin  n  wull,  which 
waa  follovrcd  by  severe  inHainmatSon»  cnilinj^  in  ubscefie,  which 
opened  ot  the  lower  and  inner  part  of  the  thigh,  jjet  above 
the  knee-  la  the  eouree  of  it  jcar*  abstce^ce  fi>rmed  aloog  the 
whole  length  of  the  limb,  coniroanicatin^  with  the  bone,  aome 
in  front,  and  aomc  on  the  outer  aide,  aa  hi<^h  hb  the  trochanter 
ninjor;  ihroiij^h  thcac  npcrturea,  smalJ  pieces  of  bone  were 
occaeionrdly  discharged,  Jn  the  lirat  vear*  while  bearinjf  »onie 
weight  on  the  leg,  the  femur  gaivc  way  in  its  lower  ihird.  but 
united  again,  with  ahortening  of  three  or  four  inchea,  and  w4th 
a  decided  bend  outwardSi  From  185(>  to  !HG4,  he  suffered 
much  at  the  ongioal  ^ite  of  thi;  diaeaae ;  the  iuflanmiJiUoii 
exleodiug  to  the  knee-joint,  which  became  nearly  atiff.  For 
neurJy  hrtlf  of  ihie  ]>eriod  of  thirteen  yeai-fi.  he  w*ih  eonfiued  hy. 
fiucceaaive  attacks  of  inflammation;  and  he  finally  decided  to 
submit  to  an  operation*  when  he  saw  t)iat  ]m  future  ufiefubifiss 
and  comfort  were  likely  to  be  altogether  destroyed,  A  consul- 
tation waa  held  upon  the  case  nt  the  Ht^spital,  whidi  resulted  in 
the  deelfiun  to  remove  the  limb  at  the  level  of  the  highest  Gstii- 
louA  o^ieninj^,  which  waa  at  the  couimcncement  of  the  u[]per 
third  of  the  femur:  and,  in  caae  the  fiequestrum  should  be 
found  to  extend  higher,  to  attempt  itfl  forcible  extraction  h^ 
means  of  forceps,  wliich  I  had  before  successfully  accourplished 
in  a  mmilar  euae,  where  it  wiis  iiiiportaDt  to  preacfvc  aj<  long  a 
bttimp  as  poasibJe.  The  exact  amount  of  bone  di^ea^ed  could 
not  be  accurately  determined,  owing  to  the  severe  ]>ain  and  pro- 
tracted couHtitutioual  disturbance  which  had  several  times  ful- 
lowal  tlie  attemjjt  to  probe  the  lower  openings  in  the  ijopliteal 
region,  and  which  waa  c^iplained  on  disaection  by  the  prosimity- 
of  the  sequestrum  to  the  great  ischiatic  nerve. 

The  operation  waa  performed  Feb.  27t]i.  A  flap  was  first  cut 
oui  on  the  front  and  outer  side  of  the  thigli,  having  ita  bu&e  nt 
the  upper  aperture  already  described,  which  waa  placed  rather 
on  ita  iiiuer  aspect.  An  inner  and  iwslerior  flap  waa  then  made, 
and  the  bone  eawed  ofl'  just  above  the  point  of  junction  of  the 
ffapa,  which  proved  to  be  in  the  aound  boDC>  tliree-quartera  of 
an  inch  nbove  the  upper  extremity  of  the  sequestrum-  Thia 
was  about  four  inches  long,  and  lay  looacly  eucaeed  in  a  caiity 


AMPUTATlOPfB. 


399 


m  the  back  sind  lower  portion  uf  the  femurs  whii?li  was  open  for 
Xhe  uioflt  part,  but  was  croeseti,  at  about  the  middle  of  its  length, 
by  a  bridge  of  new  bone  of  about  half  an  inch  in  brefldth.  Ths 
nerve,  as  above  stated^  ky  directly  on  it.  The  aeqiicsinim  was 
so  loose  that  it  could  have  been  entirely  removed,  if  it  had  been 
possible  to  reaeh  it  by  any  justifiable  operation.  The  knee-joint 
had  been  partialty  disorganized  by  in  Ham  mat  ion ;  two  small  sur- 
faces, however,  reniiiining  on  the  conJjlea,  siill  covered  by  ear- 
tilage,  each  about  half  an  inch  in  diameter,  and  corresponding 
to  the  articulating  surfaces  of  the  tibia,  which  were  concerned 
in  the  slight  motion  rpmaiiiing.  On  the  curved  portion  of  the 
bone,  in  front  and  opposite  to  tlie  sequeetrnm,  were  marka  of 
the  very  oblique  fracture  which  had  taken  place  during  the  firet 
year  of  the  diaeaae.  The  speotmen  is  now  in  the  Warren  Ana- 
tomicftl  M  use  urn - 

In  speaking  of  this  case,  I  would  remark,  that  I  have  seen 
very  few  cases  of  extensive  necrosis  of  the  femur  which  have 
been  relieved  by  o|ioratioD-  The  recoi'dfl  of  the  Masaachuaetta 
General  Huepital  show  the  game  tact.  In  one  eaae,  I  remov(Ml 
half  of  the  shaft,  near  its  lower  extremity,  with  perfect  relief; 
in  another  case,  of  twenty  years'  duration,  whieb  was  one  of 
necroais  of  tlie  whole  Icnrrth  of  the  ehatt  of  the  hone,  the  o|>era- 
tion  wiiH  followed  by  so  long  and  exhausting  a  suppuration  aa 
to  compel  the  amputation  of  the  limb  just  below  the  trochan- 
ters, to  save  the  patient's  life.  This  man  afterwarda  died  of 
an  extensive  cancer  of  the  etnmp.  In  the  present  instance, 
even  if  tho  removal  of  iho  dead  bone  had  been  practicable,  the 
patient  would  have  been  lef^  with  a  deformt^d  limb,  three  or 
four  inches  shorter  ttmn  its  fellow,  and  with  little  or  no  useful 
motion  of  the  kne&-joint. 

In  this  enae,  as  ia  ii^ual  where  there  has  been  much  previous 
iuHainmittion  in  the  anipututed  limb,  the  bemorriuige  from  the 
smaller  vea$ele  was  very  abundant* 

Tho  convalescence  was  alow,  and  interrupted  by  n  acrica  of 
abscesses  in  the  slump.  Although  no  exhdiation  of  bone  took 
place,  it  was  several  months  before  the  patient  was  well  enough 
to  return  to  his  home  in  the  country,  but  with  his  slump  only 
partially  healed.      In  October,  1864.  I  f^aw  hicn   in  line  hcidtli 


H 


400 


EXTREMITIES, 


nnd  hin;h  spirits,  1u*j  stiinip  entin3ly  licak-d.  atid  hnvio*;  gained 
thinv  or  iorly  pounds  ct'  ticali.  This  iucrenee  in  weight,  na  is 
well  known,  is  not  unusual  ia  per^utts  who  have  subiuitted  to 
nniputntion  after  biiviur*  ^odg  through  with  a  toug  suppuration 
from  a  diseased  liiuh. 

Twx)  yenra  afterwarda,  he  was  seen,  quite  we]I,  and  still  in- 
crefislng  in  weight.  Ilia  fi^^re,  instead  of  bcin^  distorCGd,  oe 
btforc  tlic  o|>ei'ution,  was  erect;  and  he  walked  weJl  with  a 
Palmer  leg. 


Case  CCXLI.  ^-  Ampr/ttr/wn  of  Jlti^h  for  Anchtflo^itt  of 
Knee-joint,  ^ecroniit  of  Tibifi^  find  othvi-  X** *ert#f .  —  May  3, 
1866,  a  jonng  man  of  rathor  weak  and  sickly  ftppi?aranec,  20 
years  of  a<pe,  entereil  the  Hospital  For  an  amputation  of  the 
thigh-  Three  years  before,  ho  fell,  strikiiii;  liis  \q\\  knee,  pro- 
ducing a  swelling  s^od  inflattimation  of  the  kuec  and  Je^  which 
contined  [lim  to  hia  bed  twenty-two  months-  A  year  after,  \ 
lar^e  portion  of  the  I'roni  of  the  tihiiT  in  a  necrosed  etate^  waa 
removed- 

On  investigation,  I  found  the  aflocted  knee  larger  than  tLo 
other,  stiff"  and  painful.  Above  it  were  the  cicatrices  of  two 
idcerg ;  buloWf  a  depression,  marking  the  position  where  the 
bone  had  been  removed.  Close  to  this,  a  sinus  existed,  mnniog 
upwurdti  and  outwtirds  to  the  inner  condyle  of  the  femur,  wher« 
dead  bone  CDuld  be  felt.  The  foot  wjia  inverted,  preeentirg  llie 
appearance  seen  in  tjdipes  varus,  whioli,  the  patient  said,  took 
place  when  he  attempted  lo  walk  after  the  operation  for  necro* 
sis.  There  was  not  only  invoraJon,  but  exlcn^iion  lo  such  b 
degree  us  to  givG  the  np[ieitrance  of  tulipea  equinus  :  the  le^if  was 
shortened  four  inches.  The  limb,  being  entirely  useless,  wi 
amputiUed,  Jlay  5th,  with  an  anterior  flap  of  skin  ;  a  t'Jrmilar 
cut  bein;^  made  behind,  so  as  to  bring  the  t^i<-aLrix  on  the  back- 
part  of  the  stump. 

The  patient  did  pretty  well  until  May  31st,  although  il 
was  some  suppuratiou  in  the  stutnp  and  retraction  ijf  the  flapSt 
when  an  abscess  tormed  on  his  Idl  Inp,  which  was  relieved  by 
an  incitaion.  In  this,  as  in  some  other  cases,  wliere  a  retraction 
of  the  llaps  occurred  from  suppuration  in  tlie  stump,  a  very 


ABIPCTATIOXS- 


401 


rapid  cicatrization  took  |>lftoe,  from  estension  mnde  on  tlie  ia- 
legn^ments  with  adhealve  plnaier  and  a  weight.  On  tho  IfJtli  of 
June,  he  wos  well  enough  to  ro  home. 

The  IblJowin^  la  the  dc^criptioti  of  the  amputated  portion : 
The  tibiii  nnU  fibula  were  dUWated  on  (lie  hack  part  of  the 
femur,  and  auchylosed  lo  iC  and  to  each  other;  tlie  ^mtellu  was 
anchyloBed  to  the  extemal  condyle.  On  the  front  piirt  of  the 
tihia,  a  [ohet  and  deep  sulcus  exlsiedf  from  which  had  been  re- 
moved a  sequeetruin  of  the  whole  cahbre  of  the  bone,  nine 
inches  long,  which  the  psitient  carried  with  hjru*  The  foot  wna 
in  a  complete  state  of  extension,  combinetl  with  slight  evcrsion, 
BO  as  to  thna  an  Fdcnoat  continuous  line  with  the  tibia,  and  in  a 
aiate  of  false  anchyloaie. 


Case  CCXIAI. —Ampulndon  of  hoi h  TM^/i 3  for  Hail- 
road  Iitjfi7-t/.  Utifilh  lw^7itif'lJtrEB  dayn  after.  — On  June  2, 
1864,  a  man  was  brought  into  the  Hospital,  who,  two  hours 
before,  was  thrown  from  the  railroad  track  by  the  engine.  He 
Bustaiued  ft  compound  comminuted  fracture  of  botli  bonea  of 
each  leg,  with  deep  ragged  wounds  near  the  ankles.  When 
brought  in,  he  was  almost  in  a  state  of  collapse,  having  lost 
much  blood.  Stimulants  were  freely  givon,  which  were  fol- 
lowed by  some  re-action.  Ho  was  etherized,  and  both  lege 
flmputulcd  juet  above  the  knee-joint  by  the  circular  method. 
But  little  hlcjod  was  loat  during  the  operation.  Fuur  vessels 
requiKHj  iigaim-es  in  the  left,  and  three  in  the  right  stump. 
The  pnticnt  wns  so  depressed  during  iho  operation,  that  it  waa 
necessary  several  times  to  suspend  the  us^  of  the  ether,  in  order 
to  ascertain  hi«  exact  condition.  He  ralhed,  however,  from  tlie 
operation  well ;  and,  being  put  on  a  nourishing  diet  with  suffi- 
cient stimulant,  improved  until  the  ITth,  when  he  had  a  severe 
chill,  followed  in  a  dny  or  two  by  sloughing  of  the  integuments 
covering  the  ends  of  the  stumps.  From  this  time  he  gradually 
sank,  and  on  the  nit;;ht  of  the  ^5th  died. 

Nature  seemed  to  have  made  a  great  cUbrt,  in  thia  casc^  to 
sustain  itself  agninst  the  great  shock  of  the  injury,  and  also  to 
Tej^air  it.  But  in  spite  of  all  the  naturnl  efforts,  assisted  in  every 
way  by  art,  it  woe  unable  to  occompLeh  the  process.     For  two 

61 


402 


EXT&EHlXIES. 


weekc,  he  proniboti  ns  well  as  any  case  aflcr  a  simple  operatton. 
He  woe  then  seized  wilk  a  chill,  iis  stated  above,  and  slowly 
eank. 


Case  CCXLIIT. — Amputation  at  the  Hip-joint  for  a 
tariff}  Ojtieo-narvoT/iatous  Xftmor  of  the  ^emur^  Jlefovertf.  — 
A  young  mnn,  16  years  u\i},  of  very  light  coniplexioa  ftod 
redilifih  hair,  entered  the  IIospiiaK  March,  lJ*59.  He  waa  bora 
10  Maincj  iif  healthy  parents^  *dJ»  ^'>  f^r  a«  was  known,  with, 
no  aerofuln  ia  the  family^  HJa  euiploynient  for  a  year  hMl  been 
tliat  of  ehuemaking.  About  seven  months  before  he  entered  ihe 
Hoapitnl,  at  the  upper  ord  front  part  of  the  tlii^h  a  dcep-eeatcd 
tumor  made  its  apjieuranoe^  immovable  and  filigbtlj  pnipful.  It 
inereafte<l  elowly  in  evorv  duMiction,  until  he  w;ifl  brought  to 
the  IIoi^piEnl  in  the  lEist  week  of  Mua^h,  1859.  At  this  pe- 
riod, ihe  left  femur,  whieh  was  the  seat  of  the  disease,  waa 
«li^htly  Hexed  on  the  pelvia  ;  and  the  upper  half  of  it  was  oeeu- 
pied  by  a  lar^^,  firm  tumor,  making  a  very  ditallnct  projectioa 
in  froiLt,  but  more  indefinite  behind]  where  it  mounted  up^  and 
was  lost  in  the  nates.  The  front  part  of  it  waa  somewhat 
nodulated,  and  wuh  in  immediate  eontact  with,  and  partially 
pressed  up,  Pouparl^a  ligament.  The  fckin  waa  everywhere 
movable  on  the  surface  of  the  tumor,  except  on  the  outer  mde* 
where  a  slight  rcdnees  exiated,  caused  by  the  application  of  ft 
bbeter.  There  waa  a  moderate  degree  of  mobility  of  the  joint^ 
auffiaient  to  show  tijiit  the  articulation  had  not  been  invaded  by 
the  disuaee.  The  patient  could  use  the  limb  a  little,  and  was 
able  to  wolk  out  with  support,  thoup;h  very  lame.  The  i^landu- 
lar  flVfitem  generally  was  intact.  The  appetite  was  poor.  Ho 
had  no  fever.  The  pain  in  the  tumor  required  the  use  of  an 
opiate  at  night.  The  eircumference  of  the  limb  over  the  tumor 
was  twenty-two  inehea ;  the  measurement  of  the  corresponding 
part  of  the  opposite  thigh,  fifteen  inches. 

Having  made  an  examination  of  bis  case,  I  told  the  brother 
of  the  patient,  that  all  applieationa  were  ueelej^^  and  the  only 
remedy  lel^  was  amputation  at  the  hip-joint.  The  case  being  so 
important,  on  the  following  day  I  called  a  consultation  of  the 
iiu^eona  of  tlie  Iloapital,  which  resulted  in  the  followbg  con- 


403 


I 


I 


clusiona  :  That  the  diseoae  w;ia  probably  an  osteo-aarcomatuufl 
aficction  of  the  foiiiur,  wliii?h,  if  left  to  itself*  would  very  aliortly 
terminate  the  patlcnt^a  life  in  a  most  pfijDtiil  manner ;  and  the 
onlj  thing  to  be  tlioug^Ht  of  was  the  rcmaval  of  tJie  femur 
at  its  articulntjoTi  witli  tlic  hip-bone.  On  the  other  hund. 
from  the  size  and  situation  of  the  tumor,  thnt  the  operation 
wiu  an  excccdingiy  hasanloua  one,  more  so  than  in  the  onJlnnry 
cneea  of  Ita  perforin tince ;  that  tlterc  wa^  o,  posaibility  of  hia 
dj'io^  during  the  operation,  or  widiir  the  auUequent  ten  days ; 
and,  even  if  he  recovered  from  the  immediate  shock,  that  there 
might  be  n  rc-jippcarancc  of  the  discaac :  that  these  conditions 
bein^  projicrly  placed  before  the  patient  and  hia  friends*  if  thoy 
eoncludcj  to  take  tlic  risk,  tlie  operation  ought  to  be  done. 
Thia  question  having  heta  fully  weighed  by  the  patient  and  hia 
brother,  they  decided  to  have  the  limb  I'crncvcd,  rather  than 
run  the  riak  of  aubmilting  to  tlie  lingering  course  of  the  dJaeoBe, 
The  openLtion  was  performed  in  the  following  manner,  on 
Monday,  Murch  28th,  the  fifth  dnv  after  his  entrance  into  the 
Hof^pitaL  The  oi-dimiry  nicthud  by  trandfisiiin  being  impmcti- 
enble*  and  in  \ievr  of  the  possibility  of  a  dissection  of  tlic  tumor 
from  itrt  attach II lent 9,  a  large  flap  ol'  skin  was  raJt^cd  from  ita 
front  part ;  the  incision  commencing  at  the  root  of  the  flcrotnm, 
ond  terminating  ju?t  above,  and  in  front  of  the  great  trochan- 
ter. The  flap  waa  dissected  up  quite  to  Poupart^a  ligament,  the 
faacia  over  the  femoral  artery  openc<],  the  vessel  exposed,  a  liga- 
ture pasiicd  around  it  and  tied.  An  inoiriion  wiia  then  made  on 
the  back  part  of  the  thigh,  corresp<mding  with  that  in  front, 
and  a  tlap  of  r*kin  partially  ral'^tzd.  With  a  short,  strong  knifOi 
the  musoles  niiniing  from  the  pubee  to  the  inside  of  the  tumor 
were  cut  through,  and  thoac  on  the  outaidc  treated  in  a  elmilnr 
manner.  These  incisions  loosened  the  thigh,  which  hud  bctbro 
been  eonfinccl,  and  allowed  it  to  he  depressed  and  rotated  out- 
ward. It  was  necessary  to  do  this  to  a  great  extent,  on  aecount 
of  H  lobe  of  the  tumor  projecting  over  and  obscuring  the  arlicn- 
lation*  The  knife  was  next  applicfl  to  tho  capaulc,  which  waa 
divided,  the  roiuul  li^^amcnt  snapping  ofl'  at  the  fliimc  time  from 
the  powerful  foi-ce  applied  to  it.  The  bone  was  then  diaarlieu- 
jittod,  the  great  muscles  of  the  thigh  cut  through  bclund,  and 


404 


EXTREMITEB8. 


ilie  limb  removed,  A  vory  Inrge  sponfje  was  thniBt  into  tbe 
wound,  10  prei'ont  bleeding,  wbilo  the  &iimller  vessels  in  die  flap 
ftud  trunlc  were  secured.  By  the  skilful  compression  of  the 
abdominnJ  aortjv  by  Dr.  Gay,  the  immediate  seizure  nnU  eom- 
pression  of  the  tJaps  by  Dr.  Cabot,  together  with  the  previima 
lin^ntiire  of  the  feuaoral,  scarcely  any  blood  was  li*el.  The  ves- 
sel's in  the  llaps  were  Buccossivcly  tiod  as  they  were  u[]covered 
by  the  removal  of  the  spotipe  :  it  was  also  found  neeesBary  to 
secure  the  great  femoral  vein. 

The  lips  of  the  wound  were  brought  lorrether  by  a  nuinber  of 
autnres;  a  compress  was  npplied,  mid  a  very  large  apon-i^,  to 
make  gentle  compression,  and  fill  up  the  deep  cavity  in  the  side 
of  the  pelvis ;  o^er  this  a  lowel,  and  the  whole  limdy  fiecurcd 
by  a  banda^.  The  openition  was  nocpsearily  protracted  much 
beyond  the  usual  time  f>f  an  ordinary  disnrtioulaEion  ;  yet  utter 
its  termination,  and  jnat  before  the  remi^val  of  the  patient  from 
the  table,  his  pulse  was  as  goud  as  before  the  operation  was 
commenced, 

A  section  made  of  tlie  tumor  and  the  femur,  which  were 
sawn  longitiidin^vlly  through  the  middle,  presente<l  the  following 
appearances:  The  tumor  was  beautifully  variep^aied,  and  pre- 
sented the  ordinary  aspect  of  oi^teo-sareoraa.  Jt  had  its  origin 
between  the  pcriostonm  and  the  bono,  and  extended  from  the 
middle  of  the  femur  quite*  to  its  neck.  The  periosteum  cover- 
ing the  greater  trochanter  had  been  peeled  up,  and  the  sac  of  it 
filled  with  that  yelJow  oleaffioous  fluid  whieh  is  bo  frequently 
seen  in  tumors  connected  witb  the  bone.  The  parietes  of  the 
bone  were  somewhat  thiekcned  in  the  centre,  ihinued  toward 
eitlier  extremity,  and  the  [nedullary  cavity  was  almost  obllt^ 
erated.  The  substance  of  the  tumor  itself  was  quite  tirm.  hav- 
ing the  ordinary  appearanccH  of  carcinoma  interspersed  with 
spiculie  of  hone.  A  microscopic  examination  of  it  was  made  by 
T>T.  Ellis,  and  verified  the  diaguosie.  The  head  and  neck  of 
the  bone  seemed  to  have  completely  escaped  invasion-  The 
nmjscles  covering  the  tumor  were  paHi^illy  atlherent  lu  it,  but 
none  of  them  so  completely  incorporated  with  it  as  at  firt:t  had 
been  feared.     The  tumor  seeraeil  to  have  been  eutirclv  euude- 

r 

ated ;  and.  so  far  as  could  be  ascertained^  not  the  slightest  trace 
of  it  was  left  beliind. 


AUFDTATlOTrS. 


405 


In  the  aftcrnof>n  of  the  day  of  the  operation,  the  patient 
fleeTiieil  to  be  in  a  j,rood  condition,  and  comphiineU  only  of  the 
tigihtnesa  of  the  bondage  rtround  hU  bodj.  This  wna  looacncd 
by  CuUing  it  away  imrli:illy,  and  compLctcly  removed  on  the 
following  mornin^H  He  passed  a  pretty  good  night,  under 
tJie  effect  ckf  a  draohni  of  the  eolation  of  tlie  sulphnte  of  moj"- 
phliL^  complaining  print^ipnlly  of  an  exceeslTC  thirst,  ^htch  no 
ainounC  of  drink  &ccnn^d  to  sntisfy,  and  which  I  attributed  partly 
to  the  ctl(cr»  On  -Alai'ch  30ih,  the  thirst  waa  aome^vhat  alle- 
Yi&tedi  but  lie  waa  still  without  appetite,  and  eomplained  of  n 
little  eoretkcaa  in  the  groin  ;  pre^^^iire  gave  prun  in  the  Jotvcr 
part  of  ihe  abdomen.     The  pulse  wa&  100. 

The  following  day  he  took  an  enema,  which  emptied  hia 
boweli^t  and  5ecmcd  to  linpruve  hi^  appetite,  eo  that  ho  chewed 
a  hltlo  beef;  alao  took  brnndy  and  water  and  milk  puneh,  to 
wliieh  he  waa  much  avcrec,  iie\er  having  taken  spirit  in  his 
life. 

On  Saturday,  April  2d,  the  wound  began  to  be  rather  oifen- 
sive  ;  and  at  the  aug^^i'rrtion  nf  the  vonemblc  and  diatiuguiehed 
ProfeaBor  Muoaey,  who  waa  present,  the  drcasinga  were  removed, 
and  a  yoast  poultice  applied  I  the  pu]ee  was  rather  over  100; 
the  appetite  ^till  doubtfub  On  Monday,  tlie  4lh,  hia  pulae 
was  1^0 ;  there  waa  prufusc  Bweating  while  Bleeping  ;  he  began 
to  take  his  food  more  regularly,  and  hia  pulec  t[>  have  oonsidem- 
blo  firninc&a,  lie  waa  allowed  bread,  tea,  and  baked  apple  for 
hrcjikfast ;  breads  meat,  and  baked  apple,  of  which  he  waa  very 
fond,  vegetables,  with  bnindy  and  water,  for  dinner^  for  sup- 
per, the  game  an  nt  breukfu^t ;  at  bedtime,  and  to  drink  tlirou^di 
the  night,  from  Imlf  a  pint  to  n  pint  of  milk-punch.  On  the  8th 
of  April,  he  was  reported  as  doing  well:  "He  makoe  no  coio- 
plnint,  the  puhe  ia  about  100,  and  he  may  be  i^aid  to  be  in  a 
convalceeent  condition;  the  boweU  are  emptied  every  other  day 
by  enemaLa^  nnd  he  hne  taken  no  purgivtivc  medicine  since  the 
day  of  the  operation." 

The  patient  went  on  improving  till  the  third  week  after  the 
oporfltii;n.  The  wound  healed  well,  leaving  an  aperture  at 
either  end  for  the  escape  of  ligatures.  About  the  twenty -foiirLh 
day,  on  waking  in  the  moruing,  he  felt  a  pressure  at  the  inner 


406 


EXTRE2niIEg< 


part  of  the  afutnp  ;  and^  eliortly  alter,  n  atrCMwn  of  blood  elowly 
tnt^kled  down.  Dr,  Ezra  L>yer,  the  hou^c-surgeoa  of  the  Hos- 
piCol,  yvim  immediately  fliimmoncd,  nnd  by  menna  of  a  sjMJiigo 
applied  oi'cr  the  ajjertLirca  from  which  the  ligatures  iseueil,  and 
a  Blror^  comprc&ain;;  bandii^,  euccecdttl  in  arroetins;  the  bleed- 
ing. Tiie  bleeding  recurred  o^ain  in  about  two  hours*  and  waa 
Aireetcd  in  the  Bame  wny.  When  I  saw  the  patiect,  at  9, 
A.M.,  he  was  rather  pale,  hie  puUe  mpid,  and  hid  Byetcm  hi^d 
evidently  rceeivcd  a  severe  shook*  He  was  not  mueli  ulnrmcd  ; 
but,  on  thi?  and  the  following  day,  made  great  complntot  of  ex- 
ceBfijve  thirst,  as  he  did  ufter  the  opcrutiou  :  dliowing;  tlint  it  was 
the  loifs  of  l>l{>>jd,  and  not  the  ether,  whieh  prev^iou^ly  caused  thi« 
eymptom.  From  the  free  escape  of  blood  at  the  lime,  and  it& 
arterial  eolor,  it  wnt  thought  [irobable  to  have  escaped  from  the 
great  yesael,  in  eouecf|uenc!e  of  (he  ligature  hnvinp  pnrtiidly  de- 
tnehetl  itselT;  nnd  for  this  reaaon  it  was  deemed  pradeat  not  to 
interfere  Aviih  the  wound  for  tlio  nest  two  or  three  days.  No 
new  blecdin<;  having  occurred,  1  then  bad  all  the  dreB«ings  re- 
moved. The  two  lin;fltureB  at  the  outer  part  of  the  etump  were 
flcized  by  the  firjjera,  and  withdraxTn  wilh  very  slight  foroe.  The 
four  li^itures  at  the  iuterniLl  part  of  the  stump  were  then  sep- 
arated, and  dragi^ed  upon  singly  ]  and  nil  of  them  were  removed 
without  dittieuhy.  The  two  Urge  ones,  whieh  bud  been  attached 
to  the  femorjU  artery  and  vein,  had  probably  been  for  j^ome  tiaic 
dataehed,  anil  lay  coiled  up  in  tho  wound,  cauf-ing  irritPtiim  and 
anppurationj  and  probably  the  hemorrhage  wliieh  had  given  tho 
alarm. 

From  that  time  the  wound  rapiilly  healed.     The  pnlient  left 
Ilts  hed  ill  nboitt  a  week,  and  in  ten  <lave  was  able  Co  go  out  of. 
doors.     Mar  10th,  he  returned  home  quite  v/qU. 

Iie/l/ftrk^l.  — Thia  eu^e  ii*  worthy  of  notice  from  hnving  been 
the  tiral  of  amputation  at  the  bip-Joint  thut  hus  flucceedetl  ia 
Boston.  The  following  statistics,  from  Mr.  EricbBon.  in  hii^ 
valuable  work  on  Surgery,  may  be  interesting,  as  showiniT  it» 
mortality  T  Of  1^6  oaaes,  76  died;  of  47  cases  in  which  it  waa 
done  for  injuries*  35  died  ;  of  i2caBea  operated  on  in  the  Crimea, 
&11  died.  During  the  late  American  war,  as  nearly  as  I  can 
learUf  there  were  23  ea^ea  of  amputation  at  the  hip-joiDt*  of 


AMPUTATIONfl, 


407 


which  5  recovered,  ncd  IJ^  died.  Of  tlieae,  10  were  primary 
Opcrationa  fur  gituahot  wounda,  of  vhich  3  recovered,  and  7 
d!c^;  a.ad  13  eet^ondary  operations  for  the  sriiao  couec,  of 
which  ^  recovered,  &nd  11  died. 

Tlie  flops  in  thia  case,  beiDg  prlnclpnlly  composed  of  akin, 
mntle  the  wound  much  leaa  appdiiiig  and  more  manng'cjiblc  thjin 
where  largi;  muacLihtr  flapa  are  \c\\,  as  in  the  ordinary  opcnitioD. 
Tlu3  nmy  be  considered  worthy  of  imitation,  even  when  not  re- 
<|uired  by  necessity,  aa  in  the  present  eaffc.  The  previous  tying 
of  the  3u^ry,  together  with  the  compre^eion  of  the  aorta, 
aJiowcd  the  o|>eration  to  be  pcribrnicd  in  a  perfectly  eomforlahle 
manner,  tvithout  the  alighteat  burry*  and  with  almost  a  dry 
wound,  if  the  expreflsion  may  he  uaed* 

This  patient  lived  for  aome  months  in  very  good  health :  but 
the  diacoao  returned  intcrnolljT  and  he  died  within  a  year  of  the 
operation  p 

Case  CCXLIV.  —  AmpHtaiton  ftt  tht  Hip-joini.  Death 
thirteen  Jar/rt  rtftr-r.  —  A  child,  SIX  years  old,  was  brought 
to  the  HoapLtal  on  the  I^th  of  June,  1858,  at  three  o'clock, 
having  been  injarcd  about  two  hours  beForc,  He  was  sitting  on 
the  curbatone  of  the  sidewalk,  when  a  truck  wheeled  round 
n^inat  him,  crushing  his  limb  against  the  etonea.  His  injury 
at  first  WAS  not  detected  :  being  lifled  up  by  somo  pftsscr-by,  and 
piftcod  upon  hia  feet,  not  being'  able  to  eupport  himaclf,  be  fell, 
and  rcecived,  in  addition  to  hia  other  injuries,  a  violent  blow 
upon  the  forehead.  When  brought  to  the  Hospital,  his  state 
was  as  tbllows  ;  ilc  was  quite  faint,  eountcnnnce  livid,  pube 
aranll.  The  integuments  of  the  thigh,  near  the  hip,  were  nc^trly 
cut  through  by  a  scmicirculnr  wound;  and  on  the  outside  a 
deep  wound  in  the  muaelca  communicated  with  tlic  bone,  which 
was  fractured  obliquely,  and  denuded  nearly  up  to  the  joint. 
As  the  blood  was  Rowing  from  this  extensive  woundj  the  caec 
admitted  of  no  delay;  and  annpntation  was  at  once  performed. 
The  boy  wiis   first  slimulatcd  with   aa  nmch   3pirit  aa  he  could 

I  bear,  and  ether  w^ls  admiriatcred,  whieh  quickly  brought  up  the 
cireulation.  The  limb  was  then  separated  at  the  ftaelured  part, 
Dr.  Shaw  comprcflaing  the  artery,     Dieacction  was  next  mode 


40S 


EXTREMITIEa. 


at  the  Bide  of  the  booe,  which  waa  dUnrliculnted  with  diffip[iltT» 
doth  from  ihc  aciitoitiical  relation  of  the  pnrl^,  tlicse  being 
obscured  by  ragged  muscles,  and  more  especiallj'  from  the 
remaining  portion  of  the  femar  being  loo  short  to  he  easily  con- 
trolled in  effeoilng  the  disarticulation.  The  capsule  was,  how- 
ever, opened,  and  the  bone  dUseoted  out  with  but  little  delay- 
The  boy  at  tbi^  moment  becnme  clewlly  faint,  and  was  only 
restored  by  using  frictions  of  brandy  and  ammonia;  the  Inner 
being  opiilied  also  to  ihe  noslrila.  He  waa  likewise  su^j^nded 
by  the  remaining  leg'fio  as  to  throw  the  blood  to  the  brain  ;  and, 
nnder  this  treatment,  soon  revived,  although  at  one  inonient  he 
seemed  to  be  dead.  The  vessels  were  now  tied*  and  the  wound 
temporarily  drcs.^ed-  Just  as  tbia  was  finished,  he  a  second 
time  eame  in  peril  of  his  life.  As  h  often  the  case  with  patients 
recovering  from  ether,  he  eeeined  dispo«?<3  to  vorail ;  and,  ir  fact, 
a  basin  was  held,  and  he  threw  np  a  large  quantity  of  liquid 
substance.  Immediately  nAer  thig*  he  fell  back  as  if  exhausted, 
a  cold  aweat  came  over  him,  and  the  respiration  and  pulse 
ceased.  The  frictions,  and  other  means  for  resloriiig  suspended 
aaimfltion,  were  at  once  again  resorted  to;  and  I  proceeded  to 
pass  the  finger  into  the  mmith  for  the  puryajse  of  raiHing  the 
epiglottis  and  making  a  pa^if^agt  for  the  air  into  the  windpipe, 
when  it  encountered  a  mass  of  solid  potato-like  substance,  with 
which,  on  further  investigation,  the  whole  mouth  and  fancea 
were  found  completely  blocked,  so  us  entirely  to  eKclude  die  air, 
and  almost  sutTtvcHte  tlie  p^itient.  The  teeth  hud  allowed  the 
liqnid  contents  of  the  stomach  to  pass  between  them,  but  had 
acled  as  u  ntnuncr  to  retain  the  solfd  matters  in  dte  mouth. 
The  niuuth  heing  uow  cleared^  kud  artificial  respiration  set  np, 
the  child  ^'nidually  coiumenfM>d  to  breathe,  and.  In  the  course  of 
half  an  hourf  was  in  a  safe  state.  At  9j  P.M.,  the  limb  was 
drt^ssed,  and  be  was  taken  to  bis  bed  in  the  ward.  The  patient 
lived  thirteen  days,  and  received  during  this  time  the  moHt  un- 
remitting care  from  the  nurse  in  ehar^  of  him,  and  from  Dr. 
Dyer,  the  house-surgeon  of  the  Hospital.  The  stump,  during 
thib  time,  became  quite  sloughy  ;  and  one  ortwoabHceE^t^eti  formed 
in  the  groin.  The  whole  wound,  however,  finally  assumed  a 
healthy  appearance ;  and,  when  there  seemed  to   be  every  ]>ros- 


409 

pect  of  hoF  iKrm;  ffcae  ssfeK  liirciiu^  uas  aKwi  dingg-opf  pan 
of  die  laoftL,  be  flDddecJr  £iL!i&i  sad  dkid,  nearlr  &  fcirmi^ii 

Hie  foflcnrboE  ixblt  r^*'^"^?t«  tLc  T«enlif  of  il>e  of^niknu  for 
ampmmcA  of  Bnitf  u  uw  Miinmninn'T'f  GenenJ  Hofpital, 
irooi  J>BD»T,  l^ir£.  u  JKiiQsrj,  1?^~,  —  A  penod  fj£  fonr- 
foar 


:«> 

a 

3t.W 

:«k 

n 

1»J* 

u 

ir 

ItwS 

4£ 

1 

li^tt 

I 

] 

Ml. 

14 

7 

K.,» 

«l^  lE^  S  % 


Tlx  ex'T^on  of  di^«&M^  jcrmU.  ft£  m  rab^^jTiite  for  unpnta- 
tioii,  irbk±i  iTM  rerivwi  ^'.-ii^  rear*  »;to  bj  Mr-  Sjroe,  —  mort 
puiioilwjj  f^r  ill*  *:]U^ir  %:i^  'ih'juldtT.  —  hks  fincf  bem  pr«c- 
tbed  tm  iD'j«  'jf  tLt  W;rw  j'-'JJi^  '-^  ^  tod^,  «Dd  haf  pft«ed 
inUf  fOT^ry  jl^  'jtk  'jf  tL^  ■ti>iJLh'I>JM'J  r>pCT«£ioiu-  The  excisaii 
of  the  k&<9t.  In  psnirruW.  lui^  U^^n  mucli  id'jt^  {requesdr  per- 
funoed  tLui  tliaa  of  ujt  oiL^r  lur^r^  ^jini :  tLe  difieue«  whkL.  m 
ciiiJ  pTK^iw.  require  «ur^':raJ  inteHVmice,  being  more  fivqooit 
in  the  <»»e  of  the  kseie  than  of  tlie  elbow.  Bv  tbif  opentiow, 
manj  )lmbf .  wLj':1j  «ou]'i  oTber«'i««  be  t^jod^mned  lo  ftzapoubon* 
are  uvei],  &u>i  made  u^iefd.  Exd«)>jn  of  iJbe  knee  if,  of 
GouTttf  appli'^jle  ouJr  tt^  '^-^et  in  vhidi  ibe  limb  u  ocb^ww 
souDd.  ukI  tL*:  Diov«v>ei]i£  of  ibe  hip  ukd  ankle  oniiBpaind. 

^isrforwtd  upon  wlulu,  il  already  ooiiau  a  great  niiinbcr  of 

X2 


410 


EXTUKMITIKfi- 


most  ndmirable  result* :  hut,  in  tho  cnse  of  yoiirg  Hiildren,  n 
very  graie  objection  has  ariritn  from  ihe  face,  tlmt,  in  se^'ei"al 
instuDcea,  at  firat  reported  ns  8ucc«SHful,  the  growth  of  the 
Jimb  has  been  an'ested  ;  leaving  it,  at  In&l,  niiiny  inches  shorter 
than  its  fellow.  There  19  no  doubt^  thnt,  if  the  e|nphv3efl  of 
the  hones  are  wholly  reinove^l,  the  aiibseqaent  growth  of  the 
limb  U  impaired.  It  ia  therefore  proper,  in  children,  to  pan; 
off  from  the  artindnr  Riirfiu-ps  as  rhin  n  flHi'o  ns  is  L-onei stent 
with  the  rcinuviil  uf  ihe  di^^eaaed  b^me  and  the  wliole  iiriioular 
cartilflfre.  One  case  in  my  own  [>nictice,  given  below,  in 
little  girl  of  ahimt  cig;ht  ycsirs  of  age,  an  entirely  uselesH  am 
bent-u|>  limb,  the  rcrnilt  of  st^rofulous  white  swelhng,  was  mada 
eervieenble  by  remoTing-  tbt  ecdd  of  llie  bones,  bad  stmigliR'ning 
the  joint,  1  siiw  thi?;  pntienr,  at  the  end  of  ihreo  years,  peifof'tly 
well^  and  walking  wiih  a  iilight  Ump.  The  liuib  was  shorter 
than  the  othr>r;  hnt  the  pe]vi8  Imd  so  adapted  itself  us  to  nuike 
the  losfl  of  len^h  le^m  evident  than  might  have  been  EXpec:ted, 

I  hflVQ  performed  excision  oF  the  knee-joint  three  times,  for 
cnriea,  with  moht  gratifying  sucees?*.  In  a  fonrih  caise,  —  thai 
of  an  adult  femide,  —  whleh,  fruni  the  first,  seemed  a  less  prom- 
ising one  fur  the  operation  tlian  the  others,  atitputiuion  was 
ftfterwfirda  nece]iJ^]iry, 

In  two  or  three  eiclaiona  of  the  shoiilder-joiot  for  eariea,  the 
results  hove  all  l)een  anecefisful- 

Tho  iidvnntages  uf  excising  the  hend  of  the  hiimerua  and  the 
articular  siiriaces  entering  the  elbow-Joiot  are  undoubted. 

Barton's  operntion,  remuving  a  wedge-shaped  piecti  of  bone 
for  a  contracted  and  distorted  limb,  iJa  one  well  worthy  of  imit&- 
liou,     I  have  introduced  btjiort'  two  cose^  in  illnslralion  of  it. 


Case  CCXLV.  —  Ej^a'gion  of  E;rff^rufjt  Condt/7e  0/ I^iifht 
Htanerus^ — Nov.  27,  1854,  A  man,  24  years  of  age,  being 
on  the  cnrs  while  they  were  in  motion,  stepped  off,  and  was 
thrown  ftgidnst  a  rnil,  which  penetrated  ikis  arm  nbove  the*  elbow, 
tore  open  the  integuments,  aad  broke  the  exieinul  condyle  inlu 
the  joint.  He  entered  the  lloi^pital  the  same  day.  I  saw  him 
fii-at  on  the  29d;-  The  arm  was  then  flwollen,  and  there  was  a 
moderftts  discharge  from  the  wound.     The  condyle  waa  com- 


EXCISION   OF  JOINXa, 


-m 


pletely  loose  iLnd  dpimdod,  so  thiit  it  was  di&seoterl  out  and 
rpnii>ved  withcut  nay  j^'reut  difficulty,  unci  the  wouml  icW  open. 
On  the  foUowin;^  d.iy,  u  ycaet  poultice  waa  applied  lo  the  el- 
bow. On  tlic  13cb  of  DccGLiib^r,  a  smnll  itl>80G3a  farmed  on 
the  elbow,  wliith  wn«  opened,  and  disclmr-jwd  freely-  In  order 
to  6iip|>orL  it  Willi  wa  little  pre;^*iiro  us  pus^ible,  tlie  lU'ra  was  laid 
on  a  bladder  partly  filled  wiili  water-  Jan.  lOih,  another  ab- 
ficeea  formed  on  the  nuinide  of  llie  wound,  which  had  then  nearly 
healed  up.  On  iho  i^tllh  of  January,  he  left  the  Iloepltal,  the 
wound  entirely  healed,  the  joint  posjfesein^  but  little  motion. 

About  »\x  months  aftenvard^,  he  pr^eeiUed  }umBelf,  having 
recovered  a  good  motion  of  tlie  joint* 

Case  CCXLVI,  —  Excmon  of  the  Shanlder-joint  for 
Curies,  Recover^f.  —  1S5^,  The  patient  wiuj  a  man,  60 
years  of  a;^-  Three  years  before,  the  dideuae  6rut  Tuanircj^ted 
itself  by  a  pain  in  the  shoulder.  In  18^3,  ewelUnge  appeared 
about  the  middle  imd  outer  part  of  (he  arm,  whieh  were  opened, 
and  gave  iesue  to  \\  Jnr^'o  (piautity  oi^  pua.  The  inner  part  of 
the  arm  was  soon  after  al!b<]ted  in  the  same  manner  ;  aUo,  over 
die  pectoral  muscle  r>n  the  thoras.  The  opcninp;a  left  by  theae 
abaoeaaes  were  pr^ihcd,  but  no  dead  bone  could  bo  diacovered, 

The  motiona  of  tlie  ehouldcr-joint  became  almoat  abuhshed  ; 
and  the  difohar^c  of  pus  wii3  so  large  ^  from  the  fi3tul^>iie  0|)ejiingB 
in  the  arm,  arf  to  j^^oally  weaken  the  patient.  An  inci^^ion  was 
therefore  made  from  the  opening  nearest  the  ehouldcr-joint 
towards  the  head  of  the  bono,  which  waa  found  to  bo  carious, 
though  not  extensively  so.  The  wouad  waa  kept  open  in  the 
hope  tlkat  anchylosis  would  tnke  place^  and  thus  avoid  the  neces- 
sity of  an  operation, 
^^L  A  month  Inter,   no   improvement   having   taken   plaee,  the 

^^V       patjeut  was  etherised,  and  the  eld  incision  enlarged      The  os 
I  humeri  tind  glenoid  cavity  were  found  to  be  aariocjs  to  such  a 

I  de^e  that  an  oporatiun  wns  absohitely  noce^tBory ;   and  it  wat 

^^B        performed  aa  follows  :  — ^ 

^^P  A  triangular  flap  was  raised  from  the  shoulder,  so  as  to  cx- 

W  pose  the  head  of  the  bone.     The  strong  adlir^aions  between  it 

^^L      and  the  socket  were  then  cut  through,  wliich,  with  v,  little  dis- 


418 


EXTRELMTTIEfi. 


ecctioQ,  allowf!^  the  head  of  the  bone  to  be  turned  out  nnd 
enwcd  off.  The  eocket,  being  carioua,  waa  next  rcrat>ved  by  the 
cutting  forceps*  The  wound  waa  closed  by  a  few  auturea,  and 
GOmc  strips  of  ailhcalve  phiater  upplie<l> 

At  the  tiEue  wlien  he  left  the  Hospital,  the  disebnr^  from  the 
varioua  ainusea  vfos  dccrenaitig  rapidly;  and  the  large  cavity 
left  by  the  operation  had  been  quite  fillwl  upn  His  heollb  waa 
eseoJlent. 

I  9aw  thiB  patient  again  in  1855.  His  coutlitlon  waa  ae  fol- 
lows :  The  left  ehouider,  front  port  of  the  cheat,  and  intecfu- 
menta  over  the  ecapula,  were  covered  with  puckcrctl  cicalrioDSj 
the  rcault  of  tbe  numerous  abacesscs  caused  by  the  original  dia- 
eaac.  The  upper  part  of  the  abaft  of  the  liuuiciuH  was  a  little 
in  front  of  the  old  j,denoid  cavity.  The  mctiona  of  the  fore-arm 
and  hand  were  perfect)  ao  that  lie  waa  able  to  work  at  hia  em- 
ployment-^  atocking-weaving —  for  tea  hours  a  day,  winch  re- 
quirca  the  conatiint  motion  of  theae  parta.  To  facilitate  the  use 
of  them,  and  to  relieve  the  sboulUcr,  a  aling  was  suspended  from 
the  ceiling,  in  which  the  arm  woa  placed ;  and,  by  thia  mcans^ 
he  suffered  no  inconvenience  from  the  constant  atrain  whioh 
othcrwiao  would  have  fallen  upon  it.  He  had  the  full  commaod 
of  his  hand  and  fingcra,  and  could  graap  tilings  with  nearly  aa 
much  atrength  as  with  the  other  hand.  He  could  not  raiae  the 
liand  to  the  mouth  without  inclining  the  liend  a  little  forwards  i 
nor  conld  he  cjitcnd  the  arm  to  ita  full  length,  directly  before 
liini.  With  these  c^ceptiona,  he  could  movo  the  limb  ia  all 
dirccliODH. 


Case  CCXLVH — Fzcteion  of  the  Knee-joint.  —  D.  L.» 
32  years  old,  a  handsome,  frcah-looking  man,  five  feet  eight 
inchea  in  height,  entered  the  Mnsaachuactta  General  Hoapitoli 
March  23,  lti5T,  for  an  affection  of  hts  right  knee.  TUrco 
years  before,  ho  had  wiiat  was  euppoaed  to  be  a  rheumatic  attack 
In  this  joint,  wlueh  lasted  three  weeks.  Five  montha  previously, 
the  knco  became  painful  and  swctlcJ,  and  he  was  confined  to  his 
bed  for  thrco  weeks  with  it^  but  afterwards  waa  able  to  walk 
withoaC  crutcbes.  When  ho  entered  the  Hospital,  tlie  joint 
meiftsured  three  inches  more  in  eircumforcnee  than  the  sound 


EXCiaiOPf    OF   JOrNTS. 


413 


or  left  laiee.  There  was  grenl  thickcninj^  of  the  enpP^Jo,  which 
gave  the  impression  of  its  hnving  undergone  a  long  inHara- 
matory  process ;  there  wns  aleo  fluctuntion,  hut  no  pain  except 
on  free  morion. 

A  ffiittfl-percha  splint,  eicenJing  from  llie  hip  to  tho  loee, 
waji  moulded  to  the  hack  of  the  limh,  ao  aa  completely  lo  pre- 
vprt  the  motions  of  the  knt^e  nnil  ankle  jjiioCa,  Coiinter-irri- 
tntion  wii5  ms.de  hy  the  free  uhp  of  ihi>  tincture  of  imiine.  Under 
this  ireatmetit,  the  knee-joint,  in  four  weeka,  had  dlminidhcd  an 
inch  in  drciiraference.  As  the  absorption,  although  grnduidly 
progressive,  did  not  spem  to  hp  p"oing  on  with  miffirient  artivity, 
two  deep  iBsuea  were  mwle,  on  Mny  7th,  ithove  the  joint;  and, 
on  the  20ih,  two  more  below.  The  improvement  from  these 
a[] pi i nation B  was  very  prcat,  so  that  on  Jiinp  Ifith,  at  hij*  own 
request,  he  was  discharged  from  the  Hospital,  niueli  relieved, 

Thta  patient  kepr  about  until  June  2,  1^58,  when  he  again 
entered  the  Hoepitai,  by  my  odvioe ;  the  ditieatie  having  hh- 
Bumed  a  more  rroubleaome  form.  The  lcnci<^  was  quita  painful. 
At  Ciniea  awollen,  and  almost  u^elesH.  I^Ie  was  unalile  to  hend 
it,  and  was  obliged,  in  walking,  to  Mwing  the  limb  forwiird 
between  hla  crutches.  It  was  his  wish  to  have  ampiilntion  per- 
fonncnl ;  hut,  on  wniMnltJEtuin,  it  waa  deriided  in  give  Inm  the 
cliant^e  afforded  hy  excision  of  the  joint,  and  he  readily  con- 
aeniDtl  to  folkiw  my  nilvice.  The  operation  wiw  performp<l  on 
Jnne  5th,  in  the  following  manner:  A  ^mihmar  incii^ion  waa 
made,  commenelng  over  the  inner  condyle  of  the  femur,  ex- 
tending down  to  the  tnbercle  of  the  tihia,  and  terminated  over 
the  outer  condyle.  The  whole  f!ij.p  was  dititLecteil  up,  and  the 
joint  exjiotied.  8ome  atlhcHionn  existed,  nnd  an  attempt  at  an^ 
cbyloAis  bud  been  made;  but  the  cartilages  were  in  a  great 
measure  destroyed,  and  the  bones  eroded.  The  patellu  wua 
firmly  fixed  to  the  feninr.  and  did  nut  participate  in  the  dj^eai^e, 
eo  that  it  was  determined  not  to  interfere  with  it>  The  condyles 
of  the  femur  were  sawn  off,  as  al?ii»  was  the  head  of  the  tibia,  by 
a  narrow  saw,  like  Butchers,  which  wtis  iirmnged  to  cut  on  tfie 
iDuer  instead  of  the  outer  edge,  the  saw  being  reversal  in 
the  handle.  This  was  engaged  under  the  condyles  of  the  femur, 
find  divided  the  bonet^  witli  the  accuracy  of  a  kaife.      A  couimoti 


414 


EXTREMITIES - 


Baiv  would  not  have  been  avail:tble,  in  consequence  of  the  pTf> 
leetjun  of  llic  patdlEi. ;  unJ,  but  fur  tlila  luniuijument.  a  chain- 
Huw  wcuM  liave  been  required.  Od  itie  top  of  the  tiblii,  a 
tubercular  deposit  stUl  reiiiaincU,  wlilcli  woa  cijiiipletelj'  remnved 
bj  a  gcuge,  leaving  a  cnvity  nboui  a  quarter  of  an  inth  Ueep- 
The  head  of  tbe  tibia  waa  ao  cut  as  to  leave  its  edgee  a  little 
more  dej>end«ut  thitii  the  centre,  in  order  to  favjr  tbe  eacujie  of 
fluids*  The  bony  suHace^  bein^  carefully  phiced  in  apiioaittoii, 
tlic  tlfip  waa  secured  In  Its  aituatlon  by  nunieroua  sutured,  and 
tbe  wound  covered  with  a  litile  scrajicd  bat  soaked  in  blood. 
There  waa  very  little  hemorrhage,  and  only  two  small  arteries 
vrere  aecured*  The  limb  was  tlieu  placed  in  a  gutln-percba 
Bplint,  nicely  padded,  which  had  been  carefully  prepared  before 
tlic  opcraliun,  and  moulded  exactly  to  ita  abapc.  The  splint 
reached  from  the  natea  to  the  foct,  so  tLat  the  whole  of  the  lower 
extremity  was  perfectly  confined. 

For  the  three  days  subsequent  to  the  operation,  the  pnticnt 
slept  well,  without  pain  in  the  knee  or  fever.  On  June  8tht 
when  the  le^^  w^ib  raided  from  the  epllnt  and  dreeaed,  the  wound 
waa  found  to  have  united,  except  at  the  outer  cdgCi  where  there 
waa  a  discharge  of  pua.  lie  waa  remarkably  comfortable,  and 
espcricrccd  but  little  pain  from  the  dreesiag.  He  was  allowed 
house  diet. 

On  the  lltli,  the  limb  was  again  taken  out  of  the  apllnt*  and  a 
collection  of  pus  Avaa  found  on  the  outer,  but  none  on  the  inner 
eide.  Tlie  appetite  was  not  veiy  good,  and  be  waa  therefore 
ordered  the  compound  tincture  of  trcntian.  On  the  14th,  the 
limb  woa  again  dreeaed,  and  the  wound  was  tbuiid  to  have  dia- 
chai'ged  aomcwhat  more  than  nt  the  last  dressing.  The  incUion 
below  the  [latella  had  apiiareiitly  united  by  the  first  intcntaoD, 
and  only  tbe  ends  were  open  to  allow  the  esciLpc  of  tbe  pua- 
Uia   appetite  was  much   better. 

Tlik  patient  continued  to  Improve,  and  lef^  the  Hospital  In 
about  twi)  monlhe,  not  hiivin;,'  hnd  a  bad  f*ymptom  from  the  date 
of  the  operation.  In  November,  he  was  present  at  a  meeting  of 
tbe  Boston  Society  for  i\(edical  Improvement,  having  walked 
nearly  a  mile  from  hia  residence.  At  ihia  time,  he  waa  partially 
disabled  by  a  nail  growin^^  into  the  ficah  of  one  of  the  toes  oa 


EXOieiON   OF  JOINTS. 


415 


tTjc  side  opcratc^l  upon,  so  as  to  require  the  use  of  tvrc  rnnca  ni 
wnJIciiig.  BoHv  union  accnicd  to  Imvc  tiikcn  pljure  betrt'cen  tlic 
femur  und  tibia,  Tlio  wound  hud  apparently  heakd  ;  thuugli ,  [it 
a  eiiiuii  epot,  it  ot^caeioaally  opcQcd,  and  diEScbarged  slji^lttly. 

The  recovci'v  of  the  ii^e  of  the  IJmb  in  ihia  ease  was  qnitc 
rapid,  and  [\g  was  out  as  doon  as  n  patient  after  an  ordinary 
ompiitutioii.  The  aiipcriarity  of  the  single  over  the  double  fljip. 
wlien  it  can  bo  made,  botli  tis  regards  LippeariLncQ  and  position 
of  tbc  wound,  iicud  hardly  be  iusietcJ  on. 


Case  CCXLYIIL  —  Excision  o/the  Knec-johit  for  Vfiria^. 
J^ECOvsry,  — A  p;iri,  14  years  of  fli^e,  of  ii^ht  complexion  and 
red  hair,  entered  the  Hoepilal  on  April  ^tf,  ltiJ3S)t  durin;;^  my 
eerviee.  About  eix  years  before,  ehc  had  an  aftcelion  of  tlic 
ri^^lit  knoc-joint,  tlie  origin  and  courac  of  which  she  wiis  utterly 
unable  to  deJ^criLc,  whidi  left  bcr  htuic,  and  the  limb  tll^litly 
Guntmctctl.  Nine  months  before  eoiuin^  to  the  HospitiLt,  sIiq 
entered  a  factor)'  in  Low^:!!,  wliei'c,  for  a  ^od  part  of  the  day, 
ehc  woB  obliged  to  keep  licr  knee  in  a  bent  poBition  ngainat  tbo 
nia^Juuc  at  wliieh  eho  worked.  Tlila  hrou<;ht  on  a  rccurrcnco 
of  paia  in  the  joint,  flouic  ewclling,  and  further  iiontraetton  of 
the  limb,  bo  as  to  disable  her  from  walkin;^,  und  ret|Uin;  local 
applications  to  relieve  the  EcnJernces  of  the  joint.  She  came  to 
the  lIoRpital  ^vjth  the  idea  of  having  the  limb  rcniovod,  if  it  wero 
thought  adviiiable  by  tlic  euri^eons. 

The  right  knee-joint  was  about  uue-lblnl  larger  in  circumfor^ 
enee  than  the  other,  and  tlie  natural  d^pree^iona  about  it  were 
obliloratod.  TliO  Itg  wua  bent  on  the  ihigh,  so  tlint,  on  ttandinj 
up,  the  toea  did  not  roaoh  the  door  by  nearly  two  inuhc^  ;  the 
diriciwed  knee  beiu^  prefleed  againat  its  fellow,  and  the  inner 
e<ige  of  the  foot  coming  to  the  ground.  The  surgeons  of  the 
Hospital  agreed  willi  me,  that  the  case  way  a  very  favorable 
one  for  oxeisioa  of  tlio  joint,  and  that  tliie  operation  was  to  be 
preferred  to  removal  of  the  Umh. 

On  the  30th  of  April^  she  was  etherized  ;  and  I  mailc  a  horec- 
ehoe  incision  over  the  knee-joint,  which  woa  found  to  be  oloricly 
invented  by  a  den^e  eovoring,  coasisting  of  the  di&orgnuiKod 
synovial    membrane  and  cellular  tifisue :    the   cartila;^  wero 


416 


ESTBtEHlTlES* 


eroded  tit  mnnv  points,  and  the  condyles  of  the  femur  and  head 
of  the  tibia  were  necrosed.  About  half  an  Inch  was  s?iwe<l  from 
the  fpmiir,  ard  a  quiuter  of  an  inch  frum  the  head  of  the  tibtft; 
a]\  t\\c  diseased  Ix^ne  was  removed,  and  the  pntellu  dissected  out. 
Tlierc  WAS  very  little  hemorrhage.  The  f<*iimr  and  tibin  were 
brought  into  proper  apposition^  pare  lieing  taken  that  the  ext^spd 
endfl  r}iou]i]  not  be  too  tightly  hrought  together  ;  the  Hap  vraH 
confiiieil  by  HiiiiireB  ;  and  the  hmb  pliiced  in  a  [rutIa-^»erchiL  splint, 
and  lundageih 

She  pflfised  a  comfortable  night,  and  did  well,  except  liat 
twiee  ibe  n<-tion  of  the  femoral  muscles  drew  the  tihia  out  of 
po>!;i]ion,  Ltekwards  and  upwards.  The  patienti  being  of  a 
scrofulous  hnhit,  emaciated,  and  of  jroor  vitality^  her  convale»^ 
eence  w!w  slow  ;  and  the  limb  required  fi  good  deal  of  miinnge- 
ment,  hy  splints  and  dresaings,  to  keep  it  in  a  goi>d  poBilion.  and 
promote  the  healing  of  tlie  wound.  She  waa  taken  out  uf  doora 
early,  and  every  means  ueedT  hy  food  and  Ionics,  to  invigorftt« 
the  system-  It  wns  not,  however,  until  September,  that  she 
was  sufficiently  well  to  leave  tlie  Hospital,  when  the  joint  was 
firm.  A  slight  superHcinl  wound  Etill  remained.  She  waa 
taken  to  her  relatioiis  in  California,  and  her  future  history  is 
unknown.     The  case  promised  to  be  of  Buccessfiii  issue. 


Case  CCXLIX.  —  Er-cision  of  the  Knee-joint  fir  Be- 

formed  and  tihno^t  C'nfiies:i  Livih,  C\ire.  —  A  girl,  7  years 
old,  horn  ir  China,  was  brought  to  the  Hoitpltal  in  April,  1361, 
for  the  purpose  of  barinn;  either  tbe  knee-Joint  excised  or  the 
limb  amputated.  Her  parents  were  still  ahrond,  and  no  satis- 
factory account  of  the  case  could  he  obtained.  The  knee  wils 
bent  at  nearly  a  right  angle,  and  the  patella  was  fixed.  On 
nttempling  to  walk,  ^he  came  down  npor  tlie  toea  with  a  most 
awkwfltil  and  hobbling  gJiit.  Her  health  was  otherwise  good. 
Kxcinion  was  performed  on  the  24th  of  April.  A  eemietrcnlar 
flap  was  made  in  front  of  the  joint,  exposing  the  articulation. 
As  delicate  n  slice  as  possible  wsu*  then  excised  from  the  ends 
of  each  of  the  bones,  by  means  of  Butcher's  saw.  The  patella, 
becoming  dctichcd,  was  removed^  The  bones  were  then  ap- 
proximated, tlic  limh  l>eing  straightened,  and  the  flaps  nicely 


EXCiaiON   OF  JOINTS. 


417 


adjusted  by  sutiirca.  The  limb  was  then  pinccd  in  it  gutta- 
percha «pliut,  which  hud  been  prcviimi^ly  mocddcd  to  the  proper 
EhapCf  fluil  acciirod  by  a  baridii.<ru  cKloiiditi;;  iroin  the  toea  to  the 
pclvJs-  She  wofl  not  niucli  dcprcsBod  by  tho  operatiun,  but 
poised  a  restlese  nl^bl,  and  fi>r  two  or  three  davt*  was  in  an  un- 
comfortable stale.  On  the  27th,  the  wound  bnd  the  appeoroKCO 
of  having  united  by  first  intention  ;  but,  on  the  SOth,  there  waa 
a  alight  discharj^e  of  pus.  May  21th,  nearly  all  the  dbchariTc 
hnd  eeas&I :  and,  on  tlic  :^8th,  it  was  found  that  the  boned  had 
unitctl.  June  24th,  a  aturched  band^i^e  was  applied,  instead  of 
the  pitta-peix^ha  splint ;  aud  she  wad  taken  out  daily  into  Iho 
yard,  and  exposed  to  the  «nn.  By  the  middle  of  July,  &hc  was 
able  to  wnlk,  and,  at  the  end  of  August,  was  diachur^'ed  well. 

1  &aw  this  patient  about  a  year  after  the  operation,  and  exam- 
ined licr  t-arefully-  The  knee-joint  was  slightly  Hojtcdt  from  lL« 
weight  of  the  hotly  ;  and  the  Urnb  uppcared  to  be  iibout  two 
inobee  eborter  than  iti  fellow.  The  pclvJe,  however,  had  yielded 
80  aa  to  compcnaato  for  the  loea  in  length  in  the  limb,  wbieh 
appeared  to  be  due  in  pari  to  the  want  of  nutritious  the  limb 
having  ^own  less  than  tlic  other*  She  walked  with  a  rery 
eli^bt  limp  ;  and  the  chaTigc  prodnccil  by  the  operation  waa  very 
6triking»  a  aerviceallc  JJmb  being  aubetitutcd  for  a  deformed 
and  uiielesa  one. 


Case  CCL. — £!xcuit>ii  of  Wedgc-shnptd  Piece  of  Hone 
J'rom  luiee-joini  for  Anc/tifhaifs*  Dtatk  from  Pyemia. — 
A  boy,  aged  14  yeara,  of  large  size,  and  good  muscular  devel- 
opment, in  mhh  received  a  wound  from  an. axe,  on  the  right 
knee,  which  penetrated  the  joint.  The  injury  was  fullowud  by 
severe  and  Jong -eou tinned  intlamaiation  of  tlie  joint,  fimdly 
re^ultiug  in  an  anc^hyloais,  wiib  the  Icg^  bent  at  a  right  angle 
with  the  fcuLur.  When  I  tirt^t  ^aw  him,  he  walked  on  the  tip 
of  the  toca  of  the  right  foot,  th*  left  limh  being-  thrown,  in  a 
bent  position,  forwurdfi ;  so  that  a  pcreon  seeing  him  in  motion 
would  auppoec  the  whole  o&scous  system  more  or  leas  distorted- 
Being  consulted  in  November,  1851*,  as  to  the  poeBibility  of 
Gtrnightcning  the  limb  by  any  mcohanieal  force  applied  to  it,  I 
At  onee  dcoidcd  in  the  negative ;  the  patella  being  lirmly  fixed 


418 


EXTin 


in  it&  situation^  jtud  all  motion  of  the  jt>int,  eo  f&r  as  could  be 
perceived,  deslr^*yed»  The  onlr  ruetbod  of  relief  I  could  pvty- 
^ny&G  to  him  was  aa  0|kcratioD  like  that  Brat  HLig^ested  ity  Dr. 
Bftvton,  of  i-emoving  a  wet]ge-*Iiaped  piece  of  bone  from  ihe 
joint,  or  ita  viciiiUyT  ^vhicli  1  had  onee  before  practiwd  with 
eiicceea  i  thut  removal  of  the  limb,  even,  wiia  more  dceirubJe 
tha:]  allowing  him  to  continue  in  hia  deformed  and  painful  cod- 
(lition.  Hiti  friends  and  phj^ician,  having  taken  the  subject  inlo 
full  and  dtlibtrate  cimeitleratioQ.  decided  to  have  the  o[>enjtton, 
which  I  prupoaed,  performed;  and  the  patient  vraa  hrought 
down  from  the  country,  and  placed  under  my  chiirge  at  the 
Iloapitnl- 

Tlie  operjition  was  done  on  Oct,  29,  1859.  Previous  to  tta 
perforniancet  it  waa  observed  tlial  the  liamatring  tendons  in 
the  different  naotiona  of  the  limb  were  powerfully  coniracfed; 
and,  in  fuur  or  five  cases  of  excision  uf  the  knee-joint  which  I 
have  performed  or  witnessed,  I  have  observed  tlml  these  tendons 
funned  an  obstacle,  at  the  liiue»  to  the  straightening  of  the  limb, 
and  were  ^c^y  troubleaoinc  afterwnrda,  during  the  treattneat, 
dragging  the  leg  backvvni-da  out  of  apposition  with  the  femur* 
The  o|>enitioii  woa  coniraenced,  therefore,  bv  the  eubcutaneoua 
division  of  these  tendons*  The  patient  then  Iming  placed  upon 
hifi  hack,  u.  flcmicircular  inciswn  waa  made  just  over  the  knee- 
joint,  commencing  at  the  lower  part  of  the  inner  condyle  of  the 
femur,  extending  around  across  the  spine  of  the  tibia,  and  ter- 
iniojiting  at  the  outer  condyle.  The  flap  of  skin  w^  thea  dia^ 
seeled  up,  and  the  remaining  soil  parts  divided  to  the  bone. 
Tlie  anw  was  next  jilaccd  on  the  femur,  Jviat  above  the  anchy- 
loscd  patella,  and  the  bone  sawn  a  little  obliquely  downwards, 
so  as  nearly  to  traverse  its  thickneaa.  The  saw  was  then  placed 
on  the  upper  ^urt  of  the  tibia,  juat  below  tlie  point  where  the 
old  articulation  was  supposed  tc  have  been,  and  an  ineision 
uuide  neiirly  at  a  right  angle  with  the  former,  so  lis  to  remove 
a  bolid  bit  of  bone«  with  the  patella  attcidied  tu  the  top  of  it. 
lYith  a  very  little  motion  backwards,  the  rcmaiiiin*^  shell  of 
b<me  was  uow  fractured;  and  tin:  size  and  shape  of  the  pieee 
removed  were  so  exactly  what  had  been  intended,  that  it  seemed 
oa  if  there  could  be  no  difficulty  in  placing  thu  limb  at  once  in  & 


EX0131OS'  OF  JOENXa, 


419 


BtP!ii*'ht  position  :  but,  far  aomc  rengon  which  could  not  bo  ex- 
plainrxli  jiiid  which  wt\e-  u  neon  nee  ted  with  museiiUr  Qction,  it 
W)ifl  found  iuipoBsiblii  to  do  this,  —  a  result  I  attriLutod  to  tho 
he;td  of  the  tibia  having  be^n  pnrtiolly  dieplnccti  bt^hind  the 
femur;  and  thue,  wbiJc  tho  whole  circumference  of  the  femur 
had  bcon  romo^'Cfl,  only  ft  pnrt  of  the  head  of  the  libia  iiad  been 
incluJed  in  the  incisions.  The  Ic^j  beinp;  bent  forcibly  back- 
ward!:', 80  aa  to  proCriidc  aa  much  ua  puedblc  tbc  ends  of  the 
bone,  mjd  the  intervetiini^  bit  of  booc  being  cut  awavt  the  ends 
of  both  bonoa  were  Fairly  exposed,  and  a  elicfl  removed  from 
each  of  them.  The  limb  cmilJ  now  be  brought  out  atruight, 
and  the  everdion  of  the  foot  corrected.  Lititon^s  apiint  woe 
applied,  and  the  ed^e^  of  the  wound  nieely  adjusted  by  sutiiree. 
The  hcniorrha*je,  during;  the  lirat  incieions,  was  much  more  fre« 
than  in  any  cxctfiion  of  the  knee-joint  1  have  practiced.  It  was 
partly  owin^  to  the  age  and  muscidnr  development  of  the  pa- 
tient.     The  bony  atructuro  itself  was  aho  cxeoaeively  vaaculnr. 

In  the  atlemoon,  the  pnlient,  having  recovered  from  the 
effect  of  the  ether,  and  having  taken  twenty  drops  of  laudanum, 
was  quite  free  from  pain,  There  had  been  an  oozing  nf  blood, 
which  wet  tlio  banda;^a  in  the  vicinity  of  the  joint.  Ho  passed 
a  moderately  quiet  night,  and  on  the  following  day  mode  no 
complaint  of  pain,  hie  pnlse  being  between  acveuiy  and  eighty 
in  the  mornini;*  Towards  evening,  considerable  rc-aclion  took 
plnce,  attended  with  souio  heat  of  the  limb,  and  fever. 

On  the  next  day,  he  was  quite  comfortable,  complained  of  no 
pnin,  nnd  began  to  take  nouriahmenl*  The  bandages,  being 
foul,  were  removed  ae  far  as  poeaiblo  without  diatiirbin^  the 
limb. 

On  the  fourth  day,  the  limb  wna  taken  completely  out  of  the 
B|dintt  entirely  cleansed,  and  frcah  dreeainga  opplicd.  The  pa- 
tient took  eider,  broth,  and  cutfcc,  and  expressed  himself  as 
getting  along  well.  With  tlje  exception  of  an  nperture  on  tire 
inner  pide,  at  which  the  blood  bad  Cf^capcd,  the  wound  had 
united  throughout  by  the  iirst  intention.  A  little  rcduees 
existed  over  the  outer  side  of  die  Condyle  of  the  fcmiu: ;  and  tlio 
patient  having  rolled  over,  on  the  first  night  after  the  opcratioDi 
partly  displaced  the  bone,  and  kept  up  undue  pressure  on  it 


420 


EXTEEMITJES- 


throiiirli  ihe  niijbt  t    the  displnecmcnl  waa  dieooveretl,  and  ad- 
JTisteil   oil  tlie  ensuing   d:iy. 

Every  thiag  appeiired  very  favorable  nntil  the  sovenili  dny 
after  the  o[>oration,  when  he  begnn  to  show  »ome  unfavora- 
ble aymploma:  the  pubc  became  more  rupifl,  n.  laiigiior  and 
heaviness  ft|jpcnroil,  a  die|)Osttion  to  aleep*  anil  more  or  le^  loss 
of  Hpjietite.  At  the  enrae  time,  tiie  dischnrge  from  ihe  wound 
became  tiffi-naive.  He  wns  inimedifitely  [ml  npim  full  dosea  of 
braudv  rind  (|iiiNiije,  siod  great  iitcentiou  given  to  iho  wound,  hy 
frequent  dressings  and  iiblutioiia,  to  frtc  it  from  the  foul  secre- 
tiiin^  Jis  tnuuh  ha  jirnciipiiblf^.  During  this  time,  the  limb  above 
and  below  the  wound  looked  woll,  und  the  circulnrion  seemed 
to  be  perfectly  nurmnl.  On  tlic  followinjr  day,  au  injeclion  was 
madii  into  the  wound,  tbrce  times,  of  clie  tintturc  of  iodine. 
The  eymptonift  of  purulent  fibsorptiou  rapidly  be<?anie  more  de- 
cided. The  patient  wus  i^ery  listless ;  the  ptdse  130  :  he  mride 
no  eomplaint  of  nry  kind.  By  the  next  day,  the  skin  over  a 
portion  of  the  Hup  covering  the  former  joint  hnd  a  sloughy  look  ; 
and  towards  uveuing,  in  addition  to  furmcr  evinpfoin*,  ho  bad 
difficulty  ill  o[iening  his  jaw'fi.  He  Bank,  and  died  on  the  fol- 
lowing davT  being  tliG  twelfth   frouj  the  operalion. 

The  body  bein^»'  immediately  removed,  mo  opportunity  was 
afforded  of  making  an  esaminalion.  The  aymptoraa  were  all 
tliLiric  whieh  would  be  caui^t^l  i)V  ab^^orptiou  of  a  pH'^rmoua 
material  into  the  circulation,  nnd  were  met,  aa  far  as  cnuki  be, 
at  ouce»  when  ]ier<^eive*l.  The  part  at  whieh  the  operation  was 
done  was  inspected,  and  the  bones  had  all  ti^e  ap[)cnrjince5  of 
having  been  bathed  for  a  number  of  Jnvs  in  fetid  secretions. 
There  were  no  abaces^ea  or  collections  in   the  vicinity. 


Case  CCLl.  —  ^ar/oJt's  Opeytrtion  for  Stmt  if  ft  fining 
the  liiiee-Joiiit  hy  Excision  of  a  WedgC'skfjped  liyt  of  J^iyn&. 
— A  mnu,  25  years  old,  from  Nova  Scotia,  presented  himself 
to  me  in  Scptc^mber,  1850,  on  accoimc  of  n  grent  deformity  of 
hia  limb,  owing  to  an  anehylosia  of  the  knee-joint ;  the  leg  being 
bent  at  nearly  a  right  an^de  with  the  thigh.  He  stated  that  hia 
prospects  had  been  destroyed  and  lii^  life  rendered  wretched  by 
hid  infirmity :   and  wished,  if  any  tliiag  could  be  done  for  bini. 


EXC!S10>J  OP  JOINTS. 


421 


abort  of  cxtrome  dun^cr  to  hia  life,  ihat  it  shouKl  Ic  nttomptcd. 
The  Kistopy  of  the  ojtse,  aa  given  by  liim,  was  tliie  :  In  Novem- 
ber, 18'il,  he  fell  a  di^ttLnce  of  throe  feetj  striking  the  kiie€. 
Three  Jays  nfler  ihe  fnll,  the  knee  be^nn  to  swell,  and  become 
painful.  Thia  went  on  for  four  wccka»  whca  it  was  punclurct], 
and  ft  pint  of  wat&rv  Huid  esi-apcd.  It  continued  to  discharge 
for  lifleen  moiiEh^f  daring  which  (line  many  sin.-tll  pieces  of  bone 
came  nwap.  The  opt'nin^  finally  be?ded,  leaving  ihe  joint  and 
limb  in  a  distorted  poeitioi].  His  horcdilary  tondciicice  were 
eorofiUous*  In  the  ereut  poeition,  resting  tipon  the  aound  limb, 
the  lame  foot  was  seven  and  a  half  in<^hes  from  the  ground  ;  but 
he  could  Ihnp  ab'iut  with  a  hi^h-heeled  boot- 

I  infoniied  the  p.ttient,  tlmt  ihe  only  operation  which  &UQ- 
gefited  itfielf  to  mc  n'lis  Bartrm'a  opemtioti,  which  hud  ap[>arently 
been  nlroady  described  to  bim  ;  and  at  once  lie  requested  to  have 
it  performed.  I  advised  hirti  to  enter  the  Hoapitd  for  the  con- 
venience of  appnrutuj^f  which  he  did.  Some  o^  his  frieudfl 
attempted  to  deter  him  from  ninning  any  rUk',  but  lie  said  be 
was  determined  either  to  undergo  the  operation  flu<*yoet«i  by  me 
or  to  have  the  limb  removed,  as  he  could  do  longer  bear  the 
pain   and   mortification  of  hl^   condition. 

On  the  2d  of  October,  the  operation  agreed  upon  was  per- 
formed aA  follows :  A  V-£huped  ind^ion  wne  made  through 
the  §kin  jast  nbove  the  knee-joint;  ttie  ba^e  of  the  triangle,  two 
iudips  wide,  preeeniing  outward,  willi  the  apex  at  the  Inner  fiidu 
of  the  limb-  The  Aap  was  di^^erted  up,  and  the  bone  ex- 
posed ;  the  otiier  tt^xture^  having  become  atrophied  fj^oni  ditoiiAo* 
A  wedge-shaped  jHuee  was  sawn  out  of  the  temur ;  the  saw 
not  being  carried  ijuito  throiighj  so  as  to  avuid  the  artery.  The 
remaining  portion  of  bone  woa  then  broken ;  the  £ap  woe  se* 
cured  In  it^  place,  and  the  knee  plaoctl  on  a  double  inclined 
plane,  and  firndy  fixed  to  it.     There  vvm  no  hemorrhage. 

Ou  tlio  following  day,  the  patient  ssiid  he  had  passed  a  rcst- 
IcsB  nightt  but  wuti  free  from  pain.  The  Ihnb  w^aa  dressed  on 
Oct.  7th,  and  pluoed  on  n  splint  with  a  hinge  mid  screw,  eo 
tbrtt  it  cuuld  be  extended  without  any  shock  to  the  joint.  By 
the  20th,  iJxe  limb  had  bt-en  gradually  bron*^ht  to  n  strni<rht 
position;    and,   on    the    iUth,  the   bones  hud   united,  imd  ibc 


4S2 


SXTBGMITT&6. 


wound  wns  iicnlcdp  Some  time  after  thia,  he  hnd  a  febrile  at- 
IjiL'k,  in  tlic  courac  of  which  the  union  bccnmc  aoiiicwhut  ioaa 
tinn,  ami  llirenteocd  to  dissolve ;  the  avaleni  showing  ita  ftcrofu- 
loiia  tendency,  tie  gradually  recovered,  however,  and  left  the 
Hospital. 

About  a  year  after  hU  diachtirge,  thie  gentleman  preaenled 
himaelf  to  me^  well.  The  limb  was  very  little  shorter  thaa  the 
other;  nnd.  with  a  |mir  of  lar^o  trouaera»  the  dilfereniw  in 
the  ehnpc  of  the  two  liuiba  could  ecurcely  be  didtiiigUL^hcd.  He 
wftlkcd  well  with  a  caiie;  nnd  the  improvement  between  hi* 
upright  ap|M?iirnnce  in  WJilkin^  nnd  his  former  method  of  loco- 
motion would  h[ive  iiliito^t  prevented  biru  from  being  recog- 
nized OA  the  finme  individual. 

In  BOoic  cn-eea,  greater  Bjmmctry  may  be  gained  by  making 
the  cxciflion  directly  from  the  joint,  i-ather  thnn  above  it,  fta 
there  is  then  proecntod   a  much  larger  eurfaoe   ul~  bono. 


The  fidlowing  table  givca  n  brief  r^sum^  of  the  oaees  of  ex- 
cision of  the  joint  before  dcflcribcd,  not  iDCludiDg  the  two  CAAes 
of  Barton's  operation  ;  — 


EXCISION  or  JOXNTB. 


i83 


n 


iiriijijiifii 


its? 
I- 1  - 

I 


^n 


p 


Cn.^TTER  IX- 
AKTEEJKS  AND   VEINS, 

AXEURISIIAI,  TUMOnS  AND  LH3ATUBE   OF   ABTERtES. 

TiiR  inlrmJuctioii  of  tlie  method  of  treiit.ing'  anciirismnl  tumors. 
eklicr  by  nr)m[iresj'ii>n  rm  the  vessel  above  thf.  tuiuor,  or  com- 
pn^HLtm  c^ii  ibe  tumor  it^elfV  in  tbe  [Aucg  of  tbe  severe  aud 
dan^rous  ojieriitioii  uf  lyiti<r  tbe  arttii-y,  gnve  an  nildiEioniil 
iia|iulse  to  tl»e  trearmciit  of  lliese  dist-ases.  Tlic  diPtiuguisbed 
eurguon,  Mr.  Symc,  lins  atU^orntEHl  a  revival  of  the  old  iniera- 
tion  of  opci^iiii^r  the  h!ic  ittielf,  and  tying  the  vessel  ubot'i!  and 
below,  m  apjjropriate  eafies. 

Tbo  following  caees  ilhistmte^  by  one  or  two  examples^  the 
treatmeiit  of  compression  of  the  tumor  directly.  An  interest- 
ing uase  of  fciijoi'al  anourism  treated  hy  immediate  compression , 
under  tbe  onre  of  Dr,  B.  Brown,  wliieh  I  saw  in  consul cnrion, 
is  jniblislied  in  tlio  "Bo?,ton  Medicid  find  Surit;ical  Jourrsil  "  of 
March  15,  1866.  The  tumor  in  this  cose  was  id  the  femoral 
artery,  juat  at  its  exit  from  the  pelvis.  The  compression  was 
made  by  means  of  ingenlons  apparatus,  continuing  througii  a 
period  of  about  eight  months,  and  with  full  auceeas  ;  subfititut- 
ing  a  treatmeut  without  danger  for  the  very  serious  operation  of 
the  ligature  of  the  eiternal  iliac  artery.  One  or  two  cases  are 
given  of  the  old  Hunterian  operation,  and  one  where  death  oc- 
curred after  Jigature  of  the  Jfirotid  artery  from  the  recurrent 
circulation.  The  compression  may  be  made  either  with  the  fin- 
gers, —  in  which  case  it  is  kept  up  for  several  hours  by  relays  of 
assistants,  —  by  long-continued  and  extreme  flexion  of  the  Hmb, 
or  by  special  instruments  contrived  for  the  purpose.  In  two 
cases  of  very  large  subclavian  aneurism,  which  I  have  treated 
by  the  direct  pressure  upon  the  tumor  of  a  heavy  weight,  in  the 


=> 


AXEUR18MAI.  TUMORS.  4:?^ 

* 

fihape  of  ft  cftunoD-ball,  and  where  the  Tluntcrlnn  ojioniiiim  n:i:t 
impossible,  1  have  been  &0  fortunate  as,  in  one  injiiamv,  to  i^llivt 
the  complete  oblitemtion  of  the  artorv;  nnil,  in  tlie  iithor,  1^« 
produce  GoaguhitloD  of  iJie  contents  of  tlio  eac,  falJowoil  by  $\i\^ 
poTfttion  and  iloughmg,  resulting  in  tlie  iierfoet  eiiiv  of  iho 
dueftie. 

Caae  CCLII.  —  SubcIaviitH  AiifHi-isii}  fri'oU'tf  htf  (\»):j- 
prcMioH  and  other  Means,  liecoven/.  —  (Phte  HO  A  i>*l- 
ored  mui,  39  years  "of  nge,  from  Maehb*.  Mi\,  wa*  wnt  to 
me,  MftTch  2,  1854,  having  a  large  nnouri^iin  of  the  h't\  ^^uN^l:!- 
rian  nrtery.  I  woa  called  down  stairs  early  in  tho  mornini^ 
hj  the  etatement  that  a  bJnck  man  in  a  Uying  ^I:iU'  was  lylni^ 
under  the  stftircaac.  The  patient  stated  that  ho  li'l\  lilomv^ior 
in  ftveaael  about  aweek  before,  and  had  been  kept  out  by  Mi\^ss 
of  weather,  and  finally  hod  been  laiidctl  ;it  a  ill^-'tant  fioint.  fri^nt 
wfatch  he  had  walked  to  Boston.  He  was  tiut)orin<;  nuirli  in^ni 
exceuive  pain  in  his  arm,  whieh  was  enonnou.^ly  snolh^n*  b;it1 
an  asthmatic  cough,  and  great  dyj^jmiL^a.  lie  \va:<  inuiitHli:iloly 
transported  to  the  Hospital,  where,  being  phii'Ofl  in  a  uurni  b:tib 
ftnd  thence  into  bed,  the  circulation  beeanio  more  frei* ;  :uul  lie 
gradnally  got  into  a  more  comfortable  cimdttion.  Tbe  foDonin^ 
ftCGonnt  ia  taken  from  the  Hospital  roeonis  :  — 

" Hard-working  man  ;  strained  Ium?*elf  fimrt^vn  months  ap^ 
Haa  had  uneasy  sensations  about  ^houMiT  simv  ihiii  lime.  Kirsi 
noticed  tumor  above  clavicle  in  July*  IHJj^  ;  ^vorkeil  unlil  l-Vb, 
22,  1854,  when  pain  In  tumor  and  arm  oh1i<rei1  bim  lo  ()Uit. 
Now,  pulsating  tumor  over  chmole,  its  anterior  inlorior  porlJou 
one  inch  from  sternal  end  of  ch*viclc,  C'in'umfereneo  of  lumor, 
7J  inches.     Hand  and  arm  have  been  wwolh-n  all  winter." 

After  his  admission  to  tlio  Hospital,  a  eonj^ultsjiion  of  all  the 
sorgeona  was  called,  and  the  quCi^tioti  proposed  a^  to  the  pn^ 
priety  of  any  o]>eration  being  attem|i(<H|  tor  hJii  ri^lief.  The 
whole  triangle  of  the  neek  above  the  elavielo  was  IiIKhI  with  the 
tumor,  which  extended  nearly  to  the  sternum,  f=o  that  any  pros- 
pect of  tying  the  vessel  on  the  eanliae  siilo  f'eonu'^1  lo  he  iniprae- 
ticable  :  and  the  only  operation  whieli  was  at  all  feasible  was  to 
ftpply  a  ligature  to  the  artery,  a^  it  issued  from  the  tumor,  bc- 


42*i 


ARTEMES   ANI>  VXIK9- 


low  the  clovicle ;  a  project  Lardly  worth  attemptinp.  The 
i'oUowJng  treatment  wna  therefore  resorted  to  :  — 

From  tlie  12t)i  of  MaKli  to  the  30th  of  April,  cold  applica- 
tiofia  were  made  to  the  anouriem,  \flried  with  coraprcsaion  hv 
weights.  There  wojs  do  diminution  in  its  size,  indot'd  it  rather 
increased  duiing  hits  stay  in  tlic  K<ispjtjd ;  nor  muuh  ameUora^ 
tion  in  the  Bymptoma,  except  thnt  of  pain,  which  was  entirely 
a^&uiif^cd  by  means  of  compresfiioa.  The  patient's  general 
health  waa  considembly  improved. 

May  4th,     Discharged  much  relieve*^, 

On  May  Ist,  being  obliged  to  leave  Boston  for  Europe,  I  lost 
sight  of  Ihii?  patient.  Some  montlia  after  leavin^r  the  Hospital, 
he  waa  admitted  to  the  State  Iloepital  at  Rainsford  Idand.  where 
ha  tame  under  the  care  of  Dr.  J.  R.  Lothrop,  physician  and 
Burgeon  of  the  placc>  and  now  of  Chicago,  who  has  been  Idnd 
enougli  to  give  me  the  sequel  of  thie  rcmai'kable  caae. 

"As  nearly  as  I  can  remember,  "Williame  was  admitted  to  the 
Hospital  at  Raineford  Island  in  October  of  18,J4.  Hu  stated 
that  he  had  fallen  upon  the  ahouldcr  of  thfl  ntfected  side  a  few 
days  before,  and  Buffered  much  pain  in  conacquenoo-  The 
tumor  waa  tender  to  the  touch  ;  motion  gave  great  pain;  and 
the  onJy  poaition  which  he  could  boar,  was  to  ho  on  the  sound 
aide.  Tho  ekio  over  the  tumor  was  tcnac  and  ehining ;  there 
was  no  pulae  at  the  wHst ;  Ilia  arm  was  powerless  and  cedeian- 
toua,  and  dropped,  aa  can  be  seen  by  tho  pict^^re.  The  turaor 
bad  more  the  flpi>earaiice  of  a  large  abscea*  than  of  an  aneurism- 
There  wae  no  tremor  or  pulaation  in  it,  or  commuoicateJ  tu  the 
hand;   no  sound  or  nncurismal  murmur. 

*^rn  about  three  weeks  the  pain  ceased,  and  the  pationl  was 
able  to  get  up  and  put  on  a  shirt  for  the  fir»l  time;  ndlying 
quickly  from  the  eifccts  of  the  general  constitutional  disturbancQT 
which  had  been  quite  severe. 

*'  In  time,  the  tumor  began  to  point  perceptibly  nearly  over  the 
middle  of  the  clavicle  ;  the  akin  gradually  becoming  thinner,  I 
do  not  recollect  the  time  when  spontaneous  rupture  took  place; 
but  I  think  it  waa  during  March,  18j5. 

"When  the  opening  took  place,  there  was  a  profuse  discharge 
of  mi:ced  blood  and  pua,  dark  and  rather  thick;    in  quantity 


ANEUBISMAI.  TUMORS. 


427 


about  two  quarts.  It  continued  to  flow  two  or  throe  days. 
gniduttlly  decreasing.  A  purely  purulent  diachargc  continued 
for  eeveral  raontha  :  in  fact,  when  the  pfttient  was  discliargcd  in 
June,  there  was  ever  then  ft  Blight  flow  of  pus  frono  thfl  open- 
ing. No  biiA  eymptoma  aceompnnicd  or  Eollowcil  the  epontane- 
oua  opening  of  the  Cunior:  oa  the  contrary.  Jack  woa  ia  high, 
apirita  ut  nn  event  which  he  liaj  all  along  been  wishing  for,  the 
gottin-^  out  cf  the  'corruption*'  He  h^d  predicted,  thati  when 
the  'corruption'  waa  oil  out  of  it,  ho  should  bo  all  right;  and 
be  often  begged  me  to  '  launch  "it.  In  a  short  time  after  the 
rupture,  he  was  up  and  iihoLit. 

"  The  tumor  r^-ipidly  fcubsidcd,  n.nd  was  followed  by  a  dcprca- 
Bion*  Tho  shoulder  fell  forward.  An  opening  rcmuncd  onc- 
holf  or  three-lburtha  of  an  indi  in  diameter,  Into  which  opening 
piMJeoted  a  pointed  und  curious  end  of  the  hnmerul  portion  of 
tho  clavicle-  The  eternal  portion  wna  not  visible.  The  middle 
portion  wne  wanting.  AVhcn  ho  Icll  the  hospital,  he  had  no 
distinct  pulse  at  the  wrist,  and  the  arm  yvas  still  powerless  ;  but 
his  general  health  hnd  greatly  improved,  and  he  felt  hijusclf  able 
to  resume  bid  old  employiacnt  of  ship's  cook,  wliich  be  JictuoUy 
did  Eoon  uftcr» 

"About  a  your  after  WiLiama  left  the  hospital  at  Eainsford 
Island,  he  proacrted  liimaelf  at  the  bont-bou^e  in  Iio»tcin,  with 
bid  urm  in  a  aliiig,  but  otherwise  in  good  lieakh  ;  and  I  under- 
stand that  a  letter  has  since  been  received  from  him,  in  which  lie 
stated  that  hid  hcoitJi  contlnited  frood.'' 


OfiE  CCLIII.  —  AiiGuri^tn    of   the    Rij/ht     Subclavian, 

Treatment  btf  C(finpressiaji,  Crtre.  —  May  14,  1857,  a  me- 
chanic, from  Sc^otland,  41  years  of  age,  came  under  my  core, 
having  an  aneurism  of  the  eubclavian  artery,  occupying  ibe 
whole  triangle  of  the  neck  above  the  claviele.  The  tumor, 
when  first  noticed,  thirteen  months  previously,  was  siluatcd 
about  the  middle  of  tho  clavielc.  Being  a  strong,  active  man, 
in  the  enjoyment  of  good  health,  he  gave  very  little  attention  to 
it  nt  first.  He  bad  been  employed  twcnty-aeven  years  in  the 
niunufaeture  of  eteam-cngincB,  and  much  exposed  to  changes  of 
temperature. 


423 


AltTKRIES  AND  VEINS. 


The  lum/ir  presenlod  three  prr»jc*iti^nj^ ;  itn<l,  from  its  ftrigma] 
eize  of  a  pigeon  s  e^^j;,  hml  exloadeJ  the  whole  length  of  llie 
clovide.  As  it  increased,  be  began  to  aiiffer  from  pnin  in  it^ 
alterd^^d  witli  shofTne-iH  of  brenlh.  On  etoopinpf,  »  eeuentioc 
of  w&ij;ht,  aceompniiiefl  with  tliroI>bini^,  was  produced  in  it. 

No  operation  socmed  feasible  in  this  cnso,  and  it  was  tliere- 
fore  eubn:)LttGd  to  the  ftjllowin^  trentment  i  He  was  placed  on 
hia  W'k,  in  bcnl,  nnd  ke])t  on  a  liiinted  diet  of  a  pound  of  eolid 
and  a  pint  of  liipiid  fi>od  everj'  twenty-four  hourd,  without  meat. 
BflgH  of  ice  wore  applied  to  the  aneurir^m  on  the  ITth,  And,  in 
lees  than  two  honre,  produeed  a  very  sensible  eflet't  in  rednnng 
the  puke.  On  the  l\h\\,  conipreesion  was  tried  wkli  Dr.  v\r- 
notl'a  air-cufihinn,  which  waa  applied  through  the  day,  with  ihe 
exea[>ti<jQ  of  three  intorvals  of  half  an  hour  each,  when  baga 
of  iee  were  eubstitnted.  On  the  2Ut,  he  com|jlaine<l  of  mor« 
pain  in  the  lower  Iol*e  of  the  tumor;  also  some  in  the  two 
upjier  loheSf  and  a  feeling  of  numbness  in  the  arm  of  that  side. 
Jee  wafl  used  for  fifteen  uiinutee,  instead  of  half  an  hour.  Com- 
prebsion  wns  dii^continued,  from  the  impractiiabillty  of  making 
it  equally  over  the  whole  tnmor,  on  aecount  of  its  iireguJar 
sui-iiicc  and  large  f^hn.  On  the  27th,  having  oomplained  «f 
more  pain  iiL  the  smallest  prujcetion,  the  ice  wuij  diecoEitinued. 
On  Au^.  13th,  he  left  the  Hospital,  appart^ntly  not  much  r&* 
licvcd  :  hutf  in  fact,  fnnu  ibii  Lime  tlio  tumor  fp^adually  sub- 
sided ;  nnd,  about  a  year  afti-rwrnil?^,  he  cnme  to  the  £Iospital, 
and  snid  that  the  tmiKU"  hud  cunrely  dii^ajipeared,  nnd  he  waa 
quite  well.  Unfortunately,  I  did  not  see  him  at  the  ihne,  at>d 
waa  unable  to  vorifv  the  exaet  condition  of  the  subelnvian  artery 
and  pulse  of  that  side. 

Jietiiarka.  —  The  ice  nnd  compression,  together  with  rest, 
seem  to  have  given  an  iiiipeuis  to  the  tumor  in  both  f.-ni^ps ;  in 
iht*  one  kading  to  an  obliteration  of  the  sac,  and  in  the  otlier  to 
suppuration  and  a  desirm^tivo  inflamniation.  The  appearance 
of  tho  tumor  in  the  fonner  case,  when  first  seen  bv  Dr  LoOirop, 
some  months  after  leaving  the  Hospital,  being  fiiich  aa  to  leod 
him  li>  ftuppose  it  a  large  absceaa,  and  that  some  error  must 
huve  been  mode  in  tlie  diagnosis  at  the  Hospital  aa  to  ita  aneu- 
rismal  character  ;  so  entirely  unlike  euch  an  affection  did  it  appear 


JUTELFKIRH^L    TUMORS. 


42d 


to  Mm  nt  that  time.  Whetlicr  owin;;  lo  Ircatmrnt  or  to  nnhi- 
ral  cniifles,  the  dtiinuto  recovery  of  two  such  apparently  tbcmid- 
nh]e  and  dee|jorflte  casea  is  wortliy  of  record- 


Case  CCLFV.  — Lit^nturs  of  fhe  Lt?ft  Sitbcfftiian  Artert/ 
for  SuLcJavi'an  Ajienri^tn,  with  a  lif^mafknble  Deviation  of 
the  Vejtaelf  and  Consequent  Vhrtnge  if  ifs  Hciationg.  —  The 
grent  mnrlnliTy  ntfi'ndirg  the  ligsitifre  of  the  largrr  arteriH! 
trunks,  nnd  of  the  eiilx'laviuii  in  jinrliuulnr,  yives  importniice  to 
anj  operation  oa  thf>3e  veasela.  In  the  Intter  tlie  danger  m  in- 
creaaed  by  its  deep  aituiitifjn,  —  cansing,  in  jnany  crwes^  !i  grent 
difficuJly  of  reaching  it, — jmd  l*y  the  impurtanee  of  the  orgiins  in 
itti  immediate  neigliborhcxMl,  According  to  the  vnlunLJe  tables 
fnrriished  by  Dr.  Norria,  out  of  <J9  cases  f>f  ligature  of  the  sub- 
clavian artery,  36  recovered,  and  33  died,  or  nenrly  one-half. 
In  ojierHlitjns  on  the  iliae  arteries,  out  of  118  cases,  P5  recov- 
en-d,  and  33  died.  From  38  cases  of  operatinn  on  the  c^nrotid 
artery  for  aneurism.  22  reeovcred,  nnd  16  died.  In  every  in- 
stance where  it  has  been  neeespiary  to  place  a  lipafnre  on  the 
fliiWaviim  artery,  on  the  tracheal  eide  of  tJie  ecaleni  muwies, 
the  rcftnit  has  been   faral- 

Tlie  *_iiae  whicli  1  propose  to  relate  offers  some  peculiar  points 
of  inferesr,  apart  from  the  general  one  of  the  lijrarure  of  the 
vessel.  Among  the  prLneipal  of  these  may  he  mentioned  the 
fact  of  a  ligature  having  been  applied  to  the  artery  for  nn  ancu- 
rii^mnl  tnnior  jdliiateii  nhovc  the  clnviele  :  being,  sa  far  as  1  am 
awarCf  the  first  ease  of  tin*  kind  that  Ims  had  a  suceesftfu]  result, 
because  the  recorded  aneiiri^jmal  lumors  in  that  situation  have 
required  tlie  applicafiiuL  of  n  ligiilnre  within  the  scalcni.  and  the 
termination,  as  sraicd  above,  has  been  unfavorable.  Secondly^ 
The  anntomicid  pefuliarities  in  the  rohilion^i  of  the  vessel,  to 
whieh  umr  bo  nrtrifnitcd  tlie  possibility  iif  the  ligaiure  on  the 
outside  of  the  scalcni.  ThtMhj,  The  rapidity  with  which  the 
collaicrnl  cirenlaiii>n  was  rcsfori'd,  tlit'  pulsi:  having  been  felt  at 
the  wrist  Iwonly-tbur  houz's  ai^er  the  o[>eral'Ton,  J^intiUtf^  The 
length  of  tune  the  iigrmire  remained  altaehed,  ninett/-gi:e  datja^ 
notwifliptanding  all  siife  means  were  mailc  uae  erf  to  dciacb  it. 

A  lady,  30  years  of  age,  of  delicate   eonstitutifin,  hiid  a  ton- 


430 


ABTILRIES  AND   VEINS. 


genital  club-foot  of  tlie  worst  kind,  and  a  double  curvature  of 
the  spine.  For  tbc  (ormcr  of  these  she  was  trcateJ,  when  yoiing^ 
by  Dr.  Brovm,  aC  hia  intirmurj ;  mid  tbc  foot,  alter  the  aceticm 
of  the  tendooa^  followed  by  the  ftppropriato  trcjitment,  was  oi>m- 
pletcly  brought  icto  ita  natural  position,  bo  that  she  wna  cnuLled 
to  walk  with  cn»Ct  without  the  aid  of  ^y  mGchanical  support. 
The  curvature  of  the  spine  was  eubniittcil  to  a  siniLJar  trcaticcut, 
with  the  aatnc  gucccdJ^lid  I'c&ult. 

She  consulted  me  in  the  early  part  of  December,  184Tj  for 
an  ancunsrual  tumor  eituntcd  juat  above  the  Boapulor  end  ef  the 
claviete,  about  the  tii^e  of  &  pigcon'<3  egg,  of  wbleh  ^bc  gave  tbc 
fallowing  history ;  — 

Four  Djonthe  before,  wliJlc  in  alteadance  on  a  ^ick  brother, 
ehe  had  occ-naion  to  draA'  the  cork  fn^ni  »  bottle,  and  felt  a  sud- 
den craek  ovor  tlie  elaviclo.  Her  attention  was  not  attracted 
to  it  at  tbo  moment ;  but,  a  short  time  afterwords,  a  small  swell- 
ing, having  a  decided  pulenlion,  was  diitinguidhfd  at  that  fpot, 
which  ineicascd  rapidly  iu  hzc.  It  had  a  powerful  pulsation, 
and  poeticsticd  tho  ui^ual  thrill  eharactcrldtic  of  au  anouriiimal 
aticTtion. 

1  cudcavorcd  to  discover  the  subclavian  ni-tcry  io  its  normal 
eituatiou  beneath  Uie  eUvidc,  at  the  p^jint  where  it  passes  uver 
the  first  rib-  No  largo  voaacl,  or  uny  o&scoua  protuberance  an- 
ewprin^'  to  the  tubercle  of  tho  firet  rib,  usually  tnkcn  ils  tbe 
guide  til  the  artery  in  this  position,  couUl  he  found.  Ditlerent 
parts  of  the  neck  were  then  explored,  whieb  led  to  the  Ji^cot'ui'y 
of  a  largo  ixrtery  paftsint;  obliquely  upwartl^^*  parallel  to,  and 
about  an  ineh  removed  from,  the  esternd  boi-dcr  of  the  trapcsiua 
muscle.  Compreeaion  bclrg^  made  at  this  point,  tbe  pulaationa 
of  the  tumor  ceased,  as  well  as  the  pulse  at  ihe  wrist.  Tliere 
was  no  question,  therefore,  in  my  mind,  that  this  was  the  sub- 
clavian artery  ;  but  it  wns  more  difiieult  to  determine  iba  cauee 
of  thi£  remarkable  anomaly. 

I  now  sought  for  the  fii'at  rib,  and  discovered  botb  the  first 
and  a  part  of  the  second  rib  parsing  oblirjucly  across  (be  neek 
above  the  elu\Icle-  The  insertion  of  the  scalenus  antieua  muscle 
into  the  fin^t  rib  was  ut  len^^^th  distinguished:  the  tubercle, 
however,  was  not  Bufiiciently  developed  to  be  manifest  to  tlie 


ANEURISM  A  L    TITMOHS- 


431 


touch.  The  whole  osseous  ey^tcm  of  th(?cliest,  in  thia  cn^e,  liTirl 
unJergcne  a  partinl  dUplacoraeot,  The  spine  and  ribs  nltjtchod 
had  hecTi,  OA  it  were,  moved  upwards;  while  the  Bterniim  wns 
carried  in  nn  opposite  iliref^tion- 

Milking  n  strong  compression  on  the  vessel  nhove  the  tumor, 
the  arm  became  extremely  pninful,  with  n  sensation  of  intmbneas ; 
and,  on  B.  euhseqiietit  and  tnore  careful  examinntion,  the  whole 
braclLJ.il  plexus  of  nerves  could  be  disorlmiuntedf  m  Luimedinte 
con  lad  with  the  nrtery. 

Ab  the  tumor  wns  rapidly  increasing,  it  was  evident,  thiil, 
eonaidering  its  situntion  and  the  gi'eat  danger  of  delay,  no  time 
was  to  be  lost,  if  any  surgit^ul  openiilon  wns  10  be  resorted  to- 

The  patient,  a  person  of  much  fortitude  and  strength  cf  ehnr- 
nctor,  agreed  at  ouce  to  the  course  advked.  The  openitiou  was 
performed  on  Dec-  24,  1J^47. 

An  incision  about  two  inehea  long  was  made,  eiteading  from 
near  ihe  outer  and  upper  edge  of  the  sterno-maeEoid  mnecle 
downwards,  in  the  direction  of  the  acapulo-cluvicular  artiouk- 
tion,  and  an  inch  from  the  edge  of  ilie  trapcziua  muscle ;  die 
pulsations  of  the  veaecl  being  the  principal  guide,  ns  ihe  other 
flnnroniicid  murks  were  wautinz.  This  incision  divided  the  skin 
and  BUpcrficiu,!  fascia  ;  a  second  cut  opcn^  one  of  the  brunches 
of  an  artery  gi^en  ofT  from  the  thyroid  axJa,  which  was  lied, 
A  nenoua  band  of  some  eiae  was  now  encountered^  and  at  lis 
side,  and  directly  over  the  artery,  a  large  vein,  apparently  the 
external  jugula.r.  The  vein  was  carried  to  the  upper  part  of 
the  woundf  with  a  silver  hook,  and  the  nervo  to  the  lower;  the 
dragging  upon  the  latter  cauJded  a  disagreeabk  and  somewhat 
painful  sensation  in  the  arm. 

The  sheath  of  the  vessel  was  next  opened,  the  cellular  mem- 
brane around  it  cleared  away,  and  the  ancnrisin  nee<Ile,  un- 
armed, pneecd  from  below  upwards,  on  account  of  ihe  difficulty 
of  introducing  it  in  the  opposite  direction,  from  the  interference 
of  the  scalenus  anlicus,  which  had  its  insertion  just  below.  The 
needle  at  once  encountered  nnd  raised  the  lower  nerve  of  the 
bmehial  plexus,  which  was  in  the  most  intimate  contact  with 
the  artery.  By  depressing  the  handle,  and  urging  the  point 
forwards  with  careful  meinipidation,  the  eye  of  the  ueedle  was 


432 


ABTEIUES   AND  VEDJSp 


brou^rhl  out  between  the  two.  The  instnimpnt  was  now  ilircnd- 
od  witli  tUe  lignturc,  nnd  nithdrawn.  Careful  cK|)lorn,tion  was 
iDEide  to  aecertnin  if  nny  nerve  waa  Ineluded :  the  painful  aene^ 
tione  in  the  firm,  cnused  by  drawinff  tlie  ligature  downvvarda, 
Qt  iirst  leading  to  tlie  Etuirpoeition  that  this  nii^ht  be  tlic  coae* 
But,  when  tlic  eawc  traction  was  made  directly  upwnrda,  no  paja 
was  fell ;  the  former  scnsutiona  being  pro<lLiec<.!  by  the  dragging 
on  ibe  cervical  porti«»n  of  the  bnioLiftl  plesus,  owing  t^>  their 
conucctjon  with  the  veseoL 

Tlie  ligature  wne  now  tied,  and  the  wound  droBflcd,  The 
puleatione  in  the  aneuridmid  eac,  us  well  a^  thoBo  of  the  radial 
artery  sit  tlie  wrist,  nt  once  ceased  j  and  all  uppcaranee  of  tumor 
vaniflhed.  The  patient's  arm  and  Imnd  were  a  little  cold  directly 
after  the  opcritlion,  but,  bcint;;  rolled  in  flannel,  soon  rc^znincd 
their  natural   temperatm'e, 

25tli.  Found  her  quite  comfor table.  She  had  poinded  a 
quiet  night. 

2tilh.  She  saya  that  the  pulse  ct  the  left  wrist  returned  for 
a  time  laat  evening:  it  tlicn  difloppcarcd,  but  returned  again, 
though  faintly,  this  morning.  I  could  not  discover  it  at  the 
time  of  my  visit. 

27lh-  She  has  been  eomowhat  troubled  by  cccmonal  palna 
in  the  nrm.  The  pulse  was  felt  yestcrdny  once  or  twico,  being 
intermittent.  The  ^voiiiid  ho»  healed  by  the  firet  intention. 
She  has  sufferc<i  occasionally  from  palpitation  of  the  heart. 

29lh.  The  pulee  waa  perceived,  though  feebly,  at  the  wrist, 
but  could  not  Ix'  deteeted  in  the  axilla*  The  spot  formerly 
occupied  by  the  ancunanial  tumor  now  preseuta  an  obvious 
depreaaion. 

Jan.  2|  1848.  — The  pulee  is  constant  at  the  wrist, 

14th,  The  ligature  alill  remains  on  the  artery,  notwith- 
standing the  traction  daily  made  by  the  patient,  in  accordance 
with  my  directions.  A  number  of  largo  vefiecls,  taking  their 
orijjm  from  the  subclavian,  exist  in  different  parts  of  the  nock^ 
One  of  these,  apparently  the  8upra-s capillar,  paseea  directly 
over  iJie  sac,  and  pulsates  so  Btrongly  aa  at  first  to  con- 
rey  the  impression  of  a  return  of  puliation  in  the  aneunsmal 
tumor. 


POPLITEiL    AKEL'HrSM. 


433 


March  3Qth,  Once  or  twice  in  the  course  of  the  Inst  two  t>r 
three  weeks,  finding  that  the  li^itur^  ^va^  ni>t  dotiiohed,  I  have 
aebed  it  wiili  the  furcepa,  and,  boldirg  (he  artery  furcibly  down 
on  the  rib,  Imve  twisted  the  thread  with  considerable  force. 
Thia  wa9  Uuno  tbr  tlie  tliird  time  jcEtei'dayi  when  the  Ligature 
BOparated,  nineti/-gix  daya  afler  the  oper:Ltioii, 

The  vound  almost  at  onee  closed, 

I  esiw  !h[e  patient  on  Sept.  14,  1S4S,  far  the  ]aH  time.  At 
that  [K?ri<>d  she  wha  quite  well,  hnd  recovered  the  tiae  of  her 
arm,  and  was  iii  no  wny  incommoded  by  the  operation  to  which 
she  lind  t^ubmitted.  The  ntLeuH»^mnl  tumor  Ivul  in  a  great  meiiH- 
ure  disappeiircd ;  but  it  «tilJ  conveyed  the  impression  ot'  contnio* 
ing  a  Huid,  Directly  on  its  surface,  and  incorporated  with  it, 
wiis  a  very  larpe  arterial  trunk ;  euppoBetl,  as  above  stated,  to 
be  the  supra-ecapnlar.  This  veeeol  pulanted  powerfully,  and  at 
firdt  gave  nn  nppeaniDce  of  puL^iition  to  the  tumor,  but,  by 
careful  maniptilatjon,  could  be  Bep^ralcd  from  it;  the  puUe  ut 
the  wrist  sttll  remained  a  little  leea  etrorg  titan  in  the  corre^ 
aponding  artery  of  the  other  eide. 

Cv^E  CCLV.  —  Lifjahirs  of  ih^  Femoral  Art^rr/  pyr  Poj>- 

litcai  Anetirij^n^  Uare,  —  In  September,  1833,  I  was  ro- 
quceted  by  Dr.  Joainh  Dardctt,  of  Concord,  to  bcc  a.  ninn,  a. 
blat'kamith  by  trade,  with  an  aneurism  of  the  popliteal  urtery. 
Ki>ur  or  five  months  before*  he  hnd  pcrrceive<l  a  email  pulsat- 
ing tumor  in  the  upper  ntid  back  purt  of  the  left  leg-  This 
increased  elowly  to  the  eizc  of  ft  hen's  cg^-  The  toice  woa 
bent,  and  he  was  obligeil  to  WLdk  with  a  crutch.  Tbe  foot  was 
divoUen,  excessivelv  painful,  and  '\U  motions  partially  IobI. 
The  patient  beiii*r  informed  of  the  dangers  of  the  opemiion  by 
ligalure  of  the  artery,  the  poseibiJily  of  pnmlyeis  or  i^lou^^h- 
ing  of  tbe  limb,  consequent  upon  it,  and  of  tlie  alternulivo 
of  tbe  trentmem  by  compresBion,  decided  on  the  former,  oa 
he  lived  out  of  Boston,  could  not  well  leave  his  family,  and 
it  was  impoflsible  to  have  the  compre^eioo  Batisfaeiorily  eon- 
ducted  at   home. 

The  femoral  artery  was  tlierefore  tied  at  the  middle  of  the 
thigh,  and  the  pulsation  of  the  tumor  at  once  arretted.     Tho 


4S1 


ARTERIES    AJiD    VElKS. 


pntieot^  a  very  musculnr  mnn,  wiis  directed  to  be  Vept  in  befl, 
artifi(?i.al  wjirmth  to  be  appliwl  if  necessary;  ant],  in  vase  of 
great  re^actiont  blood  to  be  taken  from  his  s-rm-  Fnr  n  week 
or  two  after  the  operation,  the  onmbnejiis  of  the  foot  waa  much 
inoreaaed,  iliougli  the  pain  was  relieved.  The  ligature  scpa* 
rated  in  sixteen  ilays. 

This  patient  was  seen  by  me  some  montlis  nfterwnrds^  when 
he  wa8  able  to  wnlk.  A  sma.11,  hard  tumur  sEill  i^xisted  at  the 
place  of  tbe  former  aneurij^m,  having  an  apparent  pulsation, 
whicb,  however,  after  Tepeatod  eTiiminations,  proved  to  arise 
and  be  commumcated  from  an  cnlarirpd  cnllateral  ve9?('l.  He 
was  diverted  to  keeji  stilly  avoid  animal  food,  and  to  do  ootliin*^ 
that  might  excite  the  aru-ml  oetlon. 

By  subsequent  reports,  he  was  quite  well. 


Case  CCLVT.  —  Largs  Ajievrtum  of  t/ie  Thorticit  Anrtti^ 
v^ith  PerfopiifioJi  'ff  the  iSlpnium.  Denlh.  —  A^-ntleinan, 
fi^j  years  old,  was  attacked  in  lS(i5  or  IWfin^,  with  dyspntrn, 
attended  with  t'onsidenthle  conirestion  ahoiit  the  face,  {"oniitijT  on 
suddenly,  after  mental  eoiGtion  caused  by  the  death  of  a  friend' 
Being  examined  \ty  IiIj*  physician,  >itrong  pulsations  were  per- 
ceived in  die  aeigliljiirliiHHl  of  thi;  t-ieruuni ;  iwd  ii  pulsHiiog 
tumor,  with  aneurismid  thrill,  was  detected  at  about  the  middle 
of  that  hone.      At  this  tiinc,  T  saw  hiiu  in  ron.mjitntion. 

Tlie  |>alient  wms  uf  plethoric  Iwdiit,  haJ  been  generally 
he^dthy,  hut  led  a  lahoi'iou8  IJIe,  being  connected  wttb  a  prints 
ing  offif^,  and  up  late  at  night.  Some  years  before,  he  bad 
hud  a  rhemualic  attack  in  his  shuulders^  lasting  three  months. 
I  advised  qiiier,  a  vcgt^table  diet,  and  ^re!it  care  as  to  esen'iw? 
&nd  excitement,  until  the  course  of  the  disease  wan  folly  de- 
vehiped.  Tinder  this  treatment,  the  thoraeic  i(vin|iloms  were 
relieved,  bui  the  tumor  grudually  increased  ;  and  lie  finally  came 
under  my  care,  with  severe  attacks  of  liemorrhage  from  the 
nose,  which  required  snr^icjd  interference. 

In  November,  iJSd^,  afler  having  thus  |iass»I  t^v^o  or  three 
yeara  in  comparative  cnnifort  hy  inrams  of  great  care,  he  was 
suddenly  taken,  while  absent  from  home,  witii  lainttiesH  and 
biJ^en^ihilily,  and  wufl  CJirriod  to  hi8  fiouse.     Oh  seeinij  him,  I 


amp:ukisu  of  aorta. 


4.15 


focind  the  right  side  of  tlie  body  pnrnly/ed.  His  (ave  \rn»  not 
re<i,  t\3  in  npoplt^xy,  but  it'  a  livid  pnlpness.  Ha  gruAnnWy 
recoven^d  hi:^  een^es ;  and,  by  tha  following  morning,  his  mind 
wflft  fidly  restored.  Tlie  tittack  ivnw  siippfisod  to  b«  cunseJ  by 
the  escape  of  a  con.pnlfl  from  the  tumor,  lodging  in  niid  obstnict- 
\ng  the  ve3f*e]a  supplying  one  poninn  of  the  hrain,  nnd  tempo- 
rarily saspending  its  fiinctiuns,  Tlie  pnra.lysis  of  the  leg  and 
a^n^,  whidi  liud  bcpn  complete,  grniluully  diJ^appenrc^l ;  bo  that, 
iLt  the  end  of  five  or  »i\.  week^^  nothing  but  a  sUglkt  stifTneAa 
remained.  At  this  time,  the  tumor  on  the  sternum  occupied 
nearly  its  entire  bfertdlii  :  it  wjw  thirteen  inclie**  in  circnmfer- 
enne,  and  had  an  elevation  uf  betAVeen  three  imd  four  Indies. 
Tlie  pB.netcd  appeared  bony  for  nbout  linlf  this  diatancc  ;  tbuiigh, 
on  exiimination  iifter  dc^Eith,  thin  pnjved  to  havj;  been  decep- 
tive; being  above  exceasiveiy  tfiin,  and  apparently  uom|)iiafd 
simply  of  the  skin  and  the  aneuri.qmal  flac,  A  aligbt  ccchy- 
mosis  bad  tuken  place  on  the  eurffiee,  Pule&tions  in  it  were 
very  active  and  ponerful. 

Some  diunge  in  the  aneLiriiitiial  tumor  hud  produced  an  tif- 
fei'tion  of  llie  air-pii^sagej^f  tto  oa,  lit  titnea,  nimost  to  tbreatcti 
HufTocalion,  Tbe^'C  symptoms,  however,  gradually  Kubaided ; 
BO  (bai,  at  the  end  of  a  couple  of  luuiitliH,  the  pntient  was  in  a 
conipEirntively  comfortable  state,  able  to  walk  about  hiB  roam, 
and  to  tnke  a  Jiioilerate  amount  of  food. 

On  the  15Lh  of  Jatjuary,  18lj(j,  airly  lit  the  morning,  at 
abnut  foLir  u'clock,  be  cojuplnined  of  a  juidden  pain  in  bis  ri^bt 
eJbow,  shoiilder,  and  «ide  of  heiul,  and  ahunat  tmmttdiatul^ 
expired. 

On  eitHTui nation  of  the  body  the  nej^t  day,  tbe  folloniiig 
were  tbe  appeiirancea  [jrewnied  ;  — 

The  sternal  tumor  had  shninken  but  lillle.  Tn  the  left  side 
of  tbe  cbest,  there  was  a  tjuantity  of  bloody  serum  :  in  the  ante- 
rior mediastiuum  wnB  a  large  coagulum,  enough  to  fill  a  cjuart 
measure.  The  pericardiiun  wns  firmly  arlhercnt  to  tbe  heart 
sud  paLrieteA  of  the  tumor.  Tliroiigh  it,  by  a  amaU  rent  half  an 
ineh  in  length*  tbe  blood  had  e»enp4?d. 

Neither  tbe  trachea,  a'HOpbagus,  nor  bonea  on  the  back  purt 
of  tbe  cheat,  appeared  to  be  interfered  with  by  the  Inmor;    the 


436 


ARTERIES    ANli    TRdS, 


im'fntiJin    of  thp   liiTyngpnl    nerve  proba.ljly   linving   n   pirt   in 
the  liirynjreal  syniploiiis  whirli  were  oceflflionally  iminiresteU. 

The  aneiinnmal  sac  was  as  large  as  the  two  £«l0,  Jtivl  closdy 
fLnd  exletifiiveiy  lullierent  tit  flic-  mitmor  pnrieles.  It  iiruae  from 
the  iift(*(!inlmg  norta  townrja  the  left  aiJe  ;  taul  the  opening, 
which  waH  of  an  oval  furm  anil  remiirkaljly  clefineil,  commeaced 
one  and  s  half  inches  mIjove  the  aortic  valves,  itvirl  ren*.'hed  to 
within  the  HJime  dislHnce  of  the  arlena  innominalJi,  It  waa 
evidpnrly  a  fnlsp  anpinism,  and  the  cavilj  was  nearly  fillL-d  with 
soft  lihrirt  and  gminuus  t^oa^la. 

There  were  alf*D  two  other  sinnll  (jntiiHfittnjiI  sacs,  qTilte  dia- 
titict  from  tlie  nlpove.  One  wns  un  inch  frmii  die  ttoriic  vulvesi, 
find  formed  s  very  defined,  rounded  tumor  upon  tlie  riglit 
Bide  of  the  artery,  of  □  dark-red  eolor,  firm  to  tJie  fi.*pl  fivim  its 
being  Sllei.]  with  coagula,  and  in  size  ahont  ei^un.1  to  a  nntnieg' ; 
the  otijer,  arieing  from  near  the  ori«:in  of  ihe  aneria  innominalA, 
was  in  every  res|>ect  siniilnr,  except  that  it  was  more  than  twice 
as  largp.  Tin*  orifiee  of  each  of  these  little  sacs  was  of  an 
ova[  fornif  quite  sniaU,  and  ho  de£ncd  aa  almost  to  look  ati  if  a 
piece  liad  been  piin<^eJ  out. 

The  nortrt,  as  fiir  an  where  it  was  cnt  oft'  towards  die  dia* 
phmgnii  wiifl  (juite  disf^aatU,  with  ci hi nidendile  rrelaceoiiH  dejHif^it, 
The  nflcending  portion  was  very  much  dilated,  and  measured 
transverfiely  nhuut  seven  inches,  withonr  inrhiding  the  opening 
of  the  large  sac.  From  the  nreh  downwarda,  it  wiis  nbont  the 
natural  eiKS*  Upon  the  right  wide  of  the  ascending  portion,  and 
commencing  two  incben  above  the  vfilvefl,  wiu*  a  "true"  aneu- 
rism, the  cavity  of  wM<"h  wa»  shallow,  hut  sotHeiently  di?tinedT 
snd  measuret]  one  and  a  half  inches  in  diameter.  This,  of 
course,  wtm  not  Included  tii  the  above  measurement.  There 
wna  also  a  defineil  dilatation  of  the  arteria  Innominata,  at  it4 
origin  and  in  Lt«  wfiole  circumferenoe,  extending  ujpwards  about 
three-fourths  of  an  inch. 

The  heart  was  healthyi  with  the  exception  of  the  adhesiona 
mentioned  above.  The  upper  vena  cava  was  completely  ohliter* 
filed  within  an  Inch  of  li»  opening  iato  the  anricTef  and  to  tbe 
extent  of  three-fourths  of  an  inch  ;  nothing  being  seen  of  tlie  vena 
aEygofii 


ANEUTtlSU   OF   AORTA. 


437 


The  fltemnm  woe  entirely  destroyed  froin  just  below  the  ojirtj- 
la^e  of  the  second  rib  to  oppoitjte  that  of  the  fifth ;  and,  the  co- 
flrrula  hnving  been  removed,  the  ragged  ooda  of  tlie  cartilages 
were  distinctly  felt  withiti  the  sac. 


Case  CCLVII.  —  Enorfnovit  Aneiiriim  of  the  Abdomxnfti 
Anria.     Dstitfi.     Atttopity 1  was  first  culled  to  the  palieut, 

A  ^nllpmaa  43  yoars  old,  in  1840.  He  wns  afflltilod  with 
severe  iieurnl;jjic  pam  in  the  left  hypoi-hondriau  region,  ck- 
temling  in  diHerent  directions  to  the  bladder,  kidneys,  and  olao 
down^varde  to  the  integuments  of  the  hi\  thigh,  where  it  ^vna 
almost  in  support  able.  At  thiit  time,  no  tumor  couid  be  dis- 
covered in  the  abdomen-  The  sufferinf;,  in  spite  of  all  reme- 
dies, became  so  severe,  that  the  pntient,  iu  order  to  got  auy 
relief,  w^a  oblicved  to  place  himi^lf  on  hU  hftnds  and  knees  ;  and, 
tlius  situated,  wilh  hiu  head  dovrnwards,  he  was  able  to  ^et  emne 
rest  in  the  course  of  the  twentj'^tbur  hours.  Thift  position  was 
mniritained,  for  the  ^ri^Liter  (portion  of  the  lime,  for  six  weeks. 
At  the  end  of  that  period,  be  was  eei^ied  wltli  a  violent  hemor- 
rhage from  the  nose,  which  wna  only  checked,  at  the  end  of 
twenty-four  hours^  by  pluffpn^  the  nostrils,  Subset^uent  to  the 
hemorrhage,  the  pains  became  somewhat  relieved;  and  be  was 
able  to  resume  the  recumbent  position,  .  An  exnmitintion  of  the 
atidomen  being  now  possible,  a  pulsating  tumor  could  be  dis- 
covered in  the  loft  liypochondrinc  region,  having  on  its  front 
part  what  appeared  to   be  tlio  kidney. 

From  timt  period  till  18-12,  the  tumor  gradually  increased  in 
BLca,  citonditiK  in  either  direction,  upwards  towai'ds  the  thoraic, 
and  dowmA'Ards  ttjwardf^  tlie  thigh.  The  pulsatiotis  were  usually 
so  strong  as  to  shake  the  whole  body,  and  were  "much  in- 
creased before  an  occurrence  of  hemorrhage  ii-om  the  nose, 
which,  from  ltt40  to  1642,  occurred  at  pretty  regulur  in- 
tervals of  two  or  three  months,  and  was  nlwaj^s  checked  with 
great  difGculCy,  but  was  attended  with  relief  to  the  system.  The 
digestive  functions  were  pretty  regularly  performed.  He  was 
obliged  to  take  hie  food  while  in  a  recumbent  position ;  otber- 
wiae  the  tumor  seemed  to  press  upon  the  stomach,  and  destroy 
the  Appetite.     As  the  tumor  encroached  on  the  thigh,  the  limb 


438 


ARTERIES    AND    VEDiS, 


grfliilanDy  hpco-me  nir^rc  :liii1  luorc  He^ed*  iinlil  it  woe  drawn  up 
ao  iis  ti>  furm  a  right  aji«:li;  witli  iIr'  body. 

July  11,  lfi42,  he  was  nQti'm  eeieed  with  a  return  of  hemor- 
rhage from  tlic  iiuse,  which,  though  checked  from  lime  to  time, 
Q^iti  returned  ^o  a.s  gruAunWy  tu  exliaiit^t  hhu.  Tlie  nostrilfl 
were  pliiggeil  huth  behind  and  befare:  the  bloods  howerer. 
was  in  such  a  fliiid  st.ttc  that  it  »tdl  coDtiDued  to  find  on  exit 
througii  the  [mncUk  hidirjiuitlia. 

The  jm dent  ii;t[uiiei.l  hii^  faculties  perfectly  to  llie  last;  mid, 
tJjrough  the  wliule  of  this  lung  and  trying  period,  bore  hia 
Huffennga  with  the  mofit  heroic  fortitude. 

The  irtjilmeiit  consisled  principally  m  small  bleedings,  vrhen 
the  Ay^tcni  from  time  to  time  hei?iuiie  plethoric^  nad  intimationa 
were  given  of  a  recurrence  of  the  heiuorrlia^e.  By  iheae 
xnciuiB,  tfic  epiJ^tiULis  was  oc:eitdli>UEdly  wurded  off.  The  patkut 
ticiself  wiiH  iilwuys  well  uvvare  when  thia  became  aeceaaarv- 

The  following  appeariuicea  were  preaeiited  at  the  poat-morlem 
e^camiiLriijon  :  On  turning  back  the  ^bdumlnal  panetie^*  all  the 
organs  of  the  left  j^ide  were  found  In  be  ruised  np  on  the  surfiice 
of  un  enornioiis  tumor.  Tlie  left  kidney  mwiipipd  the  epignfltrio 
repont  and  was  the  moat  proininent  orgjin. 

The  tumor  had  pushed  up  the  diaphragm,  bo  as  to  be,  at  ita 
npex,  on  a  level  witli  the  fourth  or  fifth  rib ;  below.  It  had 
passed  down  on  the  anrfnce  of  the  psoas  and  ili;Lc  mllat■le^, 
underneath  tlie  cruml  arch,  and  descended  nearly  to  the  middle 
of  the  thigh.  On  removal  from  its  situation,  it  was  found  to 
commence  in  t1ie  alKlominul  aorta,  oppo-tite  Eo  the  onirin  of  the 
coihae  ftxitt.  The  superior  parietea  of  the  ariery  nppeiLred  in- 
tact;  below,  ut  the  puitit  of  origin  of  the  tumors  ihey  were 
deficient  for  the  space  of  two  inches. 

The  parietes  of  the  tumor  were  formeil  beneath  by  the  ribs,  the 
muscles,  and  the  iiite^p.inieiLts  of  tlie  posterior  part  of  the  aUlo- 
men;  above,  the  usual  appearance  presented  by  an  anenriamal 
sac.  The  bodies  of  the  lower  dorsal,  and  three  superior  hiiuliar 
■verlchric,  were  nearly  destroyed  ;  also  a  portion  of  the  body  and 
crista  of  the  ilitun  of  the  left  side.  One  large  coagiittun  ap- 
pcareil  in  the  sac.  The  blood  was  in  a  very  fiukl  stale,  eo  that 
nearly  all  which  remained  in  lite  body  aeeiued  to  escupewith  the 


UOATUHE  or  CAKOTID. 


439 


irat  inciBiona-  The  tumor  -vins  nineteen  inches  in  len^h,  and 
eighteen  in  circiimterence ;  l>eing,  1  believe,  one  of  the  iargest 
on  record* 


I 


Case  CCLVin.  —  Wound  of  the  Carotid  Arten/.  Lifja- 
hire  itoice  repeated^  Death /'rorn  Heirtorrhafje //v/n  the  Jieevi^ 
r^eut  Circulation.  —  Enrly  ia  tho  flprinj;  of  184iS,  while  a  youn«f 
TnttUi  18  yciire  ithl,  wae  wnlkiii*;  in  the  atrect,  n  pcr&on  stubbed 
him  from  behind  in  tbc  neck.  The  wunnd  bled  freely  at  the 
time,  ftnd  ugain  on  the  two  subsequent  days;  the  bJccilir»g  ench 
tine  bein;]:  nrrcetetJ  by  expofiuru  to  the  oir,  and  cumprcasion. 
The  cjirtiUp:e  of  tiic  Itrt  cnr  was  diviilod  ;  mid  the  weapoQ  had 
perpetrated  the  neck  behind  the  anj^de  of  ll)e  lower  jaw,  and 
about  hiilf  an  inch  behind  ami  below  the  left  ear,  in  a  direction 
du^v-nwarJy,  inwardd,  nnd  forwards.  When  I  saw  him,  a  week 
afkT,  he  wafl  very  pak-,  and  somi^wlmt  emaciated  ;  hia  pulee  was 
;^uick  nnd  jerking  j  there  wns  eligbt  paralyaie  of  the  loft  side  of 
tiie  Iheo.  £  lictl  the  Icfl  commoD  carotid  in  the  ueun.1  nizinncr. 
ly'roni  ifie  seventh  to  tbe  ninth  ilriy,  rcE>ented  hcmorrhngea  oc- 
curred, each  time  being  checked  by  compreseion.  On  the  ninth 
dnvi  the  wound  waa  opened,  and  cleaned  out ;  when  it  was  found 
that  Ihc  blood  onmc  from  the  carotid  nrtcry,  where  the  Ji^r-iturc 
bad  been  applied*  On  cundidtiUion,  the  iirtery  yvaa  agii'in  tied 
below  the  former  place.  Two  days  after  thia,  the  blood  began 
to  How  from  the  upper  part  of  the  wound,  np|iarently  coming 
from  the  f^|>ol  where  the  first  ligature  wns  nppJicd,  and  from  cbo 
recurrent  circulution.  Presaurc  arrested  the  flow  of  bloodi 
which  recurred,  however,  in  the  courM  of  the  day*  Coma 
BUjjervencd  in  the  course  of  tlirce  days;  rcjipimlion  graduniJy 
bccHme  more  feeble;  nnd,  on  the  thirteenth  day  after  the  first 
operation,  he  expired. 

At  the  nutnpijy,  it  wns  found  that  the  wound  in  the  neck  was 
irregularly  triangular,  ailuatod  fi&  incniioncd  above,  and  pene- 
trated beyond  the  carotid.  The  lower  jaw  wae  eawn  through, 
and  the  Jctt  aide  diaarticolated.  The  wound  waa  tlicn  followed  : 
it  divided  the  nmatoid  pruceaa  of  the  leuiporal  bone,  nearly 
[uinLllel  with  the  base  of  the  skull ;  a  poi-tion  about  half  an  inch 
thick  being  aepamtcd.     It  then  piiaacd  inward,  upward,  nnd  for- 


440 


ARTERTKd   AKD   VEINS, 


wanl,  lit  front  of  tlie  styloid  prttceas  of  the  tempnriil  bone 
and  Llie  Intrruu.1  uiroud  mtury  lu  lUa  ileptli  uf  abutit  Ewo  JiniJ  a 
hair  inc^hps,  in  the  direction  of  ihe  H-oterior  pnrtjon  of  the  boJte 
of  till?  bniin  ;  and  Bto|j^»ed  verj  ncjir,  Jf  not  in  euntact  wilh,  the 
»kull,  L'loffc  to  Uie  innei-  estrcniity  of  the  ^ti'ons  portion  of  the 
temporal  bone-  About  two  iucbes  from  tbe  commencement  of 
the  wound,  a  cuvity  nearly  as  large  oa  an  ahiionil  bud  t)een 
formed  by  tbe  force  of  tbe  bloud  issuing  from  rm  artery,  ibo 
o[>cn  niouili  of  wliii'h  was  found  just  l>eyond.  Tlie  whole  of 
the  left  aide  of  tbe  neek  wa*  much  fiwullen-  Tbcre  were  ni* 
liL'ahby  irniiiulatione  in  tlie  wonnd  miule  for  tbe  purpo^^e  of  ty- 
iu^  the  caroud.  The  eiithi  of  lliat  vesseb  wbcre  it  liad  been 
<livided  by  tbe  first  Hgature,  were  separated  about  half  an  inch. 
The  eerond  lifziiture  alill  surrounded  tbe  artery,  wbkb  was  filled 
below  with  eoiiguhi  of  bttle  dcjii^Jty. 

Tlie  whole  of  tbe  brain  wad  pale,  bloodlcaa,  and  rery  soft. 
A  layer  of  lympli  covered  its  butie,  extending  from  the  middle 
of  the  fissjrc  of  Sylviua  on  one  side  U>  a  eorreaponduig  piiint 
on  tbe  other,  and  from  the  middle  of  tbe  anterior  lobes,  baek- 
wanU  and  dowowardi^  nearly  to  the  foramen  magniiiu. 

Tbe  heart  wafi  contracted,  nearly  empty,  und  tto  miiaeulai' 
xubsiam^  loose  and  flabby. 

Ttie  lefl  lung  wa«  adherent  to  the  coi^tal  pleura  by  ab-i]ng 
adhe£^ioD».  The  organs  generally  pi-efteutc^l  a  bloodless  appear- 
ance. 


Case  CCLIX. —  Wound  of  i%t}n^r-Jii:ial  Palmar  Arch, 
Tjiffiituiyi  iiviue  nup^ditd. — -March  31,  I8fjl.  A  woman*  18 
years  of  age,  received  a>  wouud  in  tlie  palju  of  the  band  by 
thrusting  it  through  a  pane  of  gloss  VThile  trying  to  present  ft 
vfcuidiirt  friiin  fjJling.  Tbcre  xvas  a  good  deal  of  bleeding  at 
the  time,  but  it  wjib  aiTcsted  by  compression.  April  Ut,  there 
was  a  I'cturn  of  tbe  hemorrhage ;  and  she  blcd»  according  to  Lbe 
account  of  her  friends,  "two  quarts."  ^he  was  then  biouiibt  to 
the  tloapitab  On  her  entmnce.  she  waa  very  weak,  and  fditit. 
There  was  a  pulsating  tumor  in  tbe  palm  of  Uie  hand,  with  a 
omall  wound  over  it.  Comprcaj^ion  of  tbe  radial  artery  Lid  no 
etibct  upon  it;    but  tbe   pulaatioos  were   at   once  arrested  by 


VASCULAfi   OR   EREcrriLE  TCMOR. 


441 


oompreeain^  the  ulnnr  artery.  It  wtis  decided  to  secure  the  »r- 
tery  iu  the  wound.  She  waa  elliemed  ;  and,  the  wound  b^ing 
etJar;fed,  the  superficial  palmar  arch  was  cxpi>a^,  and  thu 
aource  of  the  bleeding:?  at  once  diecoverpd.  The  artery  was  tied, 
and  tlic  wound  iiloaed,  SI»o  was  ordered  heel'toa,  and  brandy 
ami  water.  Ou  the  following  Jay,  the  2dt  there  was  an  (jozing 
of  blood  from  the  wound;  and  comprcsaioa  was  applied, 

On  the  4th,  quite  a  hemorrhage  occurred;   and.  on  Hponfring 
the    wound,   the    ligature   applied    before    became    loo^c,    ami 
e  away.     The  wound  was  ofjened^  and  the  aflme  veascl  tied. 

e  waa  disehar^;p?d  on  tJie  23d|  well.  The  seouud  bleeding  in 
this  case,  ilk  all  probability,  waa  oecasioned  by  the  arch  having 
been  raieed  up,  and  the  ligature  applied  to  the  loop;  tbo  force 
of  the  circulation  gradually  presain;*  the  ligature  ofT,  At  the 
time,  it  seemed  to  have  been  lied  with  ordinary  force.  On  a 
second  application  in  the  i^amc  way,  the  result,  wtia  successful. 

In  recent  ca^ee  of  ihia  kind,  it  is  l>eil  to  search  for  the  vesael, 
and  lia  itt  if  possible,  in  the  ground;  otherwise,  try  pressure. 
Xfthia  faila,  tie  the  brachial  rtrtery,  although  this  is  not  always 
certatin  ;  as,  in  one  instance  1  have  seen,  the  hemorrhage  re- 
curred after  this  vcaeel  was  supposed  to  be  tied^  en  account  of 
its  division  higher  up. 


* 


VAeCDLAK  OR  ERECTILB  TUMOH. 

Th!6  diae&ae  has  been  admirably  described  and  dcpicletl  by 
John  BelJ>  who  named  it  aneurism  by  anaetomosU.  The  name, 
erectile  tumor,  \s  given  to  it  on  account  of  the  striking  auiJogy 
which  it  prcaents  in  structure  with  the  erectile  liosue  found  in 
certain  pnrta  of  the  body  in  man,  and  In  most  of  the  higher 
aniuLiJa*  Erectile  tumora  aro  made  up  almoet  wholly  of  great- 
ly enlarged  bloodvefiaeU;  and  are  divided  into  urterial  and 
venoua,  according  as  one  or  the  other  cktts  of  veaaelB  ecema  to 
predominate.  The  arterial  tuniors,  winch  are  altogetlier  the 
mo«t  formidable,  nrc  ollen  of  very  rajtid  growth,  and  are  marked 
by  active  pulsation.  The  teuoiia  tumore  are  more  indolent, 
and  often  impart  to  the  touch  the  feeling  of  a  fatly  growth : 
they  may,  hovrcver,  be  partially  emptied  of  blood  by  pressure, 


442 


AKTEItlES    ANU    VEINS. 


BDil  ibua  temporarily  retliiced  m  she.  It  ta  a  common  clinrnc-* 
teristio  of  erectile  growths,  that  tliey  liet^umts  i?nliir<^ed  and 
turgif]  during  any  net  whii?h  obstructs  the  free  returo  of  tlie  blood 
to  tlie  heart,  —  such  as  coughiiiy,  crj'itig,  laughing,  &c.  ;  can- 
tracting  iigain  to  iheir  former  size  wiien  the  patient  becomes 
quiet. 

The  treatment  cf  siuall  erecitile  tumore  —  najvl  mutemi,  for 
inatnree,  —  is  very  simple.  Hud  mjiy  l>e  eillier  by  excision  or  by 
the  ligature.  In  exeJ^Jng  them,  the  absolute  rule  is  thai  luid 
down  liy  John  Bell,  —  "  not  to  c^ut  into  them,  but  to  cut  iheni 
out."  In  operating  by  the  ligature,  Jt  Is  esseiitijil  thut  iht  whole 
groi^th  nhould  be  tlicrouglily  sLraugLlateil,  If,  hi  (lie  attempt 
to  excise  the  tumor,  it  ia  unfortunately  cut,  the  whole  growth 
hIiguU  he  immediately  included  in  a  ligature,  and  allowed  to 
come  uway  by  sloughing.  I  haie  Miveritl  times  treiilwl  ereo 
tile  tumors  of  the  face  by  rG[)G:ited  small  e^uteri/iUioiis  with 
nitric  acid,  ;ind  have  thus  ^ui^oeiided  in  destroytn^^  the  whole 
morbid  tissue  piet-emeal,  without  the  loss  of  sutjstiiTice  and  ron- 
sequeril  ecnr  wbi<;h  follows  eicisian  or  xhb  ligature.  Injection 
of  the  growth  with  ^lerchloride  of  iron  Jiaa  also  been  etuployed^ 
m  rtiHtiy  oases  witli  i^uceess ;  but  death  has  occ&sionally  resulted 
froni   the  pnictiee. 

The  ojteration  fur  the  cure  of  extensive  disease  of  lldti  kind  is 
one  (if  the  most  formidable  ia  surgery,  owing  to  the  liability  to 
dangerous  or  even  faul  hemorrliage.  In  two  cases,  where  large 
pulsating  tKHiors  oceujiied  nearly  tlie  whole  forehead  and  upper 
part  of  the  head,  I  bare  succeeded  in  dej^troyjTig  them  by  a 
series  of  ojjeratious,  in  wluch  the  afferent  veaseb  were  obliter- 
'  ated  by  atrong  ligatures  lied  over  jiins  pissed  beneatli  thcTii,  and 
thus  the  whole  circumference  of  the  growth  thoroughly  Blningu* 
lated.  By  tlie  application  of  new  ligatures  as  often  as  any 
return  of  the  pl;l!^fttion  wiia  deteeletl,  and  by  tlie  free  uae  of 
etyptics  and  escharotics,  the  disease  was  finally  extirpated.  In 
another  case,  I  tied  hoLh  tlie  carotid  arteries  for  an  immense 
erectile  growth*  which  occnpicd  the  lower  lip  and  a  hirge  part  of 
the  face  and  ne<^k-  The  I'esiilt  of  this  operation,  which  was  then 
only  the  tlurd  or  fourth  iu  which  botli  the  carotid  arteries  had 
been  Aucccsafully  tied,  wad  perfectly  r^tieructory.     A  part  cf  the 


VA80UL4E  OR   ERBCTILE   TTMOH. 


14B 


lower  lip,  which  had  been  the  aeot  of  an  ulc3cratcd  aixd  a  bleed- 
ing l»mor»  woa  afterwnrda  ctcised  without  trouhlcBome  hcnaor- 
rha^ ;  and,  on  seeing  the  pntient  two  ycata  3ubacqiii?ntly,  the 
vnflcular  tiflflue  was  found  to  have  wLioIlr  disappeared*  In  a 
pulaatin^jj  tumor  of  this  charactcF,  occupying  the  palm  of  the 
hand«  and  hold,  qjj  it  ^verc,  liko  a  ball  in  its  gmsp,  the  tumor 
gradually  increascdj  and  finally  involved  noarly  the  whole  upper 
extremity.  The  hmb  wne  nmpiitntcd  noar  the  shoulder,  in  time 
to  eavc  the  lite  of  the  pntient ;  nlthough  the  erectile  liasuc  had 
partially  invaded  the  structure  of  the  port,  and  many  li^turca 
were  required  to  arrcnt  the  bleeding.  The  Bpccimen,  which 
shows  a  direct  continuity  of  the  lar^y  dilated  arteries  with 
the  vcnou3  trunke.  was  beautifully  injected  aud  prepnrcd  by 
Dr>  K.  JM.  Hodges.  1  have  also  had  under  my  care  a  girl, 
ninotcon  yeari*  of  age,  with  a  lar^o  venous  erectile  tumor*  occu- 
pying nearly  half  the  cavity  of  the  moutlj,  and  ban^fing  down 
&om  the  lower  lip.  It  also  included  a  large  portion  of  Uie 
tonguOf  and  at  times  serionely  affected  [leglutitlon  nnd  respiration. 
This  caee  was  operated  on  by  the  ligature,  tying  both  the  tumor 
of  the  cheek  and  that  of  the  tongue  on  the  same  clay.  The 
tjgaturea  came  away  at  the  proper  time,  and  the  result  was  fully 
Bucccsaful, 

1  have  ppokon  thus  at  length  of  thb  disease,  on  account  of  ita 
rarity,  and  Irom  the  fact,  that,  ovring  to  the  absence  of  piiof  it 
is  too  often  nogleetcd  until  it  has  acquired  enormous  proportions. 
In  such  cases,  it  is  rarely  to  bo  cured  by  a  single  operation  \  bat 
requires  a  patient  and  persevering  use  of  needles,  ligatures, 
caustics,  and  sometimes,  although  very  rarely,  the  knife,  before 
it  can  be  completely  extir[>ated. 


Case  CCLX.  —  J^ormidabls  Case  of  ^^  An^iritrn  bi/ Atvio- 
tomottis  '*  of  the  Scalp,  Operation  by  LiyatuTt.  Crtre.  — 
A  healthy  young  man,  19  years  old,  entered  the  Hospital  on 
the  fifteenth  day  o^  April,  1801,  for  the  treatment  of  a  tumor 
of  tlic  scalp,  which  hod  begun  to  grow  with  great  rapidity. 

About  five  years  before,  it  was  noticed  that  the  bloodvcwela 
under  the  skin  of  the  forehead  were  bceuming  enlarged ;  but  it 
was  only  for  about  a  year  that  a  decided  tumor  had  existed. 


444 


AKTEKEEft    ATTD    VEINS. 


The  tHiEor  wna  rtitual^il  in  the  nieiliati  Ime,  ami  mea^nreil 
ill  \U  loiicTfi^l  (liiLiiietcr  ubout  three  niclti?.i,  ami  in  ita  amallec^t 
nfjLrly  two ;  its  elcvatiuQ  being  about  two  inches  alwve  ilie 
friHital  heme.  Its  shape  was  IrregTilaj;  its  bulk,  about  OuiL  of 
hulf  a  large  orange;  ltd  A|)pe&r»ince,  that  of  a  lurgc  mass  of 
earthworms  eiiclo^nl  in  a  eack-  It  wa^  of  a  retlili^h  color,  6oti 
and  coiiJ|ireri^ib]e,  and  had  a  pulhation  HjnizhronouB  with  that 
at  the  wrist.  It  nn^  supplied  by  a  great  number  t>f  large,  tor- 
tuous veBS<?la,  which  pulsated  strongly.  Tlie  terapi>ral  and 
frontal  wterieti  in  front,  and  tlie  (xxripilal  artery  liehlnd,  sf^uied 
to  afTcird  the  chief  supply  of  blooJ  lo  the  tumor.  Tlie  frontal 
arteries  were  especially  enhirged,  lieiijg  quite  etjuaJ  in  size  to  the 
ratlial  artery.  The  patient  had  Iried  compression  for  six  weeks, 
without  dhninishing  tlje  elite  of  llie  tumor  or  the  puh*atioD  iii 
it.  All  the  ^easeb  in  the  neighborhood  of  the  tumor  were 
greatly  enlarged,  and  the  whole  surrounding  tififiue  bad  that 
aueurianial  thrill  which  belonga  to  u,Hecdon9  of  thiB  descriptioD. 
It  fteemed  to  I*  spreailioy  gnulnully,  and  ii]vtj|ving  the  whole 
thickneee  of  the  ecjdp  on  the  top  of  tlie  head.  The  attack  of  it, 
therefore,  by  ligature  of  tlie  large  vesseU,  appeared  to  be  at  first 
cjf  somewhat  uniiertJiin  pnnnise. 

Optiraiion.  —  On  tlie  17th  of  April  (the  patient  being  ether* 
ized),  by  meaiia  uf  curved  needles  a  strong  ligature  was  intro- 
duced under  eaeh  large  vessel  supplyuig  the  tumor.  au<l  Jit  hh 
great  a  diatanee  as  poeeible  fronj  ihe  erectile  tiaaue  composing  it- 
Tbe  ligatures  were  tied  as  llgliUy  as  possible,  including  tlie 
pkiu.  The  effect  of  this  wiu  to  diminish  the  puhatiou  ia 
the  tumor,  but  not  entirely  to  check  it.  Inside  this  circlet 
three  needles  were  thertifore  introduced  under  the  skin,  eacb 
about  three  inches  loag*  so  aa  to  include  all  the  tissue  around 
the  tumor.  Ligatures  were  introduced  Ijonenth  thoie  needles, 
and  firmly  tied.  This  served  to  cut  off  the  oironlftLion  between 
the  tumor  and  the  surrounding  tissues.  There  sdll  remained  a 
Heiisatiun  of  vascukr  motion  in  tlie  substaiiee  of  the  tumor. 
Two  stroug  ligatures  were  iJierofore  passed  through  the  base  of 
tills  last  cirele,  and  were  brought  over  the  summit  of  the  tumor, 
and  firmly  tieil.  The  operation  occupied  al*out  an  liour  und  a 
quarter.     In  the  evening,  the  patient  waa  quiet,  and  slept  a  good 


VABOULAB  OR  EQEOTILE   TUMOK. 


445 


part  of  die  time  ;  hi?  pulac  was  VO.  On  the  18th,  he  had  aomc 
hcadacho.  ixtid  was  niudi  ineliued  to  sleep ;  ekin  hot,  piilae  82, 
There  wns  DO  piUentioo  in  the  tumor,  itnd  ^miUl  vesications  wcro 
appearing  on  its  Burftkce.  On  the  l^th,  he  vt^  comfortoblo ; 
puJac,  akin,  and  tongue  iiAlural ;  bowtjla  had  moved  without 
medicine  ;  api>ctitc  I'jiir,  ami  no  unplei&unt  eymptoma.  On  the 
23d,  putient  liaJ  ruinaJned  eomforUihle  since  last  report ;  was  flit- 
ting up  in  bed-  There  wtis  a  ehirht  serous  diachargo  by  the  fiido 
of  the  nceillcfl.  On  the  Siith,  there  was  a  swelling  of  the  right 
parotid  gland,  and  a  gloesy  appearance  of  the  tiasucs  het^t^cen  it 
and  tlic  tumor.  Walcr-dreseinga  were  applied  over  the  whole 
Burfacci  On  the  ^Tth,  n  ligature  and  a  needle  were  removed* 
2Dth.  It  was  found  that  a  part  of  the  tuiuDr  indiided  between 
the  ligatiiree  waa  jjtil]  nlivc ;  but  no  pulsation  could  be  detected 
in  iti  On  the  ^d  of  Mavt  I  removed  all  the  euturea  and  a  por- 
tion of  the  slough,  which  was  parliidly  dctaclied.  On  the  11th 
of  May,  ttic  }>atioDt  wae  again  othcrhicd,  and  two  largo  needles 
passed,  nt  right  angles  to  cneh  other,  under  the  base  of  that 
portion  of  the  tumor  which  remaineti  (dive.  A  large  and  strong 
ligature  was  then  passed  under  them,  And  tied  with  great 
foree.  On  t.be  15th  of  May,  the  patient  having  gone  on  well, 
and  the  tumor  being  quite  loose*  the  ncedlee  wore  withdrawn  *  A 
thiek  bilk  ligature  wild  pasttcd  around  the  base  of  the  tumor,  and 
liei)  wltli  a  jerk,  eutting  off  it^  remaining  attaehmcntfl,  and  com- 
pleiely  separating  all  the  dJseai^ed  tiflsuc*  TIujj  wae  followed  by 
<tuito  free  blceiUng,  requiring  the  npplii.yttion  of  lignturea  to  one 
or  two  large  arteriea.  The  bleeding  which  occurred  from  the 
flmall  vceeelfl  was  checked  by  the  Ui*c  of  a  solution  of  perehloridc 
of  iron,  Un  the  ^.^tli  of  iMay,  the  csHmr  formed  by  Uic  laat 
application  separated,  leaving  a  healthy  granulating  aurfaoe. 
Thifi  healed  kindly.  Some  weeka  later,  there  being  a  suspicion 
of  a&liglit  erectile  tiat^ue  remaining  in  a  portiou  of  tlic  j»kiu,  I 
exciecd  it,  which  hnished  the  cure. 

This  ease  is  interesting,  first,  from  the  large  size  of  the  erec- 
tile tumor ;  scoondly,  from  the  great  calibre  of  the  principal 
vesseU  which  ^uppUe^l  it ;  and,  thirdly,  from  the  immiLnity  from 
unheaJthy  action  in  the  skin,  notwithstanding  the  great  amount 
of  that  tiriBue  implicated  in  the  ligatures.    The  {wrotid  gland,  at 


3fc      I 


I-     >!<■>*-  ^       - 


":-'.    £11.   _:tr^   zr 


446 


abtehie!?  aito  VEirsft. 


ore  time,  was  certainly  irrltateil,  miJ  the  straining  of  the  whole 
Hcalp  enused  a  certain  amount  of  swelling  and  an  sipprniLeh  to 
o^JemA;  but  there  was  never  tiny  lliin|^  liJie  erythema.  !in<I  bui 
little  constitutiOEuil  disturbance.  There  is  but  little  Jotibti  thnt, 
if  the  tiiruor  hiiil  goue  on  much  longer  uncheckol,  the  viisciilnr 
system  of  the  scalp  woulil  have  become  »it  implicated  aa  to  make 
any  attempt  to  relieve  the  patient  by  o;>eratian  imavEuling. 


Case  CCLXI,  —  Ligati/re  of  hoth  Carotiri  Arteries  for 
a  remarkttblc  Erectife  Twaror  of  the  Mvuik,  Fnce,  and 
^ecJ^,  —  A  young  man,  23  years  of  ago,  oonftulied  me  on 
Oet,  1,  1845,  for  an  enonnoiw  tumnr  of"  the  lower  lip  and 
tongue,  which  hiid  supervened  ou  u  birth-murk  oocupying*  a 
good  part  uf  the  face  and  neck,  and  presented  the  following 
appcTinince^  :  — 

The  hcEid  of  the  patient  was  larger  than  common :  the  left 
side  of  the  face  was  almost  wholly  ocenpieJ  bv  a  diBcoloratioa, 
which  xviis  orii^nally  less  extensive  and  Lighter  coloi*ed.  but  had 
ttttaiuod  the  extent  and  appearance  above  mentioned.  The 
right  aide  presented  a  discoloration  about  half  the  extent  of  the 
left.  The  lower  lip  was  much  enlarged,  everted,  and  gave  three 
Ewpecta :  esternally,  the  thick  lumefiGd  lip  ;  internally,  a  fungoid 
tumor,  covered  by  red  granulationj*  distended  by  bloo<?»  ns  if 
ready  to  break  thmugh  i  tlie  whole  Burmoxinted  by  an  irregular 
ulceration  with  thi''kpnefl  edges  and  a  hardened  base.  The  red 
granular  appearance  extended  undemeatb  the  tongue  to  the  infe- 
rior surface,  the  left  half  of  which  was  enlarged. to  double  its 
natuml  aize  and  partially  protruded  between  the  teeth  ;  its  upper 
portion  being  the  sent  of  five  or  six  *niaU  ulceratioi:8.  The  dis- 
coloration of  the  face  also  extended  on  the  outHide  of  tlw  lip 
downwards  over  the  ehin  and  neck,  covering  a  apace  of  seven 
or  eight  inches  in  diameter ;  the  wholcT  eflpt^eially  that  on  the 
face,  being  rather  more  full  and  distended  with  blood  than 
natural,      (See  Plate  lit.) 

The  history  of  the  case  was  this  :  The  mark,  as  above  stilted, 
waa  congenital.  About  1641  the  Hp  and  tongue  began  gnulu- 
ally  to  swell,  and  the  former  very  shortly  ulcerated-  The 
ulceration   occaaionally   heidetl,   until   the   last   year>   when   the 


VASCULAQ  OR  BUECTJU:  TUUOK. 


447 


enlargement  Lecftine  permanent.  By  compression,  the  blood 
could  be  eAtirely  expelled  from  the  lip,  and  m  the  anmc  manner 
from  ibe  toii^c.  Since  the  erectile  tissue  hoci  been  developed 
in  the  lip»  tlio  dieeol oration  of  the  face  had  become  moro  marked, 
bad  cxteniledt  nnd  evidently  partook  of  the  churactcr  of  the 
erectile  tumor  in  ita  neighborhood. 

Thin  oaHG  was  a  very  critical  one ;  and  tlic  two  moat  prominent 
dangcrd  whiel]  threatened  him  were  ihej^e :  Fir^l,  a  poaaiblo 
defeneration  of  the  ulcerated  lip;  and,  secondly*  alirrniug 
hemorrhage,  vrhich  waa  likely  sooner  or  later  to  take  place, 
and  which  must^  in  all  probubilltyi  prove  rupidly  fatal. 

The  following  la  the  course  I  proposed  to  him  ;  First,  to  have 
the  left  carotid  artery  lied;  Second*  after  a  considerable  Jnlcr- 
val  of  time  to  lie  the  right  carotid;  Third*  to  attack  what- 
ever p*»rtiDn  of  the  tumor  remained  by  nieana  caltulntcd  to  pro- 
duce eoutractlon  of  tiic  vcsacU  and  obhteration  of  the  erectile 
tissue, 

Tif  ihia  course,  afVer  weighing  well  all  the  dnptrers  connectod 
with  it,  the  patient  agreed;  aud,  on  Oct.  5lh,  1  tied  the  left 
carotid  artery.  He  recovered  from  the  oi>eration,  and  was  out 
in  about  ton  days.  At  that  time  the  lace  had  become  more 
pale,  the  erectile  tittsne  and  the  lar^c  tumor  of  the  lip  much 
dhuiniflhed  Jn  sizci  and  the  painful  ulceration  which  surmounted 
it  was  mpidly  healing.  He  seemed  to  be  in  perfect  health.  I 
wlvised  him  to  go  home,  remain  three  or  four  wecka,  and  then 
return  to  hare  the  other  carotid  tied. 

He  returned  Nov.  Tth,  when  the  tumor  of  the  Up  waa  found 
to  have  dimmii^hed  onc-ludf.  The  fulncsB  of  the  face  and  neck 
waa  less,  and  the  discolored  pjirtd  wore  much  paler  than  when 
he  left.  TliQ  BiKo  of  the  ton^e  was  Igbs,  and  the  ulccratci]  spots 
on  it  had  <^uite  healed-  His  health  remained  good.  It  was 
determined,  tlieroJotc,  to  proceed  at  once  to  Ihc  ligature  of  the 
carotid  of  the  right  aide- 

The  patient  being  placed  in  a  sitting  posture,  tlie  carotid 
artery  was  laid  bare,  and  a  ligature  pasacf!  under  it.  It  waD 
dilated  about  one-third  moro  than  its  natund  sice-  He  was 
then  placed  un  hid  bed,  with  the  head  sli^^ditly  eleyated:  the 
pulfic  woa  found  to  be  !$U  in  the  minute.     The  ligature  woe 


448 


ARTEUIES   ANB  TEtNS. 


drawn  fi^lit.  At  first  lie  exhibited  no  chaiiire ;  but,  shortly  after, 
the  jiiiUt:  n|l[le^.red  lo  luliur,  and  became  sli^^Iitly  Irr^^gulur  :  ilie 
odI/  HjmpLom  Dotlced  m  tbc  patient  wua  tbat  be  became  drowsy. 
Alter  waltin*,'  about  fifteen  mluute^,  the  eecond  knot  vna  tied* 
nod  tfie  wound  dreaaed- 

No  iiit:oDvenitQce  waa  exj^eriEQced  from  thia  0|»emtiun,  fartlier 
than  n  tdigbt  ftautDesA  ilurhig  the  oflemoon  on  attempbiig  to 
mlae  bia  he.'uJ-  He  wm  directed  to  keep  perfectly  quiet,  and  to 
maiiiliiiii  atriclly  thtr  horizontal  |>asitloD. 

On  ihc  third  daj,  there  waa  &  s\i^\il  aorcDeas  about  the  larynx, 
which  lasted  three  da,y&.  Nov.  lDlh»  at  the  end  of  ten  daya,  be 
waj>  ill  j;ood  heallbi  and  able  to  go  down  stairs-  TIjg  face  was 
mu^  paler  than  before  the  \ast  operation,  and  the  morbiil 
appeurriueez^  vn^n^  dlmmifiblDg. 

Nov.  2Gth.  TIjc  Likt^ration  of  the  lip  woa  quite  healed  ;  but 
the  li[i  itself  tviia  still  tlilck,  and  aomewh^it  everted  by  the  erectile 
tissue,  which  cntere<l  iulo  its  whole  substance. 

It  was  riincluded,  that,  although  the  swelling  was  ^lulunlly 
diuiiiiisliing,  y^t  !t  wonld  mil  wholly  disappear  without  a  further 
operation;  and  that,  as  the  patient  lived  at  a  considerable  dis- 
laiice,  tile  dij^ease,  if  dir^posed  to  returu,  might  get  heyotid 
control  befoi'c  tlic  proper  menne  could  be  npplictl  to  cheek  its 
increai»e.  1  therefore  detennined  to  remove  the  di&CJised  portion 
of  the  lower  Up,  Pi-eviously  to  this,  and  in  order  to  avoid  hem- 
orrhage, I  j>erforined  tlie  following  operations  :  — ' 

A  cataract  needle  was  pluuged  into  the  vascular  texture  on  llie 
left  «ide,  and  caniRil  in  different  directions,  so  as  lo  break  up 
and  dt'fttroy  its  orgjLnization.  No  hemorrhage  followed  tin* 
aj>[iliration'  Three  days  aflcrwards,  a  similar  aperation  wa« 
repeaLed  on  the  ri^ht  aide. 

Nov-  29ili.  A  final  operation  was  performed-  A  strong 
compression  being  exercised^  by  means  of  two  steel  forceps  pre- 
piired  for  the  purpodc^  on  each  side  of  the  lip,  sa  ika  completely 
lo  interrupt  the  coutae  of  blood  into  it,  a  portion  not  les^^  than 
two  Inches  in  length  at  its  free  e<lge  wii*  removed  by  a  triangular 
incision.  At  fir^t  tlicre  was  not  the  slightest  liemorrhngc,  the 
two  lipa  of  the  wound  remaining  perfectly  dry  :  nn  the  com- 
pression being  removed*   however,  blood  gradually  oozed  from 


VASCULAE  OR   ERECTILE   TUMOa. 


449 


the  whole  cut  surlace.  Thif?  wan  easily  checked,  and  the  edges 
of  the  wound  apjiroximnted  by  n  launiher  of  pointe  of  tHe  inter- 
rupted suture,  ami  a  powerful  coiupresaing  huinln<re  applied, 

For  the  first  Iwenty-four  hours,  he  waa  carefiitly  watched, 
Towarls  evening,  n  coogulutn  was  found  projecting;  from  the 
wound,  whiclt  wan  removed-  From  this  time,  there  waa  no 
farther  hcmorrhn^e  or  bjid  symptom  \  aud  the  wound  bealed  by 
tlie  fir^t  intezitLon. 

The  portion  of  JIp  removed  presented  a  spongy  tiaaue,  like  the 
body  of  a  leech,  and  gave  a  senention  in  cutting  like  a  piece  of 
diaenae<l  hinp; ;  parte  of  it  were  indurated  from  the  previous  Hub- 
cuEnneoua  iDciaions,  The  muscular  tisaue  btid  almost  completely 
disfippeared. 

Ou  Dec,  12th,  the  pnticnt  returned  home  quite  well- 
At  thia  time,  the  drawing,  Plato  FV-,  wne  made-  As  will  Iw 
seen,  the  discoloration  of  the  ftice  had  become  much  paler^  and 
that  of  the  neck  and  cheat  had  almost  wholly  diaiippeared.  The 
ear  bad  lost  its  awollcii  nod  doop-reddish  color,  and  had  become 
of  a  natural  size  and  of  a  pnle  as|iect. 

No  pulantion  eooid  be  discovered  in  cither  of  the  temporal 
arteries,  or,  in  faut,  in  any  of  the  arteries  of  the  head.  In  the 
neck,  just  above  the  clavicle,  two  large  aneriee,  nearly  the  aiae 
of  the  Parotids,  were  acen  pulsating  poworfidly  under  the  akin  ; 
being,  iti  aU  probability,  ,the  eupra-acapular  arteries  greatly 
enlarged- 

Meriifirka. — It  ie  now  mther  more  than  sixty  years  since  Sir 
Astley  Cooper  first  applied  a  ligature  to  the  carotid  artery  for 
ftneuri^^io  ;  nod  the  operation  at  thnt  time  wns  looked  upon  with 
great  dtatruet,  from  the  fear  of  a  fatal  disturljanoe  to  Ihe  funcuons 
of  the  hrain.  It  has  since  been  frequently  repeated,  and  with 
as  good  siiocces  as  perhapa  any  of  the  greater  operations  in 
surgery.  The  object  appears  to  he,  tbat  aufficient  time  aboiild 
elapse  between  the  ligature  of  the  carotids  to  allow  the  (Collateral 
veaaela  whirh  supply  the  brain  to  he  dilated,  so  as  to  carry  the 
quantity  of  blood  required  for  the  performance  of  its  functions- 
It  seemed  probable  (hat  hemorrhage  would  seal  the  patient's 
fate,  or  the  morbid  degenerution  of  Vissue  would  haaten  his 
.death,  unless  some  sure  and  active  means  were  adopted  to  arrest 

57 


450 


AKTKRieS  AVD   VSmS. 


the  di9«^*^.  If  c}i?  di««:u«  htA  been  etmated  mt  a  gretit  distanett 
frora  th^  ves^ls  to  be  lifted,  on  the  sciiJp  l«r  nistuio>e,  th«ra 
wuu]d  ha%"e  been  n  question,  wheilier  xht*  supply  of  blom]  mi'giil 
noi  be  kept  op  bv  a  coUnt^ml  supply  t}iFO[ig1i  the  vertebnd 
aiteriee,  by  tneaua  of  the  opbtbalmic.  In  [he  present  caae»  no 
danger  of  tbia  kind  was  Utely  to  ^ve  eaose  for  imiuediiite 
apprehenfiion,  and  the  aedre  put  of  the  di»caac  mi^ht  euilv  be 
estirpnie^i  before  the  annetomosing  vessels  Iram  other  qmrteri 
had  bepTjn  to  supply  the  lunior,  —  iin  opinion  Bupported  by  the 
eTent.  The  attempt  to  remoi'e  the  lip  without  the  ll^ture  of  the 
carotids  would  pivbably  liave  been  attended  %rilh  fntnl  heraor- 
Thage ;  and^  even  if  the  patient  had  eswiped  Ms  aceidpnt,  tJ>e 
diseased  tissue  in  the  nei^borhood  would  have  been  an  obji^ction. 

ThU  patiefit  I  bad  an  opportunity  of  seeing  three  yeiu^  After- 
wards, and  of  making  some  observfltions  on  the  slate  of  the 
cirpidation  in  tho^  purts  about  the  faee  and  nerk  supplied  by 
the  carotids^  The  situation  of  the  temporal  arteries  bein^  ea^ 
ploped,  no  appeiUTinee  of  puliation  in  them  (Nwild  be  dii^covered. 
The  ftAUie  was  found  to  be  tnip  in  regard  to  t!ie  labinl  fine- 
ries. The  angular  arteries,  where  they  ino»Ptdate  with  the  Dusnl 
branrh  of  the  ophdialmic,  pave  die  faintest  pulsatorv  motion. 
In  the  reg-ion  of  tlie  neck  were  a  number  of  large  ves'ieU^  having 
their  origin  from  the  ^bclaviiui ;  among  which  the  supra-scnpular 
was  chiefly  to  be  distinguished.  The  lip  was  mlhpr  more  fiill 
in  appeanince  than  when  tlie  report  of  the  <yiBe  -wtm  niadi?,  but 
^e  Irom  uhTeradon.  The  funrtions  of  the  bniin  hail  noi  in  nny 
wav  been  disturbed. 

I  have^  however,  twice  attempted  this  operation  in  anetiriem 
by  anaslomuHid  of  the  upper  lip,  where  the  ditseane  hns  been 
partial.  One  of  tlieT*e  wifes  i^  deembed  In  Dr.  J,  C.  Warren's 
work  on  Tumors.  The  individual  had  n  lirge  red  mark  occu- 
pying nearly  ^jne-hnlf  of  the  left  side  of  the  fiice.  During-  liis 
childhood,  the  upper  lip  on  that  side  had  enlar^Z  until  it  formed 
a  permanent  t.Lunc^r,  hanging  down  and  oliwuriiig  the  under  lip  : 
the  ^ms  had  partjikeit  j>f  the  dir^cu^e ;  had  liucoiue  s}Kin|fy,  ami, 
widi  the  rest  of  the  diseased  maaa^  were  bleeding  on  the  leji^t 
injuiy.  Rather  mcire  than  half  of  tin?  iipfier  lip  waf^  alVecteil- 
T  removed  the  whole  of  this  by  tnemiB  of  two  incisions  made  Jn 


VASCDLAR  OR  ERECTILE   TUMOB. 


451 


tbe  adjoininn;  soimd  textures,  A  triangular  pioee  beiu;;  thus 
incIuJw],  a  number  of  dikteJ  vefieelu,  which  supplied  tbe  erectile 
tissue,  were  tied ;  and  the  oaly  hemorrhap;e  which  waa  Irouhle- 
Eome  arose  from  the  augle  of  the  wound,  whtn-e  the  diaeaae  had 
extended  up  into  the  uo^Crile.  The  int1»mm cation  superveoing 
on  this  opcrntion  wti^  c^utHeicnt  to  obliterate  the  mi>rbjd  tji^ue, 
wliieb  per^'uded  the  mouth  and  Jt^  neighborhood.  Three  moiitha 
afterwards,  1  saw  nluioat  oxactly  n  similar  case  of  disease  (t>n  the 
right  aide  of  the  fiice)]  which  was  t^uccei^si'aiJy  treated  tii  the 
eame  manner. 


Case  CCLXH,  —  Anomuiitn  by  AnasfomosU  HiwceBsfully 
tnfdted  h/  Various  Operational — The  eiihje<?t  of.tliis  case  waa 
an  inhabitant  of  Nova  Srotin,  a  hoalthy  man,  33  years  old.  He 
bnd  on  hi^  forehead,  prinoipally  below  the  roota  of  the  hnirf  a 
little  to  the  rij^hl  of  the  raedia:i  lire,  a  soft,  pulsating,  irre^^ular 
tumor,  ubout  thi-ee  iuohes  in  diameter,  and  from  a  half  To  three- 
fourths  of  au  [ueb  iu  Ehickticsa,  which  gdve  him  a  very  formid* 
able  iiJ^pect, 

Tbia  tumor  was  of  a  reddish  color,  becoming  redder  and 
larger  when  the  patient  wai  excited,  either  by  bodily  exercise 
or  meatal  disturbance.  It  a}>peared  to  consist  of  coils  of  veasela. 
It  wflfl  easily  eompre8ae<I,  and,  on  removal  of  the  pressure,  im- 
mediately enlarged  again.  A  number  of  pulsating  bloodvessela 
were  seen  to  enter  it  from  different  directions,  principally  on  the 
rijfht  side.  Of  these  might  bt»  di6tinguishe<l,  first,  tlie  tempond 
arterji  wliicb  was  in  n  very  enlarged  and  tortuous  state  aa  ^ 
dowa  aa  the  lower  part  of  the  external  ear;  second,  a  branch 
of  the  frontal  artery;  third,  the  facial  or  angular  nrtery,  from 
the  interna]  commissure  of  the  eyelids.  On  the  letl  side  were 
seen  tlie  left  temporal  artery,  whieh  viis  nearly  aa  large  as 
the  right,  and  the  left  facial  artery,  which,  with  its  fellow,  the 
artery  of  the  right  side,  and  its  aceompanying  veins,  formed  a 
vascular  tumor  at  tbe  mot  of  tie  noac.  Tlie  vciua  tbemselves 
were  of  an  ent»rmoua  size,  pnaaing  down  from  the  lunior  on 
either  eide  oY  the  nose,  coverin^f  aud  ptirtUJIy  obsL'Ui'Jng  the 
intemul  commissure  of  the  eyelids.  Beside*  tliese  vessels,  the 
whole  Bcalp  in  ihe  neighborhood  of  the  tumor  aeenied  alive  with 


«» 


ASD 


bc^B  BXMCtt  5«ui  b<fart^  wilkoat  h^  known 
CM»e,  bf  «  ivtn  reUkb  ipaC  «a  tke  n^  nde  of  tlv  fiMvltfad.^ 
TliBe  tTM  AA  oce«aoBd  thiohbipg  of  ihe  orocid  mrtcnes, 
tkuUrlr  that  oT  the  right  At^.  Tbe  p«daU  wu  «iso  wbject  to 
dktTttttng  hcftdacfaev,  moBampuMaed  wjA  incRucd  MtioD  of  die 
Moodfawtli  of  die  tamar  and  of  die  heftd  genefsllT-  This 
ribnUoTj  ftcdoo  of  die  mrtcnal  ^ratem  of  tb«  head,  iwck.  «ad 
i]p[>er  oxETCnutics,  wu  quite  remaricftble-  He  tu  iaespMlBlcd 
br  it  fri.>m  idl  active  exerttoa,  and  wa£  readv  to  undergo  an^ 
operafion   ihni  proiFU«ed  Xa  relieve  him. 

The  coune  of  thU  tumur,  if  not  nrrMied  hy  ffnT^ical  tntft^j 
merit,   could   be   reaJily  foreeeen-       The  morbid   at^tion  wrmld^ 
l^iuliially  Involve  otb<?r  ve&^el£«  imtrl  die   Hhi>]e  »c^p  becamoj 
filled  with  enlarged  arteries.      The  vessels  of  the  eyi^lids,  of  tktn\ 
fju^  [^ncr&Jly^  and  even  of  the  inteHor  of  the  moaih,  u'ere  likely 
to  Uc  involved.     The  pfitieat^e  condition  would,  in  this  war, 
beooiiie  almoHt  imupportAblc ;    and  \m  life  would  perhnpe  be 
bftzarded  by  the  rupture  of  the  tumor,  which  eeemed  atmoatj 
reodv  fo  tnkc  place. 

What  rnesn^  shonld  be  adopted  to  arreal  it*  progrpas?    ThosaJ 
wliieli  naturally  presented  themselves  in  the  6rat  place  were  ofj 
two  descriptions  :  First,  ligature  of  the  carotid  artery-     But^  in 
thirt  case,  tlie  ligature  of  a  single  carotid  might  not  sufEc'e  to 
Arreat  tho  How  of  blood  into  the  tumor;  gioce  the  vessels  which, 
aup|i[ictl    il,   althouirh   principally   from   the  right,   were  partly 
friJin  iIh'  li.?ft  ewriJtiii.     The  ligitttire  of  both  carotids  wculd  there- 
fore b«  necPBHury  :  hut  the  result  was  lesa  Ifkely  to  he  successful 
lliiin  in  the  |irti;eding  ca^e,  on  neeounl  of  the  greater  dielaECe  of 
the  tumor  frum  the  Jirterles  lied,  and   from  the  probability  uf  its 
having  other   means  of  supply  through   the  vertebral   arteries, 
wbii'h  iniK^CLiliitu  freely  witli  the  branches  of  the  inCeiTial  enrotid  ; 
tlje  ophUmhnit;  in  thiu  ciu^e  being  unusually  dilated.     The  Hecond 


VASCDLAa  OR  ehectilb  tumor. 


453 


mode  of  operating  which  euggested  itself  was  to  expose  the  ditler- 
ent  vesaele  Bupplying  the  tmnor,  anJ  pusa  a  lignturc  under 
them.  The  objection  to  thia  course  Wixs  the  length  of  time 
an  opemtioD  upon  so  man^  vee^s  would  require.  Were 
there  any  meana  that  cyulJ  be  Ucviaed  other  thnii  these  two? 
Tlie  tumor  wiLd  mucli  too  large  to  admit  the  sulc  juid  ctloc^tual 
applieiUion  of  caustic.  It  eould  not  be  cut  out  witliout  daiiger- 
O110  liemorrhagCp  It  waa  too  large,  and  loo  much  conneutcd  with 
the  bune*  to  admit  the  application  of  ligature  en  mctsac. 

Oct.  31,  l^'ld.  Having  compresecd,  on  the  right  nide.  the 
frontal  and  the  two  tempore -parietal  artcnea,  and  on  the  left 
aide  the  continuation  of  the  temporal  artei'y  through  the  froiitnl 
region,  and  the  tempo ro-parietal,  the  pulfiatiune  of  the  tiiiUL^r 
appeared  to  be  arrested  i  and  its  conlcnta  were  readily  expelled 
through  the  large  veins,  running  Into  the  tac.ial  vein.  It  waa 
detonuiaei-I)  therefore,  to  intcrn[|jt  the  cii^cuktion  throu^^^h  the 
five  vejdcob  £r«t  luentloDod;  three  on  the  right  side,  and  two  on 
the  left.  Instead  of  exposing  and  taking  up  these  vcaaela  in  the 
uatial  woy,  they  were  compressed  by  a  ii-^'ature,  thrown  over 
the  nocdlcfl  pasaed  under  them,  in  the  form  of  a  figure  of  S. 
Afler  this,  tlic  pulsation  of  the  tumor  waa  taucli  diinininfied. 
Voncaection  wa^  then  performed,  and  Uie  patient  placed  in  bed 
with  hie  head  elevated* 

Nov.  tilh.  The  needles  were  removed.  Very  alight  eorences 
bad  been  experienced  from  them.  The  tumor  woa  dimlmshing 
in  eize;  the  vceeeitt  constituting  it  ap|x;artd  moru  Hoceid  and 
compreaeible.  The  aoreneae  and  all  the  uucomforiable  aenflationa 
connected  with  it  were  leesencd. 

I^th>  The  pulsationd  in  the  right  and  left  temporal  arteries 
atill  continuing,  a  needle  wiu^  paaecd  under  each  of  theeci  directly 
above  the  ear;  ufier  which  fhL>  pulmition  BubeidciU  and  also  tlie 
general  ecnee  of  beating  about  the  bead.  The  patient  was  much 
more  eomfortablci 

2Iat.  In  eonacqucnee  of  q  slight  bleeding  from  the  wound  of 
a  pin  iuaertcd  on  the  Hith,  it  was  tliought  best  to  nbetruct  tlie 
ve^r^cla  on  the  anterior  and  on  the  interna]  part  oi'  the  tumor; 
and  pine  were  parsed  in  each  of  these  eituntiunfl.  There  wa£ 
then  no  puluatiou  iu  tlko  tumor;  the  tendorneae  oxiating  ou  the 


tfae 


phce-     A  li^Mnic  «««  earned  unafid 

tfcackgj-  It  wu  to  be  feared,  bpwcf,  (Jhil,  at  ilic  pn  nlcv- 
ii«d  o^  1^  Lmimiha|;ft  widd  item,  Xfcoc  bcia^  &  wxnt  ef 
■tWMimmndifiiMi  in  kii  lad^^.  aad  b  ovilv  tbst  be  miotic  bi 
nan  GanfiiU  J  vatdwd  is  cvcof  afcoaod  n^lNK  of  the  tonorr 
Le  wM  adraed  to  go  to  the  Hotpital,  wkoe  be  caaic  exckuiv^ 
■nder  Uhs  au«  of  Dr.  4<Am.  C.  Wafrea,  to  irlM»  I  am  laAAt^ 
for  iht  remaioiiig  hLetofr  of  tbc  case. 

25tli.  "  The  puUe  waji  novr  natura],  7i» ;  the  intern^  setiA- 
tioii*  were  Enitch  improrcid;  there  wbp  do  nbratory  motion  uf 
tbe  artcfie*  oi'  the  head,  and  Dooe  were  diacofcnble  tn  the  tumor, 
thuugh  a  pubation  gtiU  ezut«d-'  A  fi&ght  tcdema  extewled  from 
the  tutaor  Ui  Uie  ao^  and  erelids.  Oixk^loq^t  a  drop  of 
blood  atartcd  iVom  the  needle  wounds.  FroiD  time  lo  tiuie, 
leechcv  have  been  applied  with  great  relief- 

dOl}i-  "Oil  thle  daj,  a  vewel  wae  diflcofered  nmning  from 
tlie  left  fronbil  artery  acroj^a  the  leFl  ejebrow,  oommuntCfttiE]^ 
with  a  bnwcb  in  the  angle  of  the  eye  on  the  right  «ide, 
dience  ninntng  up  nlong  the  left  edge  of  the  tumor,  till  it 
ruuulied  it^  AU]^teni^r  pi^iatcrior  border.  It  did  not  produce  a  pui« 
Butiuii  in  ihifl  jjurt  uf  the  ttiLuor ;  but  ekirtuig  aioug  ite  edge  for 
■oine  difltoncct  &«  it  did,  there  was  a  ^rang  proLnbilitT  of  ita 
*l^n"[lll^^  vc^eeli*  into  the  mosB,  thus  tending  to  keep  up  the 
ijLOtbjiI  m'tidii.  The  necdke  which  were  inserted  on  the  22d 
InMt.  cwjned  an  Influmtnation  and  iudurjition  of  the  tissue  in 
tlniir  iiii;^'hh<jr]nio<[i   and  were  removed  without  hemorrhage. 

"Ah  cmuprcpMon  of  the  artery  riein^  on  the  forcliead  checked 
the  fi|reciHe<]  piilfiuti'jn,  it  wntj  determined  to  lie  this  veaseK  A 
liMdle  wan  ju^i^oiijjngly  paeF^i^d  under  it  oxi  Dec*  IsL  Defure 
plAeing  the  li^iiture,  tho  veAdcl  waa  couiproflW  on  the  ncodlc:. 


VA80CT.AR  OR  EBBCTILE  TDSIOB. 


i55 


without  interrupting  tlic  pulsation  along  the  edg:c  of  the  tumor. 
Anotfier  ncctHc  wna  theretVirc  pn^scd  under  thai  purt  oF  tJic 
artery  where  it  penetrntcJ  nt  the  superior  internal  nn^le  \.tf  tho 
tumor,  embracing,  over  the  needle,  a  votfcuUir  aub<taiicc  nt  IcujjI 
half  nn  inch  wide,  A  li^aturo,  pushed  in  the  fi^rc  of  S  over 
this  needle,  suspended  idl  puirialion.  The  patient  hiui  some 
pain,  which  lasted  a  cyupie  uf  hours;  nttep  which  he  he<;niue 
easy. 

Doc,  3d.  "Two  needles  hod  flcparttte<L  from  the  aubetance  of 
the  tumor  without  hemorrhage.  Beaidea  the  needle  paafied  on 
Ucc.  1st)  thei'e  still  remained  one  needle  nt  the  lower  part  of 
the  tumor,  which  was  passed  under  an  artery  from  the  right 
ircntul.  The  tumor,  which  h^ul  been  hard  from  inHammalion,  waa 
eoftcred ;  it«  heat,  except  near  the  needle  pnseed  the  last  time, 
had  suhHided.  There  was  no  throbbing  in  any  of  the  arteries 
about  the  head  :  the  earotid  bent  naturally.  The  patient  was 
tranqiiLl,  felt  well,  and  eat  np,  which  ho  had  not  been  able  to  do 
for  flome  time  on  aceount  of  the  throbbing  in  the  head  pro- 
duced by  any  motion-  U.e  had  a  goo<l  appetite.  Hia  Ibod 
was  rcfftrioted,  however,  to  half  a  pound  of  eolid  farinaccouft 
matter  per  day,  and  about  a  pint   and  a  half  of  l]f|uid' 

6th.  ''  Although  all  pulaatiima  were  at  an  end,  die  tiiukor  still 
cjcifited,  hut  in  a  diminished  state.  It  was  thought^  that,  If  left 
to  ttaelf,  it  would  in  all  probability  disap|>ear  without  further 
applicatione ;  but,  as  tho  palient  lived  at  n  great  disLnnee,  it 
aeemcd  to  t^e  n  duty  to  see  that  the  tumor  waa  certainly  ond 
perfcdly  enidieated  before  he  went  houjc  to  Novo  Scotia.  The 
best  mode  ef  accomplishing  this  was  by  the  application  of 
cauiiitic,  which  was  rttorted  to  without  much  danpcr  of  hemor- 
Htage,  the  peat  vopboIs  being  cut  oH',  The  use  of  caustic  waa 
therefore  eommenoed  by  the  application  of  caustic  potaAfi,  in  a 
solid  form,  to  tho  wound  lett  by  tho  eeparation  of  one  of  the 
needles.  This  wound  was  about  one  inch  long  and  two  lines 
wide.  A  little  blood  followed  the  oj^plication ,  whicit  might 
have  nriaen  frr^m  the  pressure  of  the  enualie;  and  therctbre  n 
portion  of  the  saTne  aubatancc,  in  amount  eight  gnuns,  was  ap- 
plied in  powder. 

16th.     ^The  caustic  hod  been  applied  throe  or  four  timo». 


15S 


ABTERIES   AND   VBlIfS. 


Twice  A  flJiglit  hemorrlinge  had  occuired,  requiring  an  mttnni»- 
sioa  in  iu  lU'ie.  A  ;)ul«atQry  movement  liaviit^  re-appeitrt-J  in 
the  relics  of  the  tumor,  the  application  of  ice  two  or  tbreo  tini^^ 
a  day  waa  directed,  to  be  conttoiLcd  as  long  aa  tlie  patient  roftld 
bear  it.  To-day  the  caustic  was  re-applied  to  the  ulcerated 
Durfooe,  which  waa  about  an  inch  long  and  balf  Em  inch  wH^e- 
The  tumor  had  scnsiblj  dlmjoished  in  i^'izc,'* 

It  will  be  uuiiecesaary  to  proceed  witb  all  tlic  subsei^ucnt 
details  of  this  ca^-<e.  It  ia  suBicieut  to  state*  that  the  JilTerent 
portiona  of  the  diacaacd  inasa  which  rctuaiued  were  siicccsstvelj 
attacked  with  caustic  ]>otasli,  and  with  the  occasional  a^ipliciLtion 
of  croton  oil.  Anj'  emiJI  arteriea  which  were  discoveretl  nju- 
ning  into  the  turaor  were  treated,  as  in  ihe  commencement  of 
the  ca^,   by  the  nccdlefl* 

On  i>th  April  an  operation  waa  performed  to  exciae  a  portiaa 
of  the  erectile  tiesue,  which  c:cifltcd  at  the  njiper  part  of  the 
woiindt   when  u  large  veaecl   wns  opened  and  tied. 

May  20th.  After  the  wound  from  the  inciaion  and  cauatic 
was  nearly  healed,  a  fulneae  waa  perceived  at  ita  lower  angle, 
immediately  above  the  supra-orhitir  forameUp  A  triangular 
piece  uf  tlic  suapicioua  part  was  Lherefore  cut  out,  and  the  fuprii- 
orbitar  artery  ticdp  The  whole  wound,  after  thia  last  operation, 
waa  nearly  the  aize  of  a  flilvcr  dollar.  Strips  of  adhcaive  plotter 
were  applied  to  apprijximatc  its  ed^ea.  The  wound  came  to- 
gether witli  great  r^ipidity.  In  a  fortnight  after  tlic  last  incision, 
it  was  healed  with  a  iunated  cicatrix,  and  the  parts  appeared 
perfectly  soundn  The  patient  was  in  excellent  heoltli ;  and, 
May   20th,   waa  diachargcd  to  return  home. 

liftnarkf*^ — In  conaidcring  this  case,  the  firat  circumstance 
which  preecnia  itself  is  ita  protracted  ami  com])licatcd  treat- 
ment. The  neceaait^'  of  this  arose  from  the  obstinate  character 
of  the  afibctiun^  Tho  fir@t  operation  wa^  inaoHicient,  and  ad- 
ditional intertercnco  waa  required  under  the  various  appearances 
which  occurred.  Four  different  racasurca  were  aaccesBivalj 
adopted. 

1.  The  large  veeselswcre  interrupted  by  needles  pasaed  under 
the  artorica,  and  compression  made  on  them  by  a  thread  in  the 
form  of  a  figure  of  ^. 


VAfiCULAR  OR   EEEOTILG  TUMOR. 


457 


2.  The  lj;^&turee  being  iDsuflScicnt  to  repress  tbo  action  of 
the  sinjbUor  voBflela,  caustic  applicationa  were  resorted  to  for  the 
purpose  of  destroying  the  morbid  texture,  tmd  In  part  obiiter- 
ating  it  by  the  in  Summation  produced  by  the  action  of  lUe  caus- 
tic. To  thia  end,  ii  very  t'rco  iip}ilicntion  waa  niado  of  caustic 
potAdh,  and  re[icatcd  between  twenty  and  thirty  times, 

3.  Excitiion  of  the  rciuaiua  of  the  vaacutar  texture  was  per- 
furmcdi  after  the  arteries  su|)plying  it  hud  been  so  far  obliterated 
ad  to  remove  tbo  apprcheaaioa  of  bemorrhogo. 

4.  Coniprcfiaion  by  odUeBive  plotter  and  a  bandage  had  a 
sensible  induence  in  finiehin;^  the  cure. 

Tho  general  treatment  gave  important  aid  to  the  local  applica^ 
tiona.  The  patient  was  kept  very  etJli,  and  for  the  greater  part 
of  the  time  in  bed,  with  the  head  much  elevated.  Hie  food  wae 
realrieted  to  the  emalleat  quantity,  &d  that  he  waa  reduced  tor 
a  tioie  to  a  state  of  total  proAtration  of  the  muscular  pi>wer. 
During  moHi  of  the  trcatpjcnt,  if  a  stuall  addition  was  nuide  to 
hjti  food,  its  effect  was  genomlly  aocu  in  tlie  production  of 
arterial  vibrations  and  the  recurrence  of  headache.  Abstrac- 
tion of  blood  and  the  use  of  purgotives  were  reeorted  to  when 
necessary. 

It  is  worthy  of  remark,  that,  while  eryaipfllne  prevailed  all 
around  this  patient,  he  was  never  aifccted  by  it  In  the  elighteat 
de^^ree  during  exposure  of  at  least  three  months. 

In  concliifliont  it  may  be  ftaid  that  this  atFectioa  could  only 
have  been  deatroyed  by  a  resolule  and  active  perseverance  in 
tike  various  remedies,  continued  through  all  the  turnings  of  the 
dieea^. 


Case  CCLXIII.  —  Reviarkath  Case  of  Aneurism  by 
Anaatomosh,  Operation.  Cure-  —  A  boy,  16  years  old, 
partially  froze  tlie  lolje  of  hie  left  ear  in  1818.  This  remained 
larger  than  the  lobe  of  the  right  ear ;  and,  in  fact,  alowJy  in- 
creaeed  in  pixo,  finally  forming  a  distinct  tumor,  red  on  its  Bur- 
face,  anil  having  a  powerful  puUatJon.  In  18^12  it  w^as  found 
neeesBary  to  undertake  some  means  to  arrest  Lte  growth-  For 
this  purpose,  compressiou  between  two  plates  of  metal  ^xaM 
odvUed  and  proctifed  by  his  eurgeoQ.     Although  this  was  done 


458 


A}£TfiKl£S    AND    V£1NS. 


in  the  moat  carf?fiil  end  scientific'  way,  yet  ilie  eufferinj^  became 
so  eevero,  that,  after  having  persevered  with  it  for  a  fortnifrht,  it 
WHS  found  neceasary  to  abandon  its  furtUer  application. 

When  tlie  patient  applied  to  me,  it  was  with  the  full  deter- 
mimitfon  of  having  any  c>perfttion  done  that  might  be  though: 
expedient-  The  tunjor  had  arrived  at  that  condition  whc^rein 
it  was  evideal,  lliat,  if  an  ojMjration  ehould  not  he  succefieful  in 
removing  it  complettlj,  it  muat  soon  pass  beyond  the  reaoh  of 
surgery,  spreading  over  the  eai'  and  takin;^  iiossession  of  the 
face,  as  in  the  cjwe  cited  by  Dtipuytren  In  hia  "Lemons  Orales," 
which  resisted  numerous  nnd  formickble  operations,  performed 
by  some  of  the  most  distinnfuished  surgeons  in  Paris. 

The  nppcaraiiee  of  the  tumor  at  this  time  was  as  follows: 
The  lobe  of  the  left  ear  was  occupied  by  ii  globular  tunior  the 
size  of  a  hens  egg.  The  aurfiice  waa  re<l^  and  ci:»vere<l  by  large 
veins  running  over  iC  in  all  dirertions  :  the  redness  and  swelting 
belonging  ta  the  lufnor  extended  above,  into  rh<!  ecnchn  of  the 
ear,  and  ran  up  for  a  short  distance  on  its  back  pnrt-  In  front* 
it  slightly  encroached  on  tlie  cheek.  On  taking  h  in  the  hand, 
it  had  a  powerful  pulsating  motion :  not  that  alooe  presented  by 
the  common  ereciile  tumor,  but^  added  to  this,  what  niigbt  be 
expected  in  an  aneurism  of  a  lar^  artery,  the  carotid  or  sub- 
clavian for  instance.  By  manipulation ,  vessels  of  considerable 
size  eould  be  perceived  tunning  into  it  from  the  oar  and  face. 

At  firet,  I  was  at  g.  loss  bow  to  attack  the  disease,  the  danger 
of  hemorrhage  appearing  to  be  great  Irom  any  cutting  operation  ; 
and,  if  ligatures  were  iisedj  the  same  danger  wa^  to  be  appre- 
hended on  the  separation  oi'  the  ihreafls.  A  combination  of  the 
two  was  finally  resorted  to- 

The  patient  being  etherized  with  chloric  ether,  the  tumor  was 
dragged  upon,  so  aa  to  stretch  tlie  integuments  as  mUL-ii  ns  pos- 
gible.  A  pair  of  screw  forceps,  similar  to  an  enterotome,  was 
now  made  to  embrace  the  whole  base  of  the  tumor,  about  tliree 
inches  in  lenglli,  that  is  to  say,  the  whole  enlarged  lobe  of  the 
ear,  with  a  portion  of  the  cartilage.  This  was  tightly  screwed 
up,  so  as  completely  to  interrupt  the  course  of  the  blocMJ  into 
it,  A  needle^  threaded  with  a  strong  double  ligature,  was  next 
passed  behind  the  forceps,  and  the  nee^lle  cut  off,  leaviug  the  two 


VABOULAR   on   ERECTILE  TCMOH. 


459 


thrcocfs.  The  tiimor,  now  itpparcotly  effbctunllj-  coatroUe*!.  wjw 
cut  flway  close  to  the  forceps.  It  was,  howover,  iit  oiitic  found, 
thai,  on  the  tension  of  the  piuls  bein^  reliovod,  that  portion  of  it 
towards  tbo  check  liad  escaped  from  tlio  gmap  oi  the  fotcepa,  and 
ttn  arterj  was  e:cpoeed  nearly  as  large  oa  the  cjitcmal  carotid- 
Thie  waa  seized  by  un  n^sie^tant  with  tooChed  forccpa*  and  a 
lignture  applied  to  it,  The  grasp  of  tho  forceps  being  now 
slowly  rolajtud,  it  was  observed  that  the  whole  cut  surface  was  dia- 
powxl  to  bleed*  Some  large  vessels  bled  violently,  and  were  lied. 
To  Btop  the  bleedbg  frora  the  other  parta,  it  was  iin&Jly  found 
necessary  tu  apply  the  Jigatiire  en  ma6SG,  wliich  wa*  done  by 
means  of  two  double  ligiiturc^,  In  the  subsequent  mana;^;^- 
raent  of  the  case,  all  means  were  used  to  prevent  too  high  a 
degree  of  intlanimntory  action  about  the  ligatures.  The  pnticnt 
was  very  enrcftilly  watched,  kept  quiet,  a  low  diet  enjoined,  and 
a  compress,  constantly  wet  with  cold  water,  applJedi  Once  or 
twice,  blood  started  by  tho  side  of  the  ligatures,  but  was  re- 
strained by  refrigerant  npplicatious.  At  the  end  of  fourteen 
dayS|  the  ligatures  eepiu^tcd,  le^vin^  an  exuberant  granulating 
surface,  upon  which  the  nitrate  of  fiilver  was  freely  used*  On 
the  twenty-third  day,  the  wound  was  almost  entirely  healed, 
and  the  neighboring  parta  vrera  in  a  perfectly  heulthy  state  j  the 
effect  of  the  inHanunntory  action  having  destroyed  ihe  cnhu-ged 
capillary  veaaels  which  had  CTiteadcd  into  the  concim  of  the  ear, 
nnd  invaded  the  integument  on  its  posterior  pnrt, 

In  order  to  have  extirpated  all  apjKuranoe  of  erectile  tissue 
at  the  iirst  operation,  by  the  knife,  it  would  have  been  necessary 
to  atieritice  nearly  half  of  the  car,  and  to  leave  the  patient  with 
a  great  deformity,  lu  order  to  avoid  this,  I  removed  the  tumor, 
trusting  to  the  effect  of  inflammation  to  destroy  the  erectile 
tissue  which  remained. 

The  ftppcnrauce  of  the  tumor  after  removal  was  quite  inter- 
esting. The  main  portion  of  it  was  composed  of  a  spongy 
tisaue,  which  enclosed  an  aneurismal  cavity,  apparently  the  ex^ 
pansiou  of  the  largest  of  the  \essels  deacribed  above,  which 
were  tied  when  the  tumor  was  removed.  From  this  cavity, 
branches  extended  in  all  directions,  which  finally  could  be  traced 
into   the   cclluhkr  tisane  covering  the  periphery  of  the   mass. 


r 


460 


ARTERIES  AND  VEINS. 


Cabe  CCTjXIV.  — JV^ci'u^  over  thf  Knee-joint, —  A  young 
man  entered  the  HospitAJ  in  JimeT  1S52,  with  n  ulcvub  on  the 
kneo.     The  depvus  wae  of  a  blnck  color,  PituntCid  over  the  in- 
ner part  of  the  knee-joint,  below  the  pntolla.     Until  within  two 
yeara,  the  tumor  bad  been  about  tbe  eize  of  n  {loU^r  ;   but,  since 
then,  a  supplementary  tumor  had  appeared  uudemeath  the  ori^- 
nal  one,  not  eof%,  as  k  usually  seen  in  these  cnses,  but  qiiit« 
bird-  and  extcndinsj  fcr  Rome  diataace  into  the  adjacent  e^Uular 
mcmbrnne,  and  apparently  attaching  itpelf  to  the  aynovial  osp- 
etile.     The  whole  tumor  had  become  extremely  ^enaltiveT  eo  that 
even  the  contact  of  the  clolhea  caused  much  sufferirg ;   and  pre- 
vented him  from  attending  to  bnfiineas.      It  was  impo^Eible   to 
make  any  fatisfactory  examination^  the  padent  dremie<l  so  much 
the  eli^hteet  manipulations.     He  wa^  dieted,  and  kept  in  the 
horizontal  position  for  a  few  daj'e ;  an  evaporating  wash  being 
externally  applied-      Thin  liad  the  effect  of  relieving  the  tender- 
neaa  in  a  eliglit  degree.     The  whole  tumor  was  now  congealed 
by  means  of  a  iTeezin;;^  mixture  of  pounded  iee  and  salt,  aeeord- 
inn;  to   Mr,  Amolt'fl  process,  which  I   had  juet  oommenoed   to 
experiment  with.     The  hard  baeal  tumor  was  then  very  freeiy 
cut  up  by  a  eubcutaneoiw  section^      The  operation  was  cntii-ely 
painlefis,   and  no   unpleasant   symptoma   ensued.      The  vicinity 
of  the  knee-joint  of  courae  precluded  any  operation  for  tlie  ex- 
cifcior  of  the  tumor.      The  above  subcutaneous  section  was, 
therefore,  once  or  twico  repeated  ;  and  re^ulteil  In  the  absorption 
of  a  large  part  of  the  tumor,  and  diminished  the  eensibillty,  bo 
that  it  could  be  handled  without  sufFering,    He  left  the  HoflpitnJ 
aC  his  own  request;  otherwise,   bv  a  repetition  of  the  above 
meana,  the  ctimplete  destruction  of  the  tumor  would  have  been 
effected. 

In  another  case,  I  removed  a  similar  nicvusT  in  an  uleerated 
state,  situated  on  the  upjier  [>art  of  the  calf  of  the  leg.  The 
patient  wae  twenty-six  years  of  age.  Two  years  before,  tha 
tumor  had  been  injured,  after  which  there  was  much  hemorrhage. 
In  spite  of  treatment,  it  had  remained  in  an  ulcerated  state.  The 
skin  around  it  was  much  infiamed^  and  at  timeii  very  painful-  It 
^as  removed  by  two  elliptical  incisiona,  without  much  hemor- 
rhage. 


» 


VASOCLAR  OH  EHEmLE  TUMOR. 


4S1 


Case  CCLXV.  —  l/nustial  Uojig  of  Varico^  Ancni'tJtm  of 
palm  of  Hand  and  Arm.  Amp^tffition.  Jtecovcrif.  —  A 
^1,  1^  yoara  of  tige^  of  a  dclicAtc  constitution,  received  nn  in* 
ji]r3^,  when  two  years  old,  in  the  pnlm  of  her  hand,  from  & 
stone  i  and,  very  shortly  nftcrward,  n  email  piilantin^  tumor  np- 
pearcd  there.  Twelve  years  nfterwnrd»  ^he  entered  the  HoBpit&l. 
At  that  time,  a  large  tumor  occupied  tho  whole  hand,  held  oa  it 
were,  in  the  palm.  It  waa  tirui  at  some  |x»mte»  soft  and  pul^ 
eating  ot  cithere ;  and  eecmcd  to  have  mflde  ila  way  backward, 
fio  OS  to  give  the  idea  of  all  the  bones  of  the  hand  having  been 
flattened,  and  formirg  a  shell  to  it.  On  eompresfiin^  the  tumor, 
it  hod  a  powerful  ancuriHmol  thrill ;  and,  In  some  ]\nrts  of  it, 
the  blood  seemed  to  be  contained  in  Inrge  ancunsmtd  eaca ;  at 
others,  arteries  of  the  size  of  the  carotid  could  be  detected.  Am- 
putation woe  advised  as  the  only  rceource,  but  dceJiiicd.  A  cast 
was  made  of  the  arm  and  band  at  tbo  time. 

In  addition  to  the  tumor  of  the  palm  of  the  hand*  there  was 
also  a  tfiipplemontary  tumor,  quite  firm  to  ihc  touch,  reaching  Up 
the  whole  fore-arm  under  the  muaclee,  without  pulsation. 

In  the  epring  of  1857,  she  came  under  my  care  again,  the 
tumor  bavjn;:  more  than  doubled  in  size,  and  the  Bwolling  on 
the  fore-itrm  increased  in  a  corresponding;  manner.  At  thia 
time,  a  distinet  aneurismal  thrill  attended  the  pulsalion  of  the 
brachial  artery;  and  the  surrounding  veins  were  in  a  highly 
varieose  atatc.  On  au@cullatJon,  tbe  tumor  of  the  hand  gave  a 
pouud  like  the  noise  of  the  machinery  of  a  factory.  The  arm 
was  quite  unwieldy,  and  at  times  very  painful  \  and  the 
dieensc  was  rapidly  increa^ingn  The  surf?;eons  of  the  Hospital, 
in  consul  til  ti  on,  decided  thut  amputation  was  the  only  means  of 
relieving  the  patient,  but  considered  that  there  was  a  possibility 
of  mectinj^  with  erectile  tis*5ue  in  the  arm.  She  was  ^juite  timid, 
and  unwilling  to  encounter  nay  more  tlian  the  ordinary  danger 
^m  an  amputation.  She  therotbrc  returned  home ;  but, 
subsequently,  the  |>ain  being  so  severe,  and  tlie  tumor  making 
advauece,  by  the  advice  of  her  phyeician,  Dr.  Jones,  she  came 
to  town,  and  submitted  to  the  operation.  In  making  the  com- 
preesioD,  it  was  deemed  necessary  Eo  place  a  tourniquet  quite 
high  upon  the  arm,  and  ictew  it  up  so  as  to  forcibly  eonipreee 


4&2 


ARTEBIBS   AMD   VElKfi, 


»I1  the  tisBUPs-  Npnrl_v  tvrcnty  vesflpl^*  Itoili  artftriefl  and  veinn, 
reqiiirei]  ligature,  a^  iL  was  soon  Itiund  flml  tJie  veins  carHeil 
BxterlH,!  bloixl,  and  were  (Itsjiai^eil  ti>  IhleeiJ.  The  cjiiflntity  of 
blooil  lost  Iji  tlje  uperjitlcvn  wue  emdl,  mi  nccuuiit  uf  tlie  very 
etfectuuj  way  m   wiiicli  die  rmiijjra^Rion  wn^  a]i^>LjeiL 

Od  the  duv  ufter  the  uperatioD,  there  wb>«  a  great  re-4ctioD  ^ 
and  t\ua  was  sa  violcot  on  the  fbliuwtng  flav.  that  it  was  fnund 
Jiecefiftary  la  take  Mood  from  ber,  whith  waa  done  wilh  re-lief. 
Tlie  wliole  htiinip,  however,  whortly  I»eeanie  nf  ii  fiery  red  color; 
and  a  Jiffuse  jiajufijl  swelling  appeared  in  the  n«:k,  abi>ve  the 
ciavicli;.  In  a  week  or  ten  diiya,  thia  sulwiiletK  but  one  innmiug 
it  WHS  ohserveil  that  ihe  breast  had  sujclenly  become  [lufled  up  ; 
and,  a  day  tir  two  afler,  a  great  quaatity  uf  pus  was  discharged 
through  an  im'Jsion  at  (liii^  point. 

After  ii  very  long  convaleaeenee,  flhe  went  home  nearly  welJ- 
During  the  whole  of  the  afler-lreutment,  tliere  was  do  hemoi^ 
rhagc  from  the  stump,  and  no  evidence  of  any  erectile  tissue 
reukainliigH 

The  arm  was  very  beautifully  injected  by  Dr.  II,  J-  Higelow, 
litid  n  wu-eful  disset^tion  niiide  hy  Dr,  R,  M,  Hodge«.  The  whk 
inje(^tii»n  waw  thiTiwn  into  the  vein.*,  and  rpturnpil  by  tlie  bracbii 
artery.  Tlie  veins  of  the  arm  and  hand  wem  greatly  dilated^ 
and  formed  a  beautiful  baaket-work  around  the  bone:  in  the 
piilin  of  tht'  hand,  they  couimimirak'd  frody  with  the  ai 
which  were  dilated  bo  a^  to  form  what  ojight  be  caljei]  h 
iinusea-  The  solid  part  of  the  roural  tumor  in  the  hand  audi 
fore-arm  was  fornietl  of  conden^^ed  and  infiltrateil  cellular  tiasue. 

The  specimen,  Togclber  with  the  east,  wna  prBsetiteil  by  me. 
in  the  Warren  Museum. 

I  savf  her  a  year  aHerwjird^,  quite  well,  and  wearing  an  nrti- 
ficifl]  nrm. 


Cash  CCLXVT.  ^  V^}iotts  Ereceih  Tumtir  of  Mouth, 
JAp^  and  Tovi^ne.  -^  A  yonnir  womaHj  19  year*  ohl»  entered 
the  Hospital,  on  the  fL.»urth  day  of  April,  1864,  for  a  con- 
genital Tenonfl  tumtir,  occupying  the  left  side  of  the  under  lip, 
which  hung  down  lite  a  hag  out  4if  the  mouth.  Thp  whole  of 
the  interior  of  the  left  cheek  wa.^  pervaded  hy  the  tumor,  an  alao 


VABCULAK    OH    EKECTILE    TUMOH* 


463 


half  of  die  left  ^ide  of  the  tongue.  Tberc  were  Iraces  «f  it  on 
the  velum  pnlati.  On  the  outaide  of  the  fsuyj,  a.  huiidle  of  vein* 
could  be  »ieeii  niTining  Troni  the  imgle  of  the  mcutlif  and  a  rouiid 
mBRs  [inssing  up  towjinls  the  ear»  nn  if  from  the  liiTimr  within. 
The  left  imder-jaw  waa  excjivated  hr  the  pressure  of  the  tumor. 
She  hud  been  Buffering  with  choking  tiims  m  the  night,  iippar* 
ently  from  the  obstruction  caused  by  the  enlnrged  tongue. 

I  deeided  to  attack  the  disense  by  the  ligiLliire  ;  and,  if  found 
neeessary^  tc  expose  it  by  an  incifiiou  uuide  through  llie  intpgu- 
ment  of  the  eheek,  from  the  ungle  ot'tlie  moutli. 

On  the  0th  of  Aprils  the  patient  being  etherized,  the  mafls  of 
the  tumor  of  tJie  cheek  and  lip  was  seized  with  hooke<l  foreepa, 
and  drawn  outwards  irom  the  moutli.  Two  needlei^,  Hrnied 
with  atout  jjgntures,  were  then  piiased  through  the  hase  of  the 
tumor,  at  right  angles;  ruwt  the  ligatures,  being  out  near  (he 
eye  of  the  needles,  were  tied  together,  so  nn  to  embrace  and 
strangulate  (he  whole  maw-  The  tongiie  was  then  seized  wilb 
forceps,  and  drnwn  out  of  the  mouth  :  a  curved  needle,  armed 
with  u  HtQUt  ligiLture,  was  passed  from  above  downwards  through. 
In  the  median  line,  just  behind  the  tumor,  and  relumed  from 
below  upwiinlj'.  half  an  inch  nearer  the  tip.  The  ligature  wa5 
divided,  and  the  ends  tied  ao  as  to  include  nnd  strangulate 
the  posterior  portion  of  the  tumor.  The  nnterior  portion  was 
thcu  strangulated  iu  a  flituUnr  mminer.  The  bleeding  was  very 
slight, 

'The  tongue  swelled  eo  na  to  fill  the  entire  moutli ;  and  the 
Buffering  was  great,  both  from  pain  and  the  obstruction  to 
breathing  aud  deglutition.  On  the  tenth  day,  the  slough  from 
lh(*  cheek  and  lip  separated  without  hemorrhage,  leaving  an 
idcerated  surface;  and,  on  the  eleventh  dny^  the  slough  from 
ihe  tongue  eaine  away,  with  the  exception  of  a  portion  included 
in  the  posterior  lig:Lture,  which  hung  by  a  small  pedicle. 
Thie  pedicle  was  surronnded  by  n  ligature,  and  the  day  after 
separated.  She  did  well,  nnd  was  discharged  on  the  6th  of 
May. 

On  the  17th  of  September,  ahe  returned  to  the  Hospital  for 
the  removal  of  the  remaining  jiortion  of  the  niDvua.  During 
the  Bummer,  her  health  had  greatly  improved. 


464  ABTERlEfi    AND    VEINS. 

She  waB  etberized,  and  the  tumor  seized  from  the  inside 
of  the  mouth,  with  hooked  forceps,  drawn  forward  aa  far  as 
poesibJe,  and  a  double  ligature  passed  through  its  base.  The 
euds  were  tied  both  wa^,  strangulating  a  lai^  portion.  She 
did  well,  the  slough  separating  on  the  tweliUi  day;  and,  on 
the  7th  of  October,  she  was  discharged,  apparently  entirely 
cured. 


CHAPTER   X. 


INJURIES  AND   DISEASES  OF  NERVES, 


IxJLiUES  of  the  nerves  belorg  more  ospeciaUy  to  militnry  aur- 
gery,  ami  have  llierefore,  uniil  very  laiely,  been  Ijtit  little 
atudletl  anioD^  us,  Tlic  Lnformatioti  given  in  the  common 
lianti-booke  is  ul?^o  quite  raea^,  ami  eminent  authorities  differ 
widely  upon  impurtnuD  poirite  bmli  of  prognoj^Ia  and  tfeatment. 

The  iminediate  effects  of  the  diviaion  or  injury  of  n  large 
myvvs  are  the  loss  of  *en«ation  and  of  riioiion,  and  a  dimitiished 
pijwer  uf  rcaUiiiig  changes  of  temperature,  which  would  ordina- 
rily cjiuae  no  inoonventence-  Severe  pain  ia  tiUo  a  very  com- 
mon symptom,  bnt  is  not  always  observed  until  the  lapse  of  a 
certain  time  after  tlie  receipt  of  the  injury.  The  Iobs  of  sen- 
BUtion  and  of  motion  iimy  be  either  temporary  or  permDuent^ 
M9  might  natLrnllv  be  QX}>cctcd ;  but  the  conneetion  between  the 
precipe  nature  of  the  injuiy  and  the  £ubsc?quent  phenomeim  has 
not  ot\eu  htjen  marked  out  with  bo  much  exnctneau  an  could  be 
deaired. 

The  proposal  of  the  plan  of  trenting  nervous  afTcctione  hy 
neurotomy  involves  the  whole  question  of  tlie  repair  of  injured 
and  dit'ided  ncrvea  ;  a  fliibjoct  not  very  fully  discuescd  in  n'orka 
on  surgery,  and  therefore  not  very  funkilinr  to  praclicaJ  eur- 
geone- 

Aa  regards  the  question  of  rc-union  of  the  two  endo  of  a 
divided  nerve^  there  ia  no  doubt  that  such  a  result  often  occurs. 
A  fiiiffitiont  proof  of  this  fuct  id  seen  in  the  rcetomtion  of  ner- 
vous ncijon  in  the  trifnciid  nerve,  even  after  the  removal  of  a 
portion  of  one  of  its  larger  branches  lor  facial  ncura]i:Jn ;  ftlfio 
in  the  occftj^ional  rcproduL-tiun  of  the  nerves  in  the  fuot  of  the 
horse,  when  divided  or  partiiUly  cxeuul,  to  cunctal  or  relieve 

6U 


4G6 


DiJUBIES   AND  DTSEAflES   OF  NESVKB. 


certain  forniB  of  Inmene&s,  TIjc  snine  fact  is  aIbo  pruvpc?  pLysji>- 
logiciJlj  by  ibe  exjieiimeiita  of  Onuksbank  anJ  Haigliton  tipoii 
tLe  vague  of  doga;  and  anatoiuiciLlly  by  Meyeri  Svroir,  TJed1^- 
mnnn,  and  tiHiera*  wlio  lave  acluslly  traced  tbe  new  Dcrvaus 
fiJuiuciita  iiL  the  cicatricial  titj.fiueT  uniting  tlje  rut  euds*  anil  frllin^ 
tbe  vtiid  cuuseil  by  tbe  excifiion  uf  a  portion  of  several  lines  (luid 
in  one^caric  nearly  an  incb)  in  lengtb.  Clinical  obfiervu lions 
bearing  upon  tbe  aaiiic  piuiit  are  recurded  by  various  nutliorj^. 
Mr,  Synte,  in  lu«  "  Treatise  on  tlie  EidNion  of  Diseaw^d  Juinu  " 
(Caae  VITI,,  p^^ge  S8),  givea  n  renmrkable  caee,  in  wbirh  llie 
ulnar  nerve  wu-h  wbnlly  divided  at  tbe  elbow,  in  (be  oj^rmtiun 
of  excision  of  that  joint,  luitl  in  vvliirb  die  funotiuns  of  llie  iirrve 
were  jierfectly  restored  in  tbe  course  of  a  few  weeks.  A  sul> 
sequent  disseelii^n  of  llie  arm.  less  ibna  a  y(*!ir  afVcr  ibe  O2>ora- 
tion,  rnvealed  tbe  fact  thnt  perfect  iniion  of  die  cut  emls  of  the 
nerve  bad  [aken  place,  and  dial  the  nervous  filaments  oouhl  be 
traced  from  Ijotli  enih  into  tbe  intermeilinte  new  tissue,  nnd 
anpnrently  also  from  one  end  to  tbe  otber.  Ir  a  simihir  raae, 
reported  by  M.  Rons,  a  pialion  of  the  ulnar  nerve  was  actually 
cut  pway  :  but,  in  the  courae  of  a  year,  sensation  had  entirely 
reuimeii  ;  and  when  the  pHfiput  was  e?camined,  fourteen  years 
aftet'  the  openition,  ibe  sensiitioa  wns  na  perfect  ns  iu  the  other 
arm-  Mr.  Paget  alao,  in  bis  Tabiable  "Lecturea  on  Surgical 
Pathology/  given  cases  of  tbe  return  of  the  function*  of  tJie 
nerves  after  ibcir  division. 

Tn  view  of  these  facts,  it  is  important  to  in(|uire  into  the  pro- 
priety of  dividing  tbe  nerve  as  a  remedy  for  triimuiitic  neuralgia. 
In  answer  to  this  question,  it  may  he  stated,  that,  if  tbe  nerve  is 
simply  divided,  sensation  will  probably  return  before  the  tissues 
implicated  in  the  original  injury  have  hn<l  time  to  recover  their 
normal  condition  ;  and  thni  therefore  the  operation  will  afford 
only  very  transient  relief,  and  may  liave  to  be  repeated  several 
times.  If,  on  the  other  hand,  a  portion  of  the  nerve  is  eicisod, 
the  restoration  of  the  nen'ous  function  will  be  very  much  longer 
in  taking  place  ;  but  there  will  also  be  great  danger  that  tbe 
repair  will  be  incomplete,  or  even  that  it  mny  fiul  nltogether, 
and  thus  entail  permanent  loss  both  of  sensation  nnd  of  moiion. 
The  deliberate  removal  of  a  long  section  of  the  nerve,  with  a 


nrjURiEs  xyn  diseasrs  of  nerves. 


467 


Tiew  to  tho  permanent  nboliiion  of  ir&  runciionr^,  can  he  but  very 
rarely  tnUtcot^,  and  then  only  its  a  kfit  resort,  as  ihe  ^oa- 
BJble  alternative  of  nrnputntion. 

The  rrLtionnl  treatmenc  of  diese  neurnl^"^  iiflVcrions  seems  to 
Tnc  to  be  based  on  tbe  Tiict}  tbat  tbcir  natuml  teDtleucy  ia  to 
recovery^  if  only  we  gqd  keep  the  pruient  coniforciible,  and  thur^ 
itHluce  him  to  wait  for  this  tardy  relief.  Tbid  can  only  be 
effected  by  division  of  the  nerve,  or  by  the  use,  either  local  or 
genial,  of  uarcoticj^.  The  protrftcted  use  of  opium  Internally, 
in  sutficieut  quantity  to  relieve  the  pair,  will  almost  inevjtnbly 
exert  a  most  pernicious  infliiGnce  on  the  health,  while  mere  local 
applications  to  tlie  skin  seem  to  have  very  little  effect.  The 
great  benefit  which  has  been  deriveil  from  the  uae  of  hypodermic 
injections  of  morphia  for  ordinary  neuralgia  naturally  eugge«te<l 
the  propriety  of  trying  them  in  thia  affection  ;  and  ti»e  succesa 
which  has  attended  the  experiment  bos  beep  moat  gratifying. 

The  following  cofiea  of  severe  traumatic  neuralgia,  which  have 
occurred  in  my  practice^  serve  to  throw  light  upon  eertuin 
points  in  the  pHthoJogy  and  treatment  of  tht9  painful  attection. 
In  all  th&9e  eases^  the  injury  eeenta  to  have  been  to  the  tissues 
Burrntinding  a  nervous  trunk,  rather  than  to  the  nerve  itaelf; 
and  the  immediate  ceiusg  of  the  painful  affection  wliich  followeil 
would  seem  to  depend  upon  the  effusion  of  infl[unm*tory  pro- 
duets  within  the  dense  fibrous  nourilemma,  thus  enlanglin;*  the 
nerve  in  a  mass  of  cicatricial  tissue,  perhaps  also  compressing 
its  Rbres.  The  highly  favorable  result,  in  die  firet  ciiae,  may  be 
readily  explained  by  the  well-known  law  of  development  of  new 
reparative  material,  by  which  it  becomes  gradually  assimilated 
to  the  |iro|>er  ti&sue  of  the  part  in  whioh  it  is  deposited.  The 
disflcction  made  in  the  course  of  the  operation  showed  that  the 
nerve  ivoa  then  firmly  glued  to  the  Hirrounding  tissuee  ;  and  it« 
release  from  theae  conneetions  was  followed  by  pertect  relief  of 
the  pain,  which,  however,  returned  in  a  diminiahed  degree,  an 
soon  iLs  the  process  of  cicatrization  had  again  commenced.  The 
pain  was  then  controlled  during  eix  mantha  by  the  daily  use  of 
hypodermic  injections  of  morphia  ;  and,  at  the  end  of  this  some- 
what protracted  treatment,  the  neuralgii^  atlection  was  found  to 
have  disappeared,  and  the  nerve  hod  «o  far  recovered  its  normal 


468  WJTTKrEfl   AND   DlftZASES  OF   SEKVES- 

(iiann'-rH  The  rtec<i[iil  aiul  ifiinl  ca»en  iii-e  e^uall^v  ini|)(jrintit,  oa 
ehomng  tlie  powerful  eflect  uf  iIib  narcotic  [ojection  ^  In  the  owe 
Cube  ill  relieving  llie  pnm,  ailiI  in  iLc  other  acCually  curing  it. 

CAftlc  CCJjXVU.  — Severe  Neuralgic  AJecf*07).  Xoltmri»rf 

n  OutiK/ifit  Itfjiiiy  ofthit  Median  Nertit.     SiihciiCatieotiJt  Tnjrc 
tion  o/  Morphia.      Operaltfni.      Injection  <:ofltiinied  Jhr  nine 
tnoiiihg.      Ret-ovtry,  —  In  the  bccoih)  Imttle  of  Hull  Riiiir  Lieu- 
lenant  A.  was  struck  liy  u  ball,  on  llie  ouMule  of  llie  niiJ^lle  i>f  the 
nnn>      Tlic:  IruH  pusaed  obliijiicly  ihrough,  traveri^ing  the  bic^iiji 
mu^rle,  B.ntl  *nm\\iv^  out  on  lIji:  in^^ide  of  Llit.'  zirio.      Fur  twu  i>r 
ihrc?  cinye,  he  wils  exposed  to  ttie  weather,  lying  under  Uie  |iifizza 
cif  »  huune.  having;  Irut  iitile  fuofl,  nod  ^^I[b  M^  hnml  constaintly 
wet  with  the  rain  wlu:',[i  was  falling-      Tlie  Wid  wna  benumlieJ  ; 
but  he  floflf^red  stime^vhat  w\i\\  a  sen^iition  of  bent  in  iC,  whicli 
was  |>artially  relieved  by  kecpng  it  espo^ed  to  the  wet*      Tliere 
wiw  no  jMiiii  in  the  woinid  ilJ^tlf.      Shortly  after,  be  was  reniwvc-d 
to  Washingttin.  where  be  first  ex|)enencH[   very  rte\ere   pain   in 
the  whole  hrmd,  Imt  more  piirtit-uWIy  in  the  jiart  of  it  au|>[j]ieJ 
by  the  medimi  nerve.     I  wiw  him  ubnut  a  fai-tnight  aAer  the 
reeeifit  of  ibe  injury.      lie  was  then  in  (^instaot  and  severe   piun 
in  the  bund  ;  mi  niueb  eo,  as  to  require  to  be  kept  more  or  lese 
under  the   Jiirtuent*   of  morphia,  which  be  waa   tJ^klu^r   to    the 
nnioiint  of  a  grain  a  day.      On  exainhiing  the  pomi  at  which  the 
wound  waJH  received,  a  pockereil  ej*diar  wa8  ^^een,  with  an   indu- 
rntiun  extending  deeply  into  the  lielly  of  the  bieep8   mnatdeT  ti> 
wbi[^b   the   skin   waa  ndiierent.     The  situntiou   occupied  by  the 
vesaelH  and  nerven,  on   the  inside  of  llie  bicvp^,  was  also  tnvel- 
oped  In  a  lua^  of  indurated  ti^triuc.      The  ftr^t  idea  suggeet^  hj 
this  slate  of  things  was  to  cut  down  upon  the  nerve,  and  divide 
it.      It  seemed,  however,  possible,  by  the  gradual  ehunge  g^^tng 
on  in  the  tiBsues*  that  a  healthy  action   might  uUtmately  be   set 
up ;  and,  at  tlie  snnie  time,  the  indurated  tissue  auiTtmuding  and 
compreH^ing   the  nerve  might  }>t  abacjrbed,  finally  relieviug  tbc 
nerve  fnun  preeaure.      The  jpiestlon  wilh,  wbefher  ihe  suffering* 
\j{  the  patient  could  tx!  fiuffit'ienlly  niitispilefl,  by  artifieijd  means, 
Co  allow  of  the  adoiiliiiiL  of  a  tenipori/ini^  couree.      lie  Avaa  ad* 


) 


n?AUMATlC  NEURALGIA. 


469 


vised  to  plitcc  the  limh  perfectly  at  rest,  wear  it  in^iUc  hU  clothoe, 
next  tliu  Wlv^  iiud  ii>  havo  ti  sleeve  mado  of  eljcet  Jndiu-rubber 
to  cnvdop  the  luwor  jin-rt  of  the  arm,  whk-li  coverin";  was  to  he 
removeJ  from  time  to  lime,  the  nrm  exposed  to  the  air,  anJ 
washed  with  &onp  and  water :  he  was  directed  to  Jiscontinuc  tlie 
use  ut'  tiio  rubber  elccve  if  much  irritation  waa  set  up  in  llie  ekin, 
and  to  envelop  the  arm  in  Dannd  inatend,  which  he  hnd  pre^ 
vioii^Iy  ftmnd  ncce88ary,  owin^  to  the  gr^'M  reduction  oftemponi- 
tiire»  He  went  home,  and  tidlowed  tiiis  plan  for  throe  ar  four 
wcekfl-  At  the  end  of  tfiat  j>criod,  he  come  to  me  t^nin,  with 
the  deBJre  of  liavln^  the  nerve  divided;  as  hic^  BuEfcrings  hjtd 
become  so  intolernblef  in  spite  of  tlic  u«e  of  opiates,  ne  entirety 
to  deprive  him  of  rest,  liefore  ro&ortin^  to  an  o|>cnitioii  cm  the 
nerve,  I  determined  to  tr^'  the  etfeet  of  eubcutanetma  injcctione 
of  morphia.  Platf  a  fjfrain  cf  sulphate  of  morphia,  in  bolutii^tii 
wa*  injceicd  deep  under  the  skin  of  the  tbre-nrm  twice  a  day. 
He  wae  at  once  placed  in  n  etnte  of  oompnrnlive  case;  and  the 
evening-  injection  ^five  him  a  good  ni^ht'e  rest,  duch  as  he  hail 
not  eajoyed  for  many  wecka.  Thi-s  phin  wne  followed  up  for  u 
month,  with  equally  ^od  effects  !  hia  digeelioii  was  not  in  the 
least  aflreete<l  by  the  iit^e  of  the  morphia,  and  he  gained  consid- 
erably in  tlc^h.  If,  however,  the  doj?e  was  omitted,  the  fHim 
became  as  severe  as  ever>  It  was  therefore  decided  to  perform  an 
operation.  An  incision  of  throe  inches  in  length  was  made  over 
the  inner  cdj;e  of  the  biceps,  and  the  integument  dissected  on 
both  fidea  separating:  the  oicalricee,  eaueod  by  the  entnince  and 
exit  of  the  ball  from  tlie  eubjuccnt  tiaaues*  The  indurated  ma^fl 
which  surroimded  the  vessels  and  nervoa  was  now  cut  into  :  an<] 
the  mLHjian  nerve  hdii*;  diwcovcred,  where  it  entered,  wna  gradn- 
njly  laid  bare  and  dirteeeted  out,  bo  that  it  lay  perfectly  ]o<^ee  in 
the  wound  fiir  an  incli  and  a  half  or  two  inchea  of  its  length. 
It  was  thought  be^t  not  to  divide  the  nerve,  but  to  await  tfic 
result  of  i\\a  healing  of  tlie  woimd.  Tlie  edgea  of  the  wound 
voro  loosely  approximated,  and  water-drci^sin^'*  applied*  For 
some  days  the  pnin  wa^  entirely  relieved,  allhoui^'h,  from  the 
effect  of  the  habiliLal  iLr^c  of  morphia,  a  qmall  dose  wi]^  rccjuireii 
to  promote  aleep.  As  the  wound  be^r^tn  to  heal,  however,  the 
pain  recurred,  but  with  much  less  severity  than  before*    DcHiring 


470 


INJURIEa   A>'ri    DISEASES  OF  NXItVCS. 


aovi  tn  return  licjine,  OEC  of  h\s  fnmilj'  waa  iii^trui'led  in  the  u^ 
of  ilie  pul>culjiufc.ma   ijijection  of  moqiliia,      Abutit  two  raontlu 
Bfterw&rds   hi;  called  on  mc,  nnJ  agnin  (March  20,  lJf03)  four 
lDD[il}i»  after  the  operation.      He  wns  tbcn  in  a  state   of  |>erfect 
bc^lUi,   nnil    htiil    r;jiiu(?d   uiiicli    Qeeh,    but   eoinplainra:!    9<lil]    uf 
reuralgic  jiaiD  in  the  hunilt  requiring  tlte  emfjluyiucDt  nf  the  nar- 
cntic  inj(!L-tio]t ;  wtjether  Tr^m  habit  or  not  ^^itnied  lt>  be  u  ijtiea- 
tiuu.     Tbe  ami,  lianU,  unci  fingcra  haU  heguu  lo   iLcquire   :?K>me 
motioii.      In  regard  Li>  tlic  Iticnl  ufTtit  uf  lLc  injecliunB,  It  iitnv  he 
Ba'iilt  tliat.  altlmu^^h  Uiey  Lad  Ijcen   uped   twice  a   day    for   6ve 
muntlifi,  hv  hiid  never  euffi^red  from   any  irrEuilou  at  tlie   |ioiDt 
of  ^unoUire,  except  in  one  inshinrc  ;  in  ibc  en*e  of  a  IVeshlv  pre- 
pared Aolulion  of  sulpbate  of  mor|]hia,  tlic  uac  of  which  yva»  ful- 
Idwed  by  tiie  production  of  n  lari^e  red  blotch,  wlienever  it  was 
injected.      On  eLiballtLiting  a  Boliitiun  of  Eicetute  of  morpliiut  no 
farther  trouble  uf  thia   nature  wru   experienced.      This   atx-'idenC 
IB  probably  to  be  explained  by  the  common  practice   of  ndding 
frpR  nulpfmric  acid  lo  promote  the  fiolubililT  of  certain  specitncn^ 
of  sulphate  of  morphia-      The  acetnle  le»  very  soluble  iii  water. 
Tbe  [latif  lit  had  lind  nearly  three  hundred  injections  of  morphia  ; 
and,  with  the  above  exeeplion,  no  traced  rciuiiiQed  of  itn  pro- 
tracted  n^ei 

Oct.  2f>,  ld6<S.  —  I  J4nvr  this  patient,  and  found  that  he  had 
recovered  hia  licaltli*  and  enjoyed  complete  immunity  from  prtin. 
The  hypodermic  injectjons  were  continued  until  the  nionlh  of 
July,  or  about  nine  months  from  tbe  receipt  of  the  injury.  He 
then,  by  a  gi'eat  elTort,  enddenly  dltHJoutiuucd  tbeiu,  anil  hml 
not  used  iheni  sincc^  The  neurul'iic  uflcclion.  except  during 
extreme  changes  of  tbe  weather,  had  left  him*  The  fore-arm 
liad  recovered  its  natural  fieneibiiity :  he  bad  tJje  power  of  coiu- 
jilcte  flrsion  of  the  elbow,  acid  of  partial  rutation  of  tbe  fore-anu  ; 
while  the  fingers,  which  were  formerly  held  in  a  state  of  exten- 
sion, could  be  approximated  to  tlje  thumb,  so  aa  to  make  the 
hand  useful  for  moat  of  ibc  ordinary  puqtoeea  of  life.  Tiiia 
motion  waa  continually  improving. 

Case  CCLXVllL  — Qunskot  Woaml  (yf  thnThirfh^impH- 
caliny  tks  Sciatic  jVcryc.  —  In  April,   IS^J-l,  I  had  uiider  my 


A 


TKAU5IATIC    NE0IULGIA. 


471 


cure,  in  the  Hospital,  a  soldier,  wbo,  two  m'tntlis  before,  wii9 
shot  in  tlie  tlii^'h,  anil  t:tkon  prisoDer,  The  hall  traversed  the 
thigh  from  side  to  «ide,  anJ  prubably  injured  tJie  eciatlc  nerve,  in 
the  immethftte  neighborhood  of  which  it  must  have  jjassed.  He 
suffered  no  inconvenience  in  the  site  of  the  wound  ;  but,  shortly 
r»fter;vard,  tt  severe  neumltfic  [rain  ooratncnced  in  the  sole  of  tlie 
footf  flcconiiia.nied  by  a  sensation  of  heat  and  grent  toniiernefl«  of 
the  part^antl  entirely  inoapuoitnTing  hini  for  li>cohiotion.  0]>i!itos, 
in  tie  usual  form,  gave  hiiu  but  little  relief;  and  the  only  iiJleviii- 
tion  of  bis  stilferip^s^  while  in  prison  at  Hichmond,  was  obt'iined 
by  keeping  the  ]cg  constantly  plunged  in  u  pail  of  told  water, 

I  ordered  the  aubcuiant^oUA  iiijectiou  of  a  quarter  of  a  grain 
of  morphia  daily  into  the  leg,  and  g^-jidually  intreaaed  the  dose 
to  a  ;^raiu  a  day.  By  thii  treatment,  the  poin  was  completely 
held  in  (ihcok,  renderin;^  his  davs  and  nibble  ccimfortable.  Tlie 
full  etfccc  of  each  do&e  waH  obtajued  in  from  five  to  ten  nnnute^ 
ftfter  injecting  it.  The  patient  left  the  Hospital  very  much 
relieved;  and  I  lost  siglit  of  him  afterward. 

In  tho  cifur^o  of  this  case,  I  exf^eriniented  as  to  the  eflect  of 
the  injection,  when  made  at  a  distant  part  of  the  body,  as  com- 
pared with  its  effeci  when  applied  in  the  inimediafe  vicinity  of 
the  affcctod  nerve.  I  found  that,  when  the  injci^lion  was  inaile 
in  the  opposite  limh  to  thnt  affected,  the  relief  was  ae  prompt 
and  as  complete  oh  when  made  directly  over  the  courae  of  the 
nerve ;  and  this  occurred  repeatedly,  in  every  inslanee  in  which 
it  wae  tried.  This  ia  a  point  of  very  considerable  importance, 
imwmuch  as  it  ia  otYen  very  ineottvenient  to  lunke  the  lujection 
in  the  exact  situation  of  the  alleeted  nerve,  n»  has  beeti  utrongly 
inaisied  on  by  aeveral  writers  ujwpn  tbid  suhjecC. 

Case  CCLXIX.  —  Ltjurif  gJ  the  Uhiftr  and  Mttucnh- 
Spirai  A'erpes,  from  a  BitlleC.  —  Captain  C,  who  liod  already 
been  twice  wouaded  in  the  thigh  and  leg,  in  the  battles  of  AV^in- 
cheater  and  Frodcricksburg,  was  struck  at  the  battle  of  Getlys- 
burp;  by  a  ball,  juaI  over  the  median  nerve  of  the  arm.  Ic 
pasecd  in  a  spiral  direction  around  the  bone,  and  came  out  half- 
Wity  down  the  limb  below  on  the  other  aide.  The  hand  and 
fore-arm  were  at  once  partially  paralyzed ;  and,  in  a  day  oi'  two, 


47« 


ISJUJUES  ANB   DISEASES  OP  NERVES. 


very  severe  neuralgic  puina  comnienceJ,  prinoipailj  in   that  part 
of  tliG  hand  fiupplk'd   by  the  ulnar   nerve.      When   I   first  saw 
hifii,  ahout  a  weok  nher  tho  injury,  iho  nrm  was  much  swollen ; 
and  the  wounds,  whioh  hud  »tiJI  on   theni   the  colit  water-i]iY!«»- 
ing,  were  lu  an   irritable  etate,  and  there  was  no  appearanco  of 
HUppiiratioD.      The  Wiiter-dreasinga  were  replaced    by  r   }eag9 
warm  poiiltioe :  Jind,   on  a  free   suppuration  beinp   eat^Lblit^hrd, 
ihe  extreme  [yaUx  in  ihe  ann  and  Ixand  wua  much  relievtil.      The 
pam,  however,  atUl  t^ontinued  to  ret-itr  at  mterrals,  fttid  the  par- 
oxysms oomiuLT  on  at  night  were  very  severe,     Finallv,  the  hv- 
podennio  injocilon  of  murphi»  wm  tried,  and  a  einjjle  doee  uf 
one-half  grain  afforded  entire  relief  fur  ihe   time  lein^  ;    und, 
iti  faet,  destroyed  the  habit  so  that  the  paroxyaiu*  did  not  recur. 
The  hand  and  artu,   however,  for  a  long  time  aftcrwjtrds,  wore 
very   unt^omfortable,   on   ncoounc   of  tho   excessive  boat   uf  tlio 
pnrtd,  which  was  only  relieved  by  the  oonstant  use  of  cold  water; 
ftiid  it  was  not  iinfil  nher  several  months  thiit  the  normal   scnei- 
bility  began  to  return,  and  this  symptom  to  disappeiir.      Seen 
Again  at  the  end  of  live  muntlis,  he  was  (Vec  from  neuralgic  pain, 
hud  some  use  of  his  band,  and  tlie  elbow  had  become  flexible 
after  eniphiyjng  foreible  ejtenajon  to  overe^jme  the  etitlbess  pro- 
duced partly  by  inaotion,  and  partly  by  tlie  contraotioii   of  the 
injureJ  muscles.     The  movement  of  rotation  of  the  forc-ann 
had   not   hL-ou  tf^eovered,   although  it  could   he  easilv  luudo  hy 
a  second  pcr^ou,   Uie  nervous  power  being  titiU  dtficieut. 

Tlie  three  cases  which  follow  are  instancea  of  excessive  neu- 
ralgia affecting  tbe  inferior  dental  nerve,  in  whbih  all  known 
medical  means  had  been  resorted  to  without  avail,  and  where 
life  had  become  insupportable.  An  entire  reli<?f  w:i*  the  result 
in  two  of  the  caiies,  and  a  partial  relief  in  tlie  other,  by  trephin- 
ing the  inferior  m3-\illary  boue  near  its  angle,  exposing  and 
exeiaing  a  portion  of  the  nerve  as  it  lay  with  its  veaseU  in  the 
bony  canal. 


Cabe  CCLXX. — Facial Xeuraigia,    TvephminfftkeLow- 

et'JatPjfinJ  I^emoV'if  of  u  portion  oft/ieIiifei-wrD&r>lul^f>rvf, 
Partial  litlief.  —  In  October,  185&,  a  young  man,  23  yoore 


FACIAL  NEDltALOlA. 


473 


^ 


of  age,  entered  llie  Hospital  on  account  of  facial  neural^ria,  of 
two  or  three  years'  Juration,  in  the  rij»]it  side  of  his  fac^.  When 
the  pain  £r&t  appeared,  it  waa  attributed  to  carious  teeth,  which 
were  removed,  but  without  relief.  The  pain  was  very  severe 
iind  jiaraxyemEil,  occurriug  after  ajiciikirig  or  eating.  Brisk 
friction  gnve  lempnrafy  relief.  He  wna  trauted  hy  tonics  and 
narcotjca  iuternaUyt  and  hy  hypodermic  Injections  of  morpliia. 
The  eitract  of  conium,  in  dotsee  of  five  grains,  seemed  to  give 
motft  relief.      On  Nov.  12lh  he  was  diflclmrged,  relieved. 

The  relief,  however,  was  only  temporary.  He  entered  tlie 
Hospital  a^n,  Aug.  ^0,  1801,  Meansvlillc  he  had  been  oper-^ 
atcd  upon,  and  two  ner^'cs  divided  In  the  U[)per  jaw. 

His  jaw  was  now  trephined  hy  one  of  the  surgenna  of  the 
Hofipital,  who  removed  a  portion  of  the  bone  half  an  mc}i  m 
diameter,  with  tlie  contained  portion  of  the  inferior  dental  oerve. 
He  had  entire  relief  for  tliree  or  four  moulliH,  at  the  end  of 
which  time  he  expeneneed  occasionally  attacka  of  pain  s  their 
severity  and  frwjuency  inere^n^d ;  and  on  the  22d  of  April, 
l^Co,  he  agiun  entered  tJie  Hoepitul,  and  came  under  my  care« 
Quinine  and  Fowlers  Solution  intci^ally,  and  aubcLitaneous  in- 
jections of  morphia,  were  tried  without  effect;  the  pam  rather 
Inereasmg.  He  insisted  on  another  operation,  wliioh  was  done 
on  the  2-id  of  May  ;  being,  of  course,  under  ether.  An  incision 
ODU  and  a  half  inches  long  was  made  [larallel  to  the  body  of  tlie 
jaw  iiejir  ita  lower  border,  and  anotlier  one  joiiii[ig  this  niatle 
along  the  edge  of  tlie  ramiL'*.  The  flap  wa:*  dij*flerte[]  up,  e^ipos- 
Ing  the  hune.  A  portion  of  the  ramus  near  its  junelion  with 
the  body  of  the  jaw  was  denuded  of  its  [jeriosteuni.  A  piece  of 
bone  half  an  inch  In  diameter  waa  now  removed  by  a  trephine 
juet  below  ibe  inferior  dental  foramen.  Great  care  wa*  necea- 
Bftry  while  trephining,  in  order  not  to  fracture  the  jaw.  9f>  much 
of  Its  0ub«tance  having  been  excised  at  the  previous  operation- 
Aller  removing  tlie  bone  and  cxjitjsing  tlic  nerve,  half  an  inch 
of  it  was  taken  away.  Temporary  relief  followed  tbcojieralion. 
Tlie  diflca>e,  ho^^eve^,  afterwards  recurred,  but  in  a  millgated 
forni  ;   und  his   subsequent  liistory  is  not  knuwn. 

It  is  important,  where  the  bone  Is  excised  oo  the  ramus  of 
the  jaw,  not  to  go  above  the  interna]  aperture,  where  the  dental 

60 


474 


DnJURIES  and  diseases  of  >'ERyES. 


lb. 


ntii 


tlic  whole  eub^f-nm 


nerve  penetrates  (tie  jnw.  utJienvise 
ihe  UfiKi  will  be  removed  ;  aiiJ  tht*  guoCiitory  nerve,  a*  it  pa*«e 
elnng  the  Inner  side  of  tlie  nonius  of  the  jaw*  may  be  miAt&keii 
for  the  Jnfcrior  dental  nerve. 

Case  CtXXXl.  —  Neuralgia.  liclief  btj  Trephining  the 
l^oiocr  Jaw-bone  Jttr  the  Jicjnovtil  of  u^  portion  of  (he  Tiifcriar 
J)cntat  JVe^^'f. —  lu  July,  18-17,  Dr,  J.  C.  Worren  removed 
a  i>iHtion  of  llip  inferii)r  dentsil  nerve  by  tre|ihining  the  hotly 
t>f  tbc  j»w  in  iL  ]in\y  ^("tj-nine  years  old,  and  thus  afPanled  her 
relief  frtim  on  exrni minting  neumlgia  of  iJiree  vents'  standing. 
She  Liid  D(j  recurreQcc  o£  tlie  pain  until  a  year  after  ;  and  then 
the  suffering  returned,  and  became  so  eevere  as  to  confine  her 
to  the  Ik?i1.  She  waw  unable  to  eut  ur  ppeak  witlwut  eiiuamg  a 
puroiysm  of  pain.  The  pain  CLJtumenced  lit  the  louver  jaw^ 
always  iit  the  same  e^Kit,  and  thence  exteuded  over  tlie  wbolc 
side  of  the  fai^G. 

A  year  und  a  half  after  the  opf-nilion,  hi^r  son,  a  laedicn]  n»ui, 
applied  to  me,  saying  ihiit  sometliin^^  must  be  altcm^jted  for  h^r 
relief.  T  suggesteil  an  opemiion  Jiir  tn-pbining  tlie  jaw  raitluT 
hnek  than  hml  been  done  befoT-e,  and  rennjvin^^  a  portion  of  ihc 
nerve  neur  where  it  enters  the  inferior  denlnl  i'oramen.  This 
waa  rendily  aji;re£^  to- 

An  mdj^imi  being  made  from  the  sigmoid  notch  down  to  the 
edge  of  the  jaw,  the  parotid  gland  wna  raified  and  tuniod  back- 
The  lower  portion  of  the  ma&aeter  muscle  was  now  dis{*ected  upa 
and  a  ^eetiun  of  bone  removed  by  ineimh  of  (hf  trephine  iuid 
chisel.  Half  iin  itieh  of  the  i^aw  fidly  expitfipd  nerve  was  ei- 
ciaed.     The  inferior  dentij  aviery  wa»  nnavuidably  rui  and  tied. 

For  Gve  or  hix  days  snbsequenlly,  there  was  a  slight  diachnrge 
of  Baliva  from  the  wound,  owing  to  the  interrerence  with  the 
parotid  ;  but  it  healed  favorably,  and  llic  operaiiun  wa*  aliended 
with  die  most  t^omplcte  relief.  I  heard  from  the  patient  a  yenr 
nfterwiirda,  and  there  bad  then  been  no  recurrence  of  tlie  neu- 
nd'Tia. 


I 


Case  CCLXXrr  —  Facial  Neuralgm.     Trephining  the 
Jjototr  JJiw,  and  lif/novti!  of  a  jmHwii  of  the  InftTior  DenU 


NEURAiaiA, 


475 


_^pri*e- —  1858-  A  Indy,  nged  40,  hnd  auffbrc(l  for  eight  ycnra 
fr*jin  ncuml^if  nttaoktj  in  the  ciglit  aide  of  tlie  l^wcr  }txw.  At 
timoa,  the  poin  was  oxoruciutiiifr.  During  this  poi-iud»  every  kind 
of  trcatmcDt  tlmt  tho  bcst-dit^cctcU  ekill  and  jiiJgnient  couEil 
dictfllo  was  employed,  but  svilhout  nv:iil.  All  the  teeth  in  both 
jaws  hud  been  extracted,  but  with  only  temporary  roiief,  J  was 
called  in  consaltation  in  1954,  and  then  advised  nn  operation; 
but  she  declined  to  undergo  it.  The  pain  extended  IVoiji  tlio 
jaw  to  the  upper  pnrt  of  the  face  ;  and  her  suftcringa  becnnic  so 
great  as  to  contioc  her  to  her  room,  and  reduce  her  Atrcngth, 
Por  the  greater  pm't  of  tlie  eix  months  before  the  oj>eration, 
fihe  WLie  kept  under  tlic  iufluenee  of  inorphi.i.  The  eljghtest 
motion  ncuT  her,  i>r  an  unexpected  draught  of  air,  were  tfuffi' 
cicnt  to  exeitc  an  atlack.  Under  these  eireuinJ^ljLiiccs,  liuding 
thill  all  the  means  tried  hnd  fuiletl  to  relieve  lier,  she  eoueented 
to  ail  operntion. 

Under  ether,  the  jaw  was  exposed  at  the  edge  of  the  modseter 
muscle  ;  nnd,  tlic  Utter  bemg  raised*  the  trephine  wns  applied, 
and  a  cirele  of  bone  about  half  an  inch  in  diameter  removed. 
This  opened  the  inferior  denial  eanaJ.  The  nerve  was  now  lifted 
on  a  probe,  and  as  large  a  portion  of  it  us  tlic  aperture  would 
adroit  of  excised.  It  wtia  ngain  divided  where  it  idaucs  from 
the  mentid  foi^nien.  The  cnhirged  And  irregular  olreoEar  pro- 
ccoacs  were  next  cut  away  witli  the  bone  forcepa. 

She  recovered  rapidly  from  the  operation;  and,  for  a  year ^ 
enjoyed  entire  immunity  from  the  neuralgic  attacks-  From 
that  time  to  1867,  a  period  of  more  tlian  eight  yenrfl,  there  were 
ueeasional  paroxy^^me  of  fuciul  neuralgia,  widj  coni^tdemble  gen- 
eral nervous  dij^turb^incc ;  but  she  luul  not  been  eoniined  to  her 
room  except  during  theao  attacks.  During  the  intervals,  aho  had 
been  in  fair  hedth, 


Case  CCLXX1II-— iVeMm/jicc,  Exciiiion  of  the  Digital 
Xftrvfi  of  thu  Forefinger^  —  A  lady,  35  yeai-s  of  age,  in  1843, 
woe  seized,  v^hile  pregnant*  with  a  severe  pain  in  the  tip  uf  the 
forefinger  of  the  right  hiiud*  The  only  Ciiuac  to  which  she  could 
attribute  it  was  the  too  free  use  of  the  needle.  The  pain  Itad 
gradually  Incrcaaed,  affecting  the  arm  and  shoulder,  and  finally 


476 


IKJUBICe   AND  DISEASES   OF  KKBTfEfi, 


Other  parte  of  the  body  on  the  enme  &i<ie.  Every  remedy 
which  the  experience  of  dietioguisheU  Burgeons  in  the  vicmity 
coidii  euggcat  Imd  been  iaeffcetuolly  tried.  Aside  from  the 
above  diaense,  bcr  health  vftm  ^'ood,  aud  she  was  in  ^0€>d  eoc- 
dition.  The  Qppcnrauce  of  die  finger  was  B^jmewhiLt  red,  nnd  the 
motioD«  impaired.  The  elifrhtest  examiDfltion  caused  exceeeive 
aufierin^.  Although  iiirorriKHl  tliat  the  tu^eees  of  an  operation 
was  doubtful,  she  consented  to  As  peribrmance,  and  it  waa 
done  in  the  fallowing  manner :  — 

After  she  wns  ethemedT  an  inciaion  was  made  a  little  iti 
front  of  the  Inner  aapect  of  the  firtit  phalanx  of  the  finger,  tJie 
digital  nerve  exposed,  iLnd  about  half  an  inch  of  it  cxci^tHl. 
The  same  operation  was  repeated  on  the  other  side.  The  end 
of  the  6nj2;er  became  at  once  benumbed,  and  the  pain  <;c4i3ed. 
She  returned  lioroe  five  days  after,  free  from  paiu  ;  aaj,  iwo 
mootha  later,  I  heard  that  she  was  perfectly  well. 

The  operation,  so  far  as  T  have  since  learned,  was  succe**Ful ; 
but  it  must  be  confessed,  that,  in  operations  of  this  kind,  the 
relief  is  very  apt  to  be  but  temporary.  Howerer.,  a  initigiition 
of  suffering,  even  for  a  time,  renders  it  worth  while  to  portbrm 
it;  and  1  am  not  aware  that  any  permanent  ill  effeote  ari^e 
from  it. 


Case  CCLXXTV. — IuJut*!/  of  a  Nerve  from  Puncture  \cith 

C  N^ecdie.  Tretttment  leithoiii  tjtt  Operation.  Cure,  — A  ladv, 
35  years  of  age,  of  delicate  organization,  was  sent  to  mo,  for  a 
stiflbcea  and  loss  of  use  of  the  thumb  of  the  left  hand,  owing  to 
an  injury  from  the  priek  of  a  needle,  received  about  a  roontb 
before.  The  injury  was  not  attended  with  much  pain  at  the 
time,  but  an  irritation  shortly  commenced  in  it,  which  extended 
up  the  arm  to  the  shoulder;  and,  ^vithout  much  apparent  in^ 
flammation  of  the  lymphatics,  a  Ewellin^  took  place  near  the 
axilla^  wliich  suppurated.  The  whole  hand  bocnuie  more  or  lesa 
etiiT  and  useless. 

When  I  Hrst  saw  her,  the  thumb  itself  was  entirely  im- 
movable :  any  effort  made  to  approximate  it  to  the  forefiDg^r 
enucied  ^eat  pain,  and  th?  whole  appearance  led  me  to  BUppoae 
any  attempt  at  restoring  its  motions  would  be  likely  to  result 


TRjiUUATIO  NETJRALGU.  477 

in  failurCi  I  recommended  to  her  a  toric  course,  nnd  free  cx- 
^rciE^e  out  of  doors;  to  balhc  ihc  whole  arm  witli  vrarm  bull  nod 
wnter  twice  a  day,  and  the  liand  anJ  t}miul>  with  nn  niLodyno 
embrocation,  allemnCcd  witl»  frictions  of  sweet  oil*  The  thumb 
itseJf  was  kept  coiiataotly  wiirni  nnd  tiioidt  by  the  use  of  &  looae 
cot  of  oiied  silk. 

Under  this  treatment,  more  or  less  varied  from  time  to  time, 
the  pjitient  very  gradually  recovered  n  little  moCioEi  in  the  thumb. 
The  imjn"ovement,  however,  was  very  alow,  and  ecnrcely  per- 
ceptible from  week  to  week ;  and  it  wae  many  months  before  she 
could  allow  the  paeaive  motion  even  of  the  pftrte.  By  pcrscvc- 
rnncc  in  tbif^  course  for  nearly  a  year,  she  uitirnately  reeo^-crcj  ; 
and  I  saw  her  eonie  yeara  afterwards,  when  she  consulted  me  on 
the  case  of  one  of  her  children,  without  any  return  of  it 

This  treatment  of  wnrmtb  and  moisture,  with  entire  rest  of 
the  liiiib,  combine*!  witb  an  invigorating  course  for  the  general 
health,  I  have  found  effectual  in  n  number  of  cases. 

Case  CCLXXV.  — Ncurtdgla  of  thf^  Forefintjtr  front  rm 
Injury.  Op^raiion^  —  In  December,  1861,  a  y^ung  raan,  19 
jearaold,  applied  to  me  to  amputate  the  forefinger  of  his  right 
hand,  on  account  of  jta  cxcc^dively  sensitive  condition,  produced 
by  an  injury  which  he  had  received  nine  yeors  before,  Tlie  fin* 
gerbad  been  caught  in  a  fulling  mill,  the  soil  part?  lacerated, 
and  the  bone^  enished,  Under  the  skilful  care  of  his  pliyt^jciun. 
the  finger  was  eaveil,  with  but  a  partial  stiUneas  of  the  pbalangeji] 
artioulationa.  The  skin,  however,  was  lefl  in  a  state  of  exalted 
flcnflibilityj  eo  that  he  could  not  bear  the  slightefit  contact  of  it 
with  another  body  ;  making  it  almost  imposf^ible  for  him  to  dre^s 
himself,  or  to  pursue  his  ordinary  avocntiona.  When  he  con- 
sulted nie>  he  had  undergone  almost  every  conceivable  kind  of 
treatment,  and  was  desirous  of  relief  from  further  suiferin'r. 
even  at  the  expense  of  amputation.  1  proposed  to  him,  before 
subfuitting  to  its  removal,  to  make  trial  of  a  course  of  treat- 
ment which  I  had  found  succcaflful  in  a  number  of  similnr  cases 
arising  from  traumatic  causes.  This  was  to  keep  the  vvhole 
Limb  in  a  state  of  perfect  rest,  confined  by  a  sling  beneath  the 
otothee,  eo  that  the  act  of  drcesisg  should  involve  no  muscular 


478  DTJUSEES  AND  DiSEAflES  OF  NEBYES. 

exertion ;  aecoDdl)',  to  keep  the  whole  capillary  circulation  of 
the  arm  atimulated  by  wearing  a  sleeve  of  oiled  ailk,  extending 
^m  the  shoulder  over  the  hand,  and  closed  at  the  end  bo  u 
entirely  to  exclude  the  atmospheric  air ;  thirdlj^,  to  be  puC 
under  a  full  course  of  the  iodide  of  potassium.  He  agreed  to 
adopt  this  plan,  and  report  to  me  in  a  fortnight;  but  did  not 
make  hia  appearance  again  until  the  Mh  of  March,  afk«r  an 
interval  of  two  months  and  a  half,  when  he  would  not  admit 
that  he  had  experienced  much  benefit.  I  now  proposed  to  him 
to  have  the  finger  girdled  by  subcutaneous  ineisiona,  bo  aa  to 
destroy  the  whole  nervous  supply  to  the  finger,  sparing,  of 
course,  the  extensor  and  flexor  tendons. 

The  operadon  was  performed,  and  resulted  in  the  entire  re- 
Uef  of  the  piun.  Two  years  after,  I  heard  from  the  patient :  the 
finger  was  then  of  good  color,  and  free  from  pain ;  but  there 
was  entire  loss  of  power  over  it,  and  it  remained  constantly 
cold. 


CHAPTER     XT. 


TUMORS. 


tliB  prcHuit  chnpter.  it  U  propoBctl  to  give  in^trmopN  of  innocent 
milignuit  ramDra,  witfi  tlie  a^>erationj^  for  didr  removal. 
The  subjei^t  of  tlielr  i^athology  will  not  be  entered  upon.  SiDCie 
the  wiirk  of  Dr-  John  C.  Wjiiren  ud  Tumor^^  piiblwhed  tliirty 
yejirrn  mnce,  the  siihjecl  has  Lecn  \i\j\y  eliiboriited  both  in  ibia 
country  iinJ  Europe. 

Tlie  diagnosis  itnd  treatment  of  tuniora,  and  the  ojierations 
performed  for  their  removal,  eonstitufe  ore  of  the  mosl  irnjwr* 
tant  de|»uitnieot9  of  Aortrerj*.  In  miiny  openilions,  &uch  oa  tlie 
ligature  of  artenefl^  amputations  of  tmiLG^  opemtioaB  on  the 
bladder,  Scr.j  certain  Rsaet  rules  L-an  be  laid  down  for  tlie  guid- 
ance of  the  hur^rt'on  ;  but  with  tunmrs  tlie  vn>tv  in  dillt^reiit- 
They  are  situaieil  at  times  merely  in  the  integument ;  again  they 
are  found  di?e|>lv  imberlded  in  tbe  tissues,  and  not  infrequently 
involve  importJint  artcriciit,  vein*»  and  nerves.  For  their  siife 
removal,  ;i  thorough  anatomii^l  knowleilge  iind  presence  of  mind 
on  the  jMirt  of  the  aur-geon  are  absolutely  requisite.  Thr  |intir?nt 
to  be  n[ierate(I  nn  should  be  well  etherized,  and  in  a  re<'nrubpnt 
potfiEion  as  a  |renerid  rule:  ihe  indHionf^  in  ilie  skin  should  bo 
free,  as  tliey  fiicditaie  the  Bub^equetit  Hiages  of  tiie  di^'^^eitiim. 
The  onvo|o|ies  of  the  tumor  are  to  be  cut  down  upon  Iwldlv, 
wLlhout  loo  mui'b  [>reliniin:iry  disseenon.  To  the  remrival  of 
tumors  iVom  deep  and  ibuigerous  situaliona,  it  eb  well  to  secure 
the  vessels  as  they  are  divided. 

Qreiit  cure  h  n^c^^Aary  In  the  operaliiin  for  recurretit  tinoors 
Hituatet^  deeply  in  the  neek,  iVoin  the  ndheHon^  and  at  times  in- 
eorjioradon  widi  ihem,  of  iiiiportnni  vessels  and  nerves.  The 
question  of  tlie  propriety  of  openiting  upon  leucocythieinLC  <r\iin- 


480 


TUMORS. 


► 


I 


dular  tumora  occurring  in  the  neck  haa  recently  arisen.  The 
true  n.-tlurc  oi'  these  growtUe  wiia  firet  described  in  18'15,  by 
BeiiDctt  and  Virchow.  They  arc  characterized  by  an  inrrcase  i>r 
the  number  of  white  corpuscles  in  tlic  blood,  end  are  frcijiiendj 
cu-cxisDcnt  witi]  an  enlargement  ^i  the  aplccn  and  lynjpliatic 
glande.  They  arc  ueually  seen  by  the  surgcun  aa  a  mass  of  aoft, 
muvable  ttimor«  in  the  neck,  and  are  a  Bourcc  of  inconvenience 
in  respiration  ;  but  do  not,  as  a  rule,  give  much  pain.  In  tboec 
that  I  hare  seen  operated  upon,  eonie  have  rccovere<l,  others 
have  died ;  the  di»eat<c  in  the  latter  being  found  to  hnve  csicn 
aively  invaded  the  glands  of  tlic  cbcatp  According  to  the  prcACitt 
alate  of  our  knowledge,  when  other  treatment  fnila,  the  tumors 
may  be  removed  in  the  hope  of  relief  or  palliation,  juat  as  wft' 
operntc  upon  Bcrofuloua  glands  or  malignant  growths-  Thft 
subject,   however,  reniains  undecided. 

The  question  of  the  removal  of  niidignant  tumora  by  surgicai 
operation  haa  been  a  eubjcct  of  Ji^cus^ion  from  the  time  of  the 
Father  of  mtdicinc.  It  wnfl  the  opinion  of  Hijjpocratcs  that  tbft 
diecaac  had  much  better  be  Icfl  to  ittielf ;  and  that  the  patient 
died  sooner  when  tlic  attempt  was  made  to  remove  it,  tbaii  wb 
it  was  allowed  to  pursue  ita  natural  courac*  The  anme  view% 
flul^''tanlirt]Jy.  have  been  held,  untd  within  a  few  year;*,  \a  En, 
land  and  the  United  StiUee. 

in  a  report  made  to  the  American  Medical  Aflsociation  in 
1852,  aupporled  by  cases  which  had  occurred  in  my  own  pnie* 
tice,  I  felt  judliticd  in  drawing  the  following  conclusioDs  :  flrM, 
That,  in  a  certain  number  of  cases,  ninlignnnt  tumoi's,  once  nv 
moved,  do  not  return  ;  aecondly.  That,  in  certain  uther  C3isf*s,  h 
the  patient,  nfter  an  immunity  for  a  longer  or  shorter  ^leriod,  fl 
hw  a  return  of  the  dise^ae,  requiring  a  second  operation,  whir^ 
eonictimca  provea  eucceaaful ;  thinlJy,  That,  although  in  a  ^ireat 
proportion  of  casea  of  extirpntiou,  the  diacaac  returns,  either  in 
the  neighborhood  of  the  wound  or  in  aomc  internal  org&n^  yet 
even  under  these  cireumt^tnnceH,  it  generally  re-^ppeara  in  a  le<8 
loathsome  form,  and  i;^  attended  with  much  lea^  eulFering,  tlinn 
if  the  original  local  didcase  had  been  allowed  to  proceed  io  a' 
fatal  termination;  fourthly,  In  conecqnence  of  the  imuiiinily 
from  pain  afforded   by  the  use  of  nniESthetic  agents,  one  of  the 


Tl'MORS. 


491 


mo^t  eerioue  of  tbe  old   objcctiona   to  extJrpnttOD    no   longer 

After  aa  expci'ieoce  of  fourteen  years  since  thiM  re}Kkrt  was 
made,  1  feeJ  even  rnort  fully  ci>nviiiPoi.T  of  Uif  pTopriety  L»f  re- 
moving muIi^Tianl  tumors, — pnrliouliiHy  of  the  bi-eaat,  —  except 
in  casea  hi^  :iiarked  impoirnient  of  the  health  from  the  disease, 
or  wlien  there  U  evidence  of  d^id^  conatitutioniil  infection ; 
nud  i\i\a  opinion  would  be  justiliQ<]«  even  if  we  uUmit  thiit  the 
dieeiidc  IB  nc^er  really  df^iriij-ed  by  «ury;ira]  removal,  I  qtd 
fully  continent,  bowevcr,  that,  in  a  certmn  number  of  instincea, 
tljo  discji^e  is  mdleally  extiqinted  by  the  i^peratioti-  There  are 
etill  ]ivin;r,  j^nd  lii  jj^oiwl  lie;tllh.  tteveral  [lUticnCa  upon  whom  1 
o[>eratcd  for  uiiduul'tctl  mali^^naiit  diiicn'^e  ten  or  fifteen  yent^ 
eiiicc.  I  have  also  a  jiuljent,  now  in  n  t^tatc  of  perfect  lieulth, 
in  whom  the  cli&eiiHe  oenurred  five  Bepnmfe  thnea  within  two 
yeurij,  and  wiit  aa  'lilon  removed:  the  hut  liiuo,  more  than  nix 
years  ago.  In  another  cane,  opentted  on  in  1859,  in  which  a 
Inr^  deirihous  tumor  of  ihe  hi-uMt  wod  nipiJIv  approaching  the 
Burfaoe,  the  whole  di^eat^e  v.-iis  removed,  mid  the  patii^nt  recov- 
ered her  health.  At  the  end  of  eigliteeu  nkonthi^,  a  tumor  ap- 
peared in  the  uxillu,  wbidi,  after  nttniniD*;  the  ftize  of  an  npple, 
waa  cnudeutod  tVum  muon^'  the  ^TCftt  vesseld  and  nerves.  At 
liie  end  of  n  ycnr,  a  hard  tuiiior,  inipftrlintr  almost  a  bony  eoneu- 
tionf  nppeured  nenr  the  tipiiioiia  proe<?d«  of  one  of  the  ilori^al 
verteLriu  :  thig  wur-  uls^o  removed  ;  nod  the  pntient  finally  dicili 
with  cerehml  cytnptinnjii,  four  yem'^  ttftor  the  fii-tit  operation. 
X)urin<;  rdi  thid  period,  slie  wiu  dieerful ;  und  moet  of  the  time 
waa  iiUc  lo  take  km^  journeyB,  and  to  enjoy  the  aoeicty  of  her 
friends:  the  quettiun  of  canoL-r  wuh  never  mentioned  between 
herEcdf  and  licr  eur^^eon.  Thin  is  an  extreme  eaflo;  and  perhnpt^ 
eome  mi;jhl  qucHUon  the  ohoii^e  between  a  large  ulcerated, 
eloui^hinj;  oaticer,  and  the  alleviution,  both  nientjJ  and  physical, 
atibrded  by  re[>cateil  operiitions. 

In  regard  to  the  propriety  of  o|>erfttin^  for  the  removal  of 
epithelial  disease,  oi'  course  there  etm  be  no  question:  ca^c^ 
of  cancer  of  the  lip  and  of  the  fuco  being  of  constant  oci^ur- 
rence,  in  which  there  hiu  been  no  return  of  the  disease  after 
its  i^;ritovul. 


482 


TUUORB. 


The  cuncer*  tjf  the  breast,  which.  According  to  niT  experience, 
licivc  been  ihe  moflt  paintUl,  nipid,  and  ItjLst  amenable  1o  *urgicd 
treatment,  are  tho^e  derelopeU  Juring  laclftlion  ;  and  they  often 
uccasiim  great  em barra lament  in  diagnosii?.  Tlic  breoat  swcUe, 
becoinea  iiiUuraiLiI,  nud  [ire^enle  the  appearance  nt  an  obstrur- 
tioa  in  the  laeiireroua  ducts  :  !n  epite  oT  remedies,  however,  ihc 
hnrdncM  increft^es ;  tlie  ekin  becomes  rough  ami  brawny,  and 
the  whale  organ  solidly  fixed  to  the  ribs;  canccroud  tiiberrlr* 
flppeiir  in  tlie  vicinity:  and  the  patient  often  diee  with  either 
cerebral  or  spinal  syrnptoms.  The  wound  iimdc  l>y  tlie  remoTAl 
of  u  tmnor  of  this  kind  irt  rviry  large,  uaiially  involving  ihf 
loaa  of  the  whi>le  internment  over  it.  1  biive  onte  or  twice 
ijpcralod  tor  tbi*  diseaae,  —  ni  the  eamoet  ^olit^icfitton  of  the 
jtHliciit,  on  acc^jiint  of  intense  pnin,  —  dressing  the  wouml  uncr- 
wards  with  dour,  which  avoidt^  the  necea^*ity  of  s-ubeequent  ea- 
poaure  to  the  air  during  the  dressings. 

It  ie  not  unworthy  oi'  notice,  that  in  removing  large  tiiniorv 
iin  the  left  ^ide  iff  the  chcet,  over  tlie  region  of  ihc  heart,  grtrHt 
ilcpreiision  of  the  vascular  AT^tein,  attended  with  eymptonie  of 
collapee,  ia  often  Been  to  occur  trom  the  CipOflUre  of  the  large 
tijifare  to  the  nir  ;  the  [*yinpEmns  diaappeniriTig  aa  soon  as  l\ws 
wnniid  ift  c^jveredn  I  h^ive  therefore  made  iiarule,  whil<^  [lie 
vessels  are  being  aecured,  lu  espoae  Qn\y  ftfl  eranll  a  portion  ot\ 
the  wiiiind  Jia  Is. abs^fliitely  necessary. 

The  ijueatiun  of  the  destruction  of  niali^ant  disease  hy  meana 
of  cauatics  i^  one  of  much  intercut,  the  practtec  havioj^  IouihI 
holh  advocates  and  opponents  among  men  nio?t  ilir-tiiigiiisheJ   in 
the  aurgicnl  art,      CJrciit  mischief  la  done    in  tbia  nay   by  char- 
latans, who  liiake  u&e  of  cmistics  for  the  deatnietion  of  all  kinds 
of  tuniore,  innocent  aa  well  as  niidignant,  whoao  removal  they 
would  never  daic  to  nttemjit  vvitfi  the  knife.      The  chief  objec- 
tion to  the  uae  of  causUca,  in  all  hut  a  few  cxcrptir>nal  cn,fies,  ia 
the  extensive  destruction  of  integument,  which  often  renders  the 
cure  verj-  alow  and  hn[)erfo"t>      In  ea^e.^  of  ajmdl  or  aiiporfirial 
malignrtnt  lumora,  capccially  of  the  epithelial   variety,   canatics 
Bometiinca  anawer  a  good  piirpoac  ;   but  If  the  tumor  ia  large,  or 
deeply  eealedt  the  proresa   ia   h^jth   ttdiuaa  and   dif'^ating.      If 
inefficiently  eni[iluye<l,  they  jippcar  to  do  great  harm  by  atlmulot- 
inir  the  "mwth  to  increased  action. 


I 


ruNGrm)  tlsior  of  forehead. 


4da 


Tbe  most  eflit-ient  eniiatit*,  perhi»|is,  U  the  cltlorulfi  nf  zint-, 
marie  into  a  pasti?  wkli  tiour,  a\n\  jiknttd  wt'll  down  into  ]n<!i>iii>nff 
made  with  the  knife.  Aoutlier,  lulvociled  hy  Vel|»paii,  and 
I  hc'lipvi?  nUu  hy  Mr.  Synio,  consists  of  stronir  >*iil[iliijric  nv'ul^ 
lulxed  ivifli  Hmri-'iml  or  some  veijetabic  |iowder.  Tin?  tri'iitint-nt 
nt'  cjiiicpr  wJtli  tlie  liy|ic»derraic  mjectioii  of  dilntp  nceiii."  ncitl, 
i lit  null  K'i«l  by  Dr.  liroatlbeni*  liiw  Itiu^ly  been  nttrncting  iniK-li 
uttention  in  Kn^bind  ;  find,  fnun  the?  evidence  given  in  ilH 
fiivor,  certiuoly  deservt^s  a  Inir  trihl,  SmiUI  cancL^roue  tulwr- 
de«  prolmUy  olfer  the  beet  aubjects  for  il.  I  hcive  seen  the 
effect  of  it  i>idy  in  one  eiLse  ;  n  l>Lrge»  solid,  fi\t'd  [.mnur  of  il 
hi»[>e]ei^A  [.^Kiiraeier,  fiitunted  just  behind  tbu  ear.  in  ii  male  palrenl 
of  about  40  yenrtt  of  a^.  In  this  ciLse,  the  «uHzLce  of  tJie 
tinnor  wua  first  laid  bire  by  a  free  iticiaion,  nml  tho  acid  injpcted 
into  its  snb^timcG,  Now,  at  the  end  of  two  woekn,  there  is  a 
di^diurge  of  thiuk,  creamy  pua  from^  tbe  eipiiaed  part  of  tbe 
tumor;  and  tlje  Lulk  of  il  —  which  yvus  of  a  Acirrhoua  lm.rdne!^ 
—  has  now  a  sort  of  spon^  i*oHnef*a-  Tbe  case  was  operated 
upon,  nnd  is  under  tbe  eare  of  one  of  my  collen^ei^  at  the 
1  II  ispitid ' 

III  eimneulion  with  tbe  ptiob>gy  of  cancer,  l  wonld  sav,  that  I 
have  had  wevenil  wcll-msirked  (;nHcs,  in  wljicb  the  dinihcaii*  wbj* 
evidently  awakened  by  a  blow  ;  the  patient  subsequently  dying 
of  nialiirnant  confititntiona]  diseoae- 

Tbe  following  unnmiaJ  CBse  of  fungoid  tuciiur,  uppnrcnily  ori- 
ginaiin^r  in  the  dura  mater,  operated  on  by  Dr.  J.  C,  Warren, 
16  introdoL-^d  here,  with  the  eolored  delineation  of  ir:  wlni^b  tbrina 
^K  frontispiece,  on  accomit  of  the  remarkable  featnreri  i.'iinnccfed 
with  it.  Tbe  patient  applied  to  me  for  advice  imee  or  twiee, 
tiunie  years  nffer  rhe  operation,  and  I  have  been  able  to  folhiw 
tlie  bir^lory  of  tlie  cone  ^inee- 

Case  CCLXXVL  —  FHHffoid  Tumor  of  the  Fo^t^hwd. 
(t>ee  Frontispiece.)  —"In  tbe  vfar  I84li.  a  yniuig  Indv  ap|iHtKl 
to  me  on  iic<?oiinl  of  u  Inumr  oTi  the  forebejid»  near  the  ri^ht 
temple,   having  the  aspect  of  a  periosteal   tnmor. 

"■  I  advised  an  incision  across  it,  to  ascertJun  itn  character,  imd, 
if  found  to  be  ftuaceptible  of  an  operation,  thai  it  >*hould  be 


484 


TVMOItfi- 


removcfl.  Tliir-  was  Dotdono;  nnt\  in  October,  1M7,  elwa^i; 
preecntcJ  hcr-eclf.  The  tumor  waa  tlii^ii  of  two  ycnra*  "T'^wlij 
It  woe  of  Inrgc  ai^c,  nppr^ii'hin^  thnt  ut'  n  JcmoQ  ;  its  eurh^ 
WAA  ukornted,  fiirpild,  anU  bl(»e*iiii^r,  Tliere  wa.s  no  pain  iq  ii, 
nor  any  ccrcbnU  urtcction.  Under  thcee  L'lrcuin.^tniK-ct^,  I  nilriiit^ 
that  tlifl  tumor  ehoulti  bo  cut  out,  if  pi>&ct]ble,  tiotl  the  hlc^hfr; 
ptirtUt'c  caiiicrized. 

""Ui-'L  27lh,  A  projcctinj*  fun;;ue,  of  two  or  thrci?  iiichrt' 
hci^lit  nniJ  widtb,  wue  iirst  rrmovt'd,  and  eutticJcnt  evidem 
obtained  of  its  bcin-c  <>f  a  tiingcjid  dmmcter,  if  any  wt-rc  waxit- 
in^;?.  The  eiirroiuiding  skin,  tcrnpoml  fnecia,  ami  musolc.  wetv- 
dividcd  on  cikIl  Bide  vi  x\iC  tuimrrt  u^bJeh,  while  it  CTclcniM 
a  apace  three  inches  in  diameter  under  tb«  ekin,  writi  found  to 
hnve  a  cimtmctcJ  cervix  of  not  more  than  an  inch  nnd  a  half  ia 
diiimclci".  Around  thia  ecrvis  wtis  fuimd  the  <^]^  of  a  fttrio- 
ruted  bone.  An  instrument,  parsed  alon^  thia  eilj-e«  enteral  fbc 
onvity  of  the  cranium.  The  tLimor  being  cut  drhWn  clncic  ti>  lb* 
bone,  tbc  aelual  cnuterv  wis  nppliod  by  a  Buceeesioa  of  JicatcJ 
irons.  There  was  a  copious  hemorrhage;  but  one  or  twro  Vr^ 
turcfl  only  were  applied.  The  patient,  bein^  under  the  Influence 
of  ether,  autfercil  nothing:- 

'^Nov.  lith.     The  patient  hnd  no  bad  s_v  nip  tome  after  tlictop«nt- 
tion.     At  thia  time  ebc  wna  fitting  up,  quite  cx>infortablo,  ainl 
experienced  no  pnin  in  the  hcwt.      The  wound,  liuvvcver,  had  ah 
uutiivorablL-  lu^pecl  i    its   edyes   were   ncurly  an   inch    thick,  Aud 
Iiiid  a  putiy  or  swollen  ii|JiH-'ftrnneD.     The  fun^Ti!*  bad  a^^ti  ^hoC 
up  half  an  inch,  nnd   rcipiired  the  diiily  use  of  cnuetic  [Hitiv^h, 
Krum  thia  thuc  to  the   \Mi  of  December,  the  cnuetic  wjia  frr- 
quenlly  ripplJed,  but  wna  fliihscrjucntly  omitted  \  and»  on  ihc  I7ih 
of  Jfluuary,  there  was  n  ^mall  thell  of  exposed  bone  to  Iw  ttiiitid 
at  llie  bnttom  nf  the  cavity*  whioh  wa^  about  two  linea  in  <Ilaiu^ 
ctcr,  wilJi  henlthy  ^^mnulationf.      On  tJic  3lst  of  Au^'ust,   it  is 
rcconled  thut  tiie  wound  closed  soon  after  l^ann;^  th^  HciepitnJ  ; 
tbc   nhell  <>r  bone  prcviou.^ly  described  etill   remaining   in  eitu, 
none  ever  having  come  awny.      Henlth  good." 

I  waa  conaulted  by  tliis  patient  some  five  years  a^r,  with  a 
slight  nppenrnnCG  of  n  return  of  the  tunior*  It,  however,  iliij 
rot  accm  Jidpoacd  to  incrcaee  rapidly ;  anil  us  she  had  no  auH'cr- 


TUMDR    or    HK.Vn. 


485 


ini;  fiMm  it,  ami  her  henhli  wn^  not  nffbctei],  I  did  nctt  fppi 
diatJ^j^oil  tr*  interftre  liy  aixitlier  gritve  optnitioti.  I  kepi  lu*r 
imder  nbservntii>n  for  n  time,  but  finnlly  loet  Btgfit  of  her. 

About  Ten  vnir?)  nfter  thin.  I  WH*  cimwullwl  Ji^'nin  \>y  the 
fnthcr  of  the  ^iirl,  In  iTgiml  to  tlip  pnipn<^ty  of  nnolfier  operHtinn- 
He  infonnetJ  me  tlint  sho  IukI  since  betn  innrried,  »ml  ^^one  to 
Cnlitornin ;  thni  she  ivitri  quite  well  ;  timt  the  tumor  bnd  pnr^ 
tially  retiirni-tl,  iinil  tlint  siie  wrtft  iWiroiw  of  knowing  wiiPllior 
another  opprniion  r*iuM  ho  [>erfbrme(K      1  ndvised  hor  n&i  tiefure- 

Tn  July,  l^lfifi,  I  learned  the  ff)l]owing  pHilii'ulars  from  her 
f'jiihpr.  [She  wjis  ■Jtifl  living  in  {'alifi»riiiB»  ilihI  Hidfert'il  no  in- 
(.ijnv<"nieni"e  frimi  the  tmoor.  It  h;ul  wlowly  (■nliirge'l,  until 
three  yeara  ng^i  ^Itiee  \^]ien  it  hud -undergone  nti  material 
L;h:iTiga. 


Ca^e  CCLXXYIL  —  NxtrfioTduirrr^  Tumor  on  Me  Ifrail 

if  n  Yuiiiii/  C/tif'I  rfinor4ul  ftjf  Operation* — Tlie  following-  awe 
is  thus  deyrrifw^]  h\  IV,  J,  C. 
Wnrrrn  :  —  "  Tn    the   munlh 

of  Api'il,  I84a.  Mr. ,  nf 

nf>vrr»  NMI.,  wrcite  to  me  (o 
ciiriit*  to  ihiit  |ilii(;v,  to  pxion- 
ine  o  tunnoT  on  the  head  of 
his  e\n]i]. 

"The  cliild  wiis  a  our^hiir 
boy*  fight  months  uhl,  i|vnte 
henltliy  t    a    wet^k    nfter    his 

birth,  a  tnini>r  of  th*?  size  of  \    \^        ^^  \ 

R  |ieri  WHS  (Ii«;ovored  on  ihe 
back  part  of  hi*  head>  Thi«  m^Tease*]  prettjr  rapidiv,  ami  the 
father  at  ont-c  fonsnhcil  ihe  ine^licjil  ifcntlemon  in  his  viciuily. 
Some  thiiugltt  it  e(ii[jiK  oiherji  thooglit  It  t^niil ;  vome  nJvi»4H] 
bim  to  huvc  it  desfnived  by  i^auHlic,  and  otherA  to  apply  r  Hgn^ 
ture  about  it-  The  latter  atlvin^  buini;  eoiipidprod  tho  mosi 
safe,  was  adopted;  n  ligature  wna  licil  nruund  the  ba^L*  of  ihe 
tumor  where  it  spriuig  from  die  head,  not  tight  onon^^b, 
however,  to  strangulate  it,  but  merely  to  irritnie  the^  ^kin  on 
which  tl  was  iipplied,  whloh  i)f  course  prothirod  no  iiopres«ioii 


4ti6 


TUHOBfi. 


on  the  dbeoac;    yet  thia  application  waa  rontiuucd  fbr  tluiv 
months. 

"Not  being  able  to  viait  ihc  pnlient,  I  ^vi«ie<1  that  the  rfiild 
ehoulJ  be  brju<:ht  to  BoetoQi     On  the  3d  of  May,  he  wan  aoccinl- 

ui£\y  bmnght. 

''  Od  examination  by  Dr.  J.  M.  Warren  and  ciiyself,  w«  ruiioil 
on  ihc  buck  of  tlii9  ctiild'a  hc;uj  u  tumor  alin^iat  na  lur^e  ns  the 
heiul  it^cUV  of  a  globular  tbrin.  It  wild  clastic  to  the  tuut^h,  not 
inidiiUiirig,  itor  ^enaitive  ti>  pressure*  It  retained  the  nMnnl 
color  of  the  «kin.  except  whci'e  tbe  arCiTtes  and  veins  rutiiiJied 
over  it;  these  vesBeU  were  enlarge*],  ainl  tlicir  hrjiitcJieA  and 
inosuulaiioiifl  prL^sented  a  bcivutit'iil  apiicanniL-c  ;  thei-e  whs  uu 
pulsation,  On  moving  the  body  of  the  tumor,  it  diti  not  ap^iear 
to  ailliei'ij  cloaely  to  the  bone  or  pci'ioeltuiu, 

^  Fi'uni  this  cxEiiiiinjLtion,  my  opinion  wn«  that  the  liiiiiur  war- 
of  tioljd  <^rowCh,  supplied  by  the  vee^ls  of  the  flkin  and  thitec  of 
the  occi  pi  to-frontal  niusde  ;  tlkut  it  wua  not  mali^mnt  in  char- 
acter; tiiiit  it  lai^bt  and  imghl  to  be  removed.  Tin;  fjneralion 
was  performed  tlie  day  following.  May  4,  18-13,  by  Dr«  .T.  M. 
Wan  en. 

"  An  inciflioD  waa  made  into  each  hide  of  the  tumor,  tYimun^ 
hcnding  ekin  onough  to  cover  the  wound,  and  tbe  tuim^r  rv-adilr 
didaected  olf  from  ihe  bone ;  six  nrterles  were  tied,  aud  the  ^kin 
bi"oii;^'ht  together  by  strifes  of  adhesive  plaster. 

"On  examination  of  the  tumor,  I  found  It  to  be  covi;i-^  nnd 
insulated  by  a  complete  coat  of  cellular  texture.  Being  tlividt^d, 
it  presented  a  very  white,  uniform,  granulated  texture,  inipr- 
rupted  only  by  some  irregular  partitions  of  cellular  tif^aue.  TUe 
microscope  dij^covered  uodiing  beyond  wbnt  h<is  been  fituted 
above.  The  most  remm'knble  circumi^tnnce  about  this  tuinur 
was  its  firmness,  which  was  very  nearly  efjuni  to  tlmt  of  Gbrir- 
cartihiginuua  texture.  On  scraping  tbc  cut  r^urface  of  the  tuinor 
with  a  knife,  an  opaque  fluid  waa  obtained  in  conr^Idcrabk  quan- 
tity, similar  in  appearance  to  turnip  juice  and  to  the  fluid 
obtained  by  scraping  a  scirrhous  tumor  of  the  bre^wt, 

"The  wonnd,  wbtch  waa  about  Sve  inches  long,  waa  foimi] 
united  almost  wholly  in  two  daya  after  the  operation.  The  cliilJ 
hjtd  no  fever,  nor  any  sign  of  indiapoeition  ;  but,  on  the  contrary* 


ti;mou  of  iirah. 


487 


Axprceaed  lir  its  movomcnis  a  feoKn);  of  relief  fi-om  the  cnc^um- 
bmnce  it  hnU  so  ]f>ng  borne.  Tho  diild  being  so  well,  ib<?  pa- 
renU,  on  the  rliLrJ  Uiiyt  took  it  home  to  Dover,  much  gr'Liiitii.iI 
with  the  result  of  un  ojienition  whi<?h  they  h:ul  iiuagined  tri  be 
luore  foniiukble  In  its  execution,  nnd  more  protrn^f^ti?)!  iu  iU 
conaequencei- 

Hemarkn. — "The  mother  nttribu»ed  the  growth  to  her  hav- 
ings, when  prefTtinnt,  iioi-iiienrully  stuml>led  ovl'V  n  hsisket  of 
oranges  ;   ttie  tumor   rescmbliny   this   iVuit  iii  itji  form. 

"The  diflsunilarily  nf  tbi^  turaor  to  the  teilure  from  which  it 
ftpning  would  lead  to  the  opinion  of  its  helnr;  n  (*nnc?ProUf>  for- 
niiitkm.  Its  consistenee,  color,  mid  the  fluid  obtained  from  it 
by  expresaioD,  were  tuoat  similar  to  rhe  apjx^JiniQcee  in  ^  seirrhus 
of  the  brenat.  On  the  other  hauj,  its  perfect  iiisulntion  by  a  sue 
from  the  surruundiniT  lexturei*,  the  nsitnre  of  the  eonnection  of 
this  fliic  with  those  textures,  nnd  their  perfectly  nalurs;!  f^ondition, 
eniihled  me  to  assure  the  parents  of  this  child  that  there  would 
not  he  a  recurrence  of  the  disease/' 

This  ease  is  interesting  fi-om  its  resefuhlance  to  another  turaor 
which  we  oeeasion^lly  aee  ati?ijng  in  (he  same  t^itustion,  imd 
which  Bpvingfl  froru  the  interior  nf  the  craninm,  Mr.  Costello, 
in  his  "  Cyelopiedin  of  Surp:ery,**  under  the  lieiid  of  Kneephn^^- 
cele,  frive«  a  deaeripiion  of  the  disease,  with  drawings,  one  of 
which,  with  n  broad  hjiao,  resembles  the  present  tumor.  About 
the  time  ihut  lhi#  c^a?*?  cnme  under  our  cure,  n  clultl  wnn  bronjrKt 
lo  our  Bnrp^cal  infrrmary,  with  a  con^nitnil  tumor  appi^rently  of 
&  siinihir  ehamoter.  It  was  examined  by  many  surgeons,  and 
ftuppoweil  tn  be  n  tumor,  sprinjrjng  frtmi  the  cranium,  of  an  en- 
cy?ued  character.      It  wa*  therefore  decided  to  remove  It- 

The  operrtlion  was  nearly  coiiiplete<I»  the  diiiseciinn  being  very 
euy,  when  it  wn*  fonnd  thnt  n  small  pedicle  of  the  tmnor  pene- 
trateti  the  crmiium,  or,  in  fiu.t,  came  out  frL>m  ir,  hh  the  tumor 
proved  to  be  bu  extension  of  the  membranes  of  the  brain.  The 
pedicle  was  diiMdc{l  with  jjrcnt  care,  and  means  were  tnkcn  to 
prevc^nt  any  air  from  eominjr  in  contact  with  tlie  interior  of  the 
sac,  tlio  ftkin  being  brought  together  over  it  at  r.ince.  The  pii- 
tient,  however,  died  in  a  few  days,  with  cerebral  symplonis. 

Ir   the  ciute  first  related,  it  was  thought  possible  that  the  diju 


46n 


TL^MOBfl- 


siK!tiun  miglit  in  ^>nie  wny  interfere  whh  the  crnnuii  okvhy ;  ii« 
rim  of  l)oim  cinilt)  Ltr  felt  i|iliti?  ruuiid  tlie  circiiEnferctice  of  tUl 
tumivr,  j^iiiih  nfi  is  mtt  iii]frt*i|iiC'nrly  seen  where  the  Tumor  bui 
1ikI|^i'iI  I'ur  a  liii>g  tliiit  !»  cuiiUiut  i^ith  the  cnutiuin,  noil  m]aA\ 
idwnyfl  renderA  tlie  dJAvm^AtA  a  littJc  diliii^iih. 

TCMOUB   in  THE  l-AROTID   IEB010N. 

'rijp  lumore  u^imlly  riiiiiicl  in  iIila  rc-ritm,  eitljer  oni^nutB  bi 
Htuiil]  ^Uuid  plucreil  iivtr  tlio  fmrutiil*  ur  uri:  eiii]>ei|4KHl  in  tu  f*^ 
f4tJinoe,  or  iin-  pliu'eil  undtT  its  lnwor  eilge,  which  ih  expiinJrtl 
U>  fonii  ji  coaling  over  llie  tuiiiur,  msiklni,^  it  iiec^e«snrv  ta  ditfft 
thruuglk  llmt  jK>rtiijn  of  tin*  {.'x^mndKil  gland  bf^furc  the  tnmiit  U 
rc;iL-]i4.-d.  Thvy  lire,  for  llie  most  ]>nrt,  innocuaua,  niid  are  re- 
moved ^I'ithuut  great  risk,  uliliotigli  diimewhat  vnscul&r.  Tlv 
tiiinorn  of  the  [nirotid  il«Of  me  [>f  a  serifnia  uhnracter,  often  iif 
a  niiilignant  nature,  and  tlien  Lnually  sdrrhoiiSi 

A«  to  the  practical  questioB  wliieh  le  atlea  raiE^ed,  whether  [In* 
gland  cnn  lie  removed  witlnmt  the  ligature  nf  the  parotic],  tW 
resnic  of  mv  experience  \n  ih'm  :  Tlie  paniLtd  ^lund  tins  Ix^n 
removed  liy  me  in  many  institneea,  stime  uf  whit;h  nro  givva 
beliiH^ :  in  none  of  them  wnm  tUe  CArotld  Hrtety  tieJ.  Ii^  »cil 
rliims  affL^rlionif,  tvh€ire  the  gland  nndergoes  a  grHiTiial  indiirativrii 
iIji*  vpuseln  are  frefpiently  pushed  buekward,  iW  llitiy  were  in 
or  Lwo  ol'  The  oa^e^  here  given. 

In   iL  CHbe  mcntroitPil  Uy  Dr.  J»  C-  Wfirrrn,   the  rnrotid 
cut  lit  dii^  end  of  llie  operuliiin.      Tlie   ve^^el  wn«  fieoured,  ftfid 
the  patient  did  welh       Tit  \\  ^eeond   cane  for  the  removal  of  a 
nL'irrhcajs  prtroiid,  in  whicli   1   a.*fii,steil   Dr.  Warrpn*  the   carutidi 
AviLH   divideil   and    ilhI.      TlirfU  i\i\yn   after.  »&  tlie  jialient    ivn«' 
Bimining  nl  Ktoiil,  tlie  vpnsel  gave  way,  and  the  IjIoimI  strurk  tli# 
■spiling.      He  almost  at  onre  fainted;  and  die  tnende  wer6  tor*] 
tunafely  eiti>]  enoiigli  Tu  jihiee   a  sponge   in   lite  woniiiK  and   to 
eliei_'k  the  fliAv   pjiriiidly.      Being  tiilleil,    I    at  onoe  tut   dovm 
upon   tlie  vessel  in   tlie  neck,  tied  it,  and  eto[i[ked  the  furtberi 
effiifiini  of  bhjinL      Bi^rMrd,   !n  hi>i  nnmc»grri[ili  on  tlii'4   iiiulyeet, 
mentioii.t  manv  initliineeft of  removid  of  thlr^  ghtnd  uitlioijt  hgatun^ 
of  the  cnn)lid,  and  (jiiulBa  a  caae  of  extiqiHtinn  (if  the  parotid 


PAROTirj   TOMOlt. 


48d 


iy  mv  gnrndfatlier,  Dr.  Jiihn  \V;irrcn.  in  1804-  remi>veil  willi- 
out  tyin^  thw  vessel,  —  the  IVmhI  iiecvt  Ufing  iliviilef],  mid  tlie 
fe(?e  paralysed .  Tfie  [mtient  iJvtfl  fifteen  venM  aftenvariU,  and 
died  iii\  n  diwose  foreign  to  the  glandular  iiHeclion, 

The  folluwing  cnscfl  are  iJliLHlralEve  uf  the  abovt:  fad?',   and 
also  of  Home  pei^uliuritie^  in  die  nature  of  the  tumora  ihemaelves  : 


Case  CChXXyiU- ~  P'trotid  Tumor.  E^.tnova/.  —  A 
jounff  miuTie<l  wtunan  entered  the  Honjjiliil  in  April,  ltf-07.  witli 
ft  EUTiKir  [>r  ihe  parociii  gland  uf  one  yeur'H  dumtiuik.  Ei^ht 
years  before,  ehv  liad  it  turiiiir  belnw  und  Iteliiml  the.  ri^lit  enr, 
whiL'fi  wiw  vt-rj'  fiurd  Jiticl  nc;ra.*iim:dly  jJididul  :  die  integunieiit 
wiu  net  dise^dored.  Al  die  end  of  foiii'  jrearji,  having  atltiiDed 
the  Bize  of  n  roliin**  egy;,  it  waj-  rciiimed.  The  wound,  she 
tljink.H,  never  ciriitrized ;  and,  in  timr  months,  the  tumor,  having 
re-appearetl  in  tlie  miilst  of  the  scar,  was  again  removed,  hi 
cEiurarter  was  ^itnllar  tu  die  preceilLng.  whh  ihc  exeepliun  that 
the  t^urf:ic!e  wftts  niMluliiEed.  The  witiiiid  liealeJ  im  iir>na1,  but 
the  eiiiitrbt  rettiuiiicd  very  red.  In  IH.O;"*  tlie  tutnur  begun  to 
furm  about  in  the  name  phtee^  and  in  18rif]  was  as  large  aa  n 
hen*tf  egg.  pnijecling  ivti  iiuh.  whh  a  nndiilated  and  red  siirfaee. 
lli?gioniiig  L*'biw  Llie  ear,  it  priireednl  upwiinl  and  forwnnl  to 
about  half  nn   ineh  in  trant  of  the  mcntus- 

On  the  first  dny  tit'  Mny-  1857,  the  patient  being  etherizpfl. 
tlie  diseased  mai«s  wna  i^nrnKinded  by  an  elliptical  inriiHion.  From 
the  mmatjon  of  tlie  disease,  the  di^^eetion  was  mode  very  vliitvly, 
requiring  nearly  nu  hour  lor  the  operation.  At  the  lower  part 
waa  a  firm  adhesion  tu  the  fibres  of  the  slcnm-mnstiiid  mii^etc,  a 
piirtion  of  whioli  wn^  reiikoved-  At  the  ij[iper  part,  It  was  neees- 
eary  tu  carry  tlie  dissection  down  to  the  artietilaiion  of  tlie  jaw, 
below  and  behind  the  angle  uf  tvhi4;b  the  dis&as<r  dewend^^  dee]>* 
ly^  rendenng  neresnary  the  exposure  of  the  leTubin  of  the  digas- 
trii'iis.  Oil  rair^ing  the  tumor  tu  cuniiniie  the  deep  dissecdon, 
\ioleiil  effort*  at  vomiting,  diffienlty  of  breatbing.  and  convul- 
fiive  retellings  from  die  traction  extrcit^ed  on  the  deep  nerves^ 
came  on ,  ho  that  it  wa^  neiTeiisary  to  desist,  and  destroy  the  small 
poriiun  of  the  base  of  the  tumor  with  the  hot  inm.  A  few  lig- 
uturt^s  were  apfibed  ;  and  tbe  wound,  rneasnriog  three  inches  and 


490 


TlMORm 


n   UM  vertlciJIy   hy   two   irnnHventely,    wn^    forerMJl  br  ■ 
cltttb.     The  growili  ni<'n^ure<]  vprtic»t]y  three  inches.     Tlnfa 

WHH  mon^  or  lc-^»  luirnlvzeil  itftrr  tlic  o|K*r»lion. 

She  \inH  ili^char^L'il  Irum  llie  lluts^^ilJiJ  akn  iIk^  I^iK  nf  Jae; 
all  llie  diBcnao  betng  u]i]irkrei]tly  removtrd,  and  rh«  «v}i<>le  n^ 
redHcefl  h*  ii  Ji!imer(»r  oi'  vuc'iWnxl  of  an  ini-li.  In  the  nA 
of  Scjilt'Hibev  fiillmvinj^,  a  k^ilcr  wjia  rtsH^ived,  eavin^  tl«i  !^ 
jmljt-nl  rcniuined  wl-11»  and  iIlc   wuuihI   wn«    henlctl. 


Case  COIjXXIX. — SiitrhoaB  Tumor  f^f  I'aroliri.  /^ 
inov'ii,  —  The  potient  wue  ti  fHrincr,  52  years  oJJ-  T^vniT-fci 
ywir*  lM?ri>rc,  u  tiiiiior  iiiatle  its  appearance    in    front  of  the  at 

This  imi'rcn'ciil'ibly  iricrcneed,   giA  Jti^  hinj    no    nam   oc  inom*' 
iiioncc  uiilil  twi>  iiiuiklliri  iHrrorc  the  i}|H'raliLiu ,  wJi^^n  it  wta  Injunf 
Uy  n  hltiw,  imH  since  then  ni[iiill.v  increased  in  nize.     The  W)|*i 
'iflor  llii"  blow,  he  pcrceivetl  that  there  was  j»um<^   itison^thililT  » 
the  Mi\   in   I'i'ont  t;t~  the   tumor.      For  euiiic    time,    he  iiml  brra 
iiDnhJi^  to  clo£e  llie  right  eye.      "Ntjw  tJiere  is  nn   ov^,  frfon^ 
ntijt,  even,  welWefir it'll   tumor  in   front  of  the    ri^bt   ear,  oW^ 
lyiii;^  the  rnniLw  of  tlie  lower  jnw,  and  occupying  ihe  posilionf' 
llie  piirolid  i^hmU.     lla  long  axis  ia  parallel  wjih  n  lin«  dn«l' 
from  the  nn^le  of  tlic  Jaw   to  the  externiJ   nngle   ni'  cbe  ctbil- 
Ila  }^rcuk'Pt  [eii^'lik  Ja   [hree   ineliee,   width   twu    U^cUes.      Upper 
niMf;;iii   ia  uu   n   li^xid  ^  idi  ihe  uu;;le  of  die  eye  ;    lower  mnr^io 
Midi  ihe  an-^le  of  ihejnw;   posterior  la  overlapped    hv  ^»xlffrftal 
I'ur.      Inle^iimtnt   is   m<n'rthle  :    not  JiseolorecJ.        Ttitnor  is 
firm  eontfidleiit'o  ;   iii.fl  tender  on  preeauic  ;  not  altneli^d  to  in. 
yet  but  filightly  movoLiIe  ;  doea  not  move  «ith  lower  jnw  ; 
not   be  felt  in    moutl^      Tlierc  m  uuich   ntimbnc«8    of  i-lieck  jc 
fi'unt,  aod  n  dull,  hut  not  ecverc  piiin  in   the   tuumr   itself. 
JJojfpitnl  lifcoid* 

When  the  piilleiit  entered  llie  Iloc^pital,  one  or  tivi>  (rlnnds  i 
llie  neighborhood  of  llie  luinur  "ere  enlar;::eil.  nppnreiiTlv  fro 
tlie  effect  of  bOine  iml^itiug  application  which  hail  beon  made 
it.      Under  Ercatment*   tl^ese,  with   one   exception,  di5;i|ipc'art<l, 
He  was  estreiiiely  deslrinia  of  having  the  tiiinoi"  reiiiuvetl  ;    ami, 
iiri  a  e{Fn^iiltalii.ai  uE'  the  eurgeoiis,  it  wua  dix'lded  that  this  sjitfu 
iteuipied. 


MELA-VOTIC   TLfMOR    OF    PAROTID- 


4»1 


Tlie  pntlcn!  bein^  etberiKeii  u'llh  clilori?  etlier,  nn  incision  wn* 
mndc  from  just  above  ihi;  eitpcnor  border  of  tbc  lumor  lo  a  Jitll^ 
1^  below  it^  iDferior  port.  Tbis  vas  croieed  by  another  incUion, 
^  ooraraencinjij  nf  the  tnasioid  [irficess,  and  terminntixl  on  ihe  L^heek. 
Tlio  fibrLUie  i^apaiile  of  tlifs  fjfltind  wn**  now  put  into,  tind  the  tunioi" 
groduallv  InoeoneJ  bv  di^soctint;  cnrcfuUv  around  its  circtimfer- 
[vnce.  It^  ndbf^BioiiFi  w^re  eo  close  and  the  texliire  ao  lirmi  th^t 
tic  WM  found  impriSBiHle  to  jirocoed  oxccpt  wJih  preat  oaufion  ; 
|tbe  veadel^  tbnt  were  ilivided  under  tite  ed^s  of  tbo  tiiiunr  bein^ 
mred  with  nitjch  dIfiioLilty.  Tho  tumor  wne  first  loos^n^ 
[from  its  atlaebment  to  tlm  z\"p;omntio  proce&fl,  tlipn  di^eooted 
■from  tlie  mai^seler  niuaelo  ;  the  transverse  facial  ai'tery  and  the 
[parotid  dnet  bcin^  divided  at  tbU  eta^^  of  the  dissection.  It 
'was  neNt  dctiipbed  from  its  firm  adfieslona  to  the  alenio-mastoid 
musele  and  mastoid  pm^ess^  and  its  ndbesione  to  the  ear  cut  off. 
Finally,  by  mesinA  of  llio  blndc  and  handle  of  the  knife,  it  was 
Hepnrnted  from  the  grent  artery  and  vein  which  ]ay  embedded 
in  its  posterior  wall,  the  latter  bein^  cut  and  lied.  Four  or 
five  arteriea  required  lipalurcs.  An  enlarged  *jijind  In  Uie  neigh- 
borhood was  removed  separately  from  the  tumor* 

Tho  mouth  was  found  pnrnlyaed  after  the  operation.  The  eye, 
which  tlic  patient  wiis  unablo  to  eloae  before,  i^itlior  in  sleep  or 
when  awake,  wiu  found,  a  few  days  mbsequent  to  the  removal 
of  tho  tumor,  to  drop  down^  bo  ^  piirtiaily  to  cover  the  eyeball 
when  he  was  asleep. 

An  examination  of  the  ttitnor,  nf^cr  its  removal,  ahowod  it  to 
be  the  parotid  in  a  scirrhous  fltalc  ;  tho  mieroficopc  dieeloeing  an 
Rbundanee  of  eanoorous  eell* :  with  it  was  hicluded  a  Ivinphatio 
gland  embeilded  in  it«  lowor  and  under  portion^ 

The  presence  of  the  parotid  duct  and  the  facial  norve  in  the 
tumor,  together  with  its  annlomicul  rclntione,  left  no  doubt  as  to 
tho  or^'Ab  diseased. 


Case  CCLXXX.  —  MclftnoUc  Dieease  of  the  Pnr^lid 
Ghind.  Operntioji  b'j  L\fr'ieuir,  cuUitt^*  a\id  Jretx^tti^^  —  A 
Bcnman  from  Maine,  unmamcd,  25  ycara  of  o^,  catered  the 
HoEpital  in  1852  with  a  melanotic  tumor.  For  three  years 
before,  he  had  had  a  Bmall  black  fungus  upon  the  rijht  check, 


498 


TUMOItS. 


in  Frctiit  of  tlie  ear,  nrd  the  glanda  of  the  nec\s  bcTfttne  &<»i 
what  irrilated. 

At  the  time  of  liis  ndiniBHian,  there  was  an  irre^lar,  lobl 
tumor,  the  upper  part  of  whirh  was  eurTnimnioJ  by  a  IjJaok  ft 
gua  ns  lar^  iie  iX  walnut,  occupying  the  ri^hl   pnrotici   rc^ii 
where  it  was  eli^jhtly  movable,  descendin;;  below  and  behind  the 
uigle  of  the  jaw,  where  it  wa^  immrivable.  ^| 

The  patient  bein^  fully  etherized,  the  tumor  was  eurroun^T 
by  AH  elliptieal  incision*  nnd  the  dis^ction  coinnionc>ed.  3ti 
however,  followed  every  stroke  of  the  knife,  and  poured 
the  whole  eurfftce  of  the  tumor,  po  as  only  to  be  checked, 
the  further  prueccution  of  the  operation  allowed,  hv  applving 
tfw  freezing  tnbiture,  and  constant  compreision  of  the  carotid. 
After  the  rcraovnl  of  aomo  cneily  detaehei]  portiona,  by  the  ad- 
vice of  the  Burgeooa  pitieenl,  the  ojwration  wna  finallv  terminate 
by  trs-nsiixin^  it  at  the  base  with  a  very  strontj  double  ligature, 
and  tying  it  in  two  segmentfl*  Before  thw,  many  li^turco  we?^ 
placed  on  bleeilinr;  vesaele,  and  the  henaorrhafje  was  vorj-  "renl. 
Wherever  the  tumor  waa  cut  or  broken,  a  great  amoi 
thick .  gnmuhir  fluid,  of  a  jet-black  color,  floAved  out. 

Upon   partial   recovery  from  the  effoet  of  the  oilier,  hi 
rha^  from  the  tumor  continued  to  such  au  extent  ns  to  rcndcf^ 
necessary  to  again  encircle  the  base  by  a  strong  lignlui'o-      The 
tumor  ultimately  returncdn 


I 


Cask    CCI.XXXI.  —  Parotid     Tumor.       Jiemoval 

married  man  from  Nova  Scotia,  58  years  of  age,  eTitercit  the 
Hospital  in  April,  185-1,  with  a  parotid  tumor  of  twcntv-sii 
yoard'  Ptandinj^-  It  was  aituate^l  on  the  le(^  side,  and  exten 
downward,  lifting  up  the  lobe  of  the  car,  partially  ctosin'^ 
mentufl,  and  causing  some  deafness.  The  iniegiimcni  over 
was  injected,  but  not  adherent.  The  pain,  for  a  ehort  tii 
had  been  severe,  preventing  sleep.  It  waa  considered  uf 
formidable  a  character,  th^it  the  flurireona  to  whom  he  had  applieJ 
declined  interferiag  with  :l. 

The  patient  Iveing  cthetiicd,  the  tumor  was  removed 
crucial  ineision  through  the  skin,  followed  by  a  careful  di^j^sccd 
terminated  without  the  ligature  of  tlie  carotid  artery,     'Xhe 


PAROTID  TUMOR. 


493 


orrhn,^  wna  vpry  Trpe ;  and  tlie  (li«^ECtl(>Tl  coiiU  imly  !ie  |>ros:^ 
Ciiti^  l>y  i?Jup|Hii;^  iViJui  litiic  to  tiEiif;,  aiuI  H}>[j1vmg  n  freezing 
mixture  uf  salt  nud  ice,  &o  ae  to  allow  an  inspection  of  tUc  parts 
to  be  divided*  It  wta  found  to  consist  of  hypertrophied  glnud- 
uUi'  tissue. 

In  a  slicrt  tlmef  he  was  dli^ultur^zud  nell ;  and,  wlicii  hirard 
frouj,  on  Nov.  G,   185G,  woa  in  good  Leoltii. 

Case  CCLXXXIT-  —  Cancer  of  the  Ptirottd.  —  A  woman, 
3?  years  uf  age,  applied  to  me  In  ttie  month  of  NuvcniLer,  1853* 
nitli  a  tucnor  o^eupylng  tlifr  seat  of  the  parotid  gland.  It  hnd 
appeared  Jirat,  two  years  before,  in  front  of  liie  etir ;  and,  in  its 
increase,  had  extended  downward  and  under  the  ear.  lifting  np 
the  lower  pirt  of  that  oi'^rnn,  II  WEia  a  little  movable,  iind  did 
not  project  mneh  beyond  the  snrroiindin;!  pnrta.  It  appeared 
firmly  nttiiched  below,  wju  somewhat  Jubukted,  and  imparled  a 
aense  of  elasticity  to  the  touch.      Her  father  dieil  of  nmcer. 

The  tmnor  was  eipnsed  by  n  careful  di^sei-'lioii  j  but,  on  its 
investments  being  cut  into,  a  gninular  matter,  like  {:ancer,  exudct) 
from  iti  and  the  hemorrhage  was  very  violent,  welling  up,  as  M 
from  the  canjtld  nr  siime  very  large  vesseK  It  was  tlierpfnre 
fouud  net'es^ary  to  tenninate  ilie  operalion  hy  tlie  ligature  ^a 
^luissr,  as  in  the  case  of  the  melanotic  a^ecliitn- 

The  disease,  examined  under  ihe  micrascnpe,  exhibited  well- 
marked  cancer-cells. 

1  learned  that  she  died  sLibsci[ue[itly  i.if  a  tunior  of  the  ab^ 
domen. 


Case  CCLXXXIIL—  Tumor  of  Pttroitd.  UcmovaL  — 
A  lady  ap|}]ied  to  me  on  June  18,  1850,  on  nceoiiut  of  a  tumor 
of  the  [litruliil  gland.  She  wns  43  year*  of  age,  and  enjnyed 
fair  healtbr  aklumgli  dyj^peptic :  none  of  her  laniily,  th^it  she 
was  aware  of,  had  ever  been  artected  witli  tumors.  Ahunt  two 
years  befoTe,  f*he  perceived  a  small  swelling  over  the  ramus  of 
the  upper  jaw,  juet  in  fmnt  of  the  external  mentiLs  cf  the  ear. 
ffie  BiEpposed  itt  And  so  did  others,  to  be  a  tnnior  proceeding 
from  ihe  bone.  During  1858,  it  increased  much  more  nipidly 
than  in  the  year  before;   and  she  was  Ji^iutly  induced,  by  the 


494 


TUMORS, 


ndvicr>  of  lirr  |>Iiysit'!iiii,  alrhiiKgli  eKtremelj  nervrnis  in  regnrd 
to  it,  Xti  u|)jilj-  lo  me  for  irdvicp. 

The  tiiinor  then  wns  ntiout  ihp  size  of  a  lien's  Cpg,  plof^ 
Hourly  over  ilic  npriciilntiim  of  ilie  J!nv,  nnJ  extendinp  tti  ih# 
mnlHr  lione.  It  did  not  exipnd  down  l)4?liind  the  jjiw,  elovnriHff 
tbc  l<d)e  (»r  th(?  cmr,  a  diLi?i;lion  must  cif  the^e  tumors  are  ili^pot^l 
to  take.  It  wsifl  perfectly  solid  and  immovjthle,  ami,  in  mv 
orlier  Bitiiation^  might  havp  been  tnken  fnr  n.  disoase  pirn***! 
b^tneeii  tlip  pi^Hoj^tnirn  »m1  thi?  boiie,  sf]  Urmlv  was  il  liK«<!- 
Tt  did  not  [wtrtJikt*  of  the  uiotiims  of  the  jaw,  which  moved 
iT!de|)endeiitly  of  it.  There  whs  no  pjiiii  attending  it,  Thr 
putienr  WHS  denf  on  flint  Aide,  which  she  ntirilniterl  lo  prestur* 
of  the  tumor  on  the  audiiorv  pHHsng-e.  As  it  wns  increasing, 
with  the  pnilwihlllty  of  lakii^  n  deep  dirtttinn,  and  ae  it  ^oeiued 
liiiklLtil  li>  tJiut  [jortiun  uf  the  piirotid  more  ^iipiTficinllv  eitunied. 
I  ndvised  .in  upunilion^  at  the  »;une  time  lit  running  her  frieiidj- 
tliat  there  w^n  a  jiiissihiliTy  ui'  its  recurrenee.  1  anxd  po^eibiJiT^, 
rather  than  pnihahility.  because  I  have  once  or  trt  ioe  fieen  lu- 
raor-*  of  this  deseription  whieh  were  eomplef.ely  liihiitod  to  tht 
parotid  ejipHuie,  imd  of  an  almost  osseons  firmness^  removed 
witliont  rernrrence.  The  jwilient  and  friends  Iwviiig  agreed  Ic 
an  upemtion,  it  wiw  perfuniied  on  Jitne  24tli ;  one  or  two  g«nt]^ 
tnen  who  aasisted  at  the  opemdon  thinking,  from  the  firmness  of 
the  Tnmori  tlint  il  inn.^t  be  an  pnrboiidroma. 

An  incision  being  mnde  over  the  wliolc  length  of  it,  and 
crnnsed  at  right  nn<!;les  by  nnotber,  the  entire  Inmor  wjis  exposed 
bv  dissect  ion.  The  pj<rolid  enpsule  bein^  (ipxl  cut  into,  allowed 
a  ^rannlar  matter  lo  p>enpe,  havinij  the  appearance  of  colloid. 
The  dissection  was  now  commenced  iD  front  itnd  rnitj^jde  uf  the 
capF^ule,  which  was  gradually  dissected  and  jieeli^]  up  with  tliC 
hrife  and  fingers,  no  us  to  remove  it  clcaidy  from  the  bone, 
and  x]\us  rdlitw  the  delioUc  capsule  of  the  upper  jiuv  to  escnrc 
tjntnjured.  The  facial  nerve  was  seen  emerging  from  the  i^landi 
and  it  wa?(  at  firat  snpposed  that  it  would  be  necesearv  to  di- 
vide it;:  \l  was  uftenvards'4  found  possible,  Ijowever,  to  split  lh« 
tumor  trfiUfiNerflcly,  dia&ecL  out  the  rerve,  and  leave  it  unin- 
jiired»  with  the  exception  of  one  or  two  of  the  bnmches  prot^ecd- 
ing  to  the  upper  part  of  tlie  face.      The  deep  part   of  the   g-lnnd 


P-^liOTlD   TtfltOR, 


495 


rhii:h  insinimtes  itwdf  Imc-k  cif  tlie  lower  jhw  ^jeeined  to  liuve 
jcaped  Ji»easn ;  a  t'urL  u|]i[:l»  I  Imw  oin'i-  or  twWe  (il>M:iveil, 
Ami  vvltidi  liaa  bfcn  frei]tK'n[Ly  ubserveil  \ty  other  Biir<^Gonj4,  Tlie 
iHJiie,  on  vkliiL'li  iIlc  tLimor  lay,  li^id  iiliiitj^it  LIil*  atLfi4.'(^t  t^f  be!n<r 
liollowtil  out  l»y  it,  Tlie  wuuml  w«m  brmi^lit  t»;rt'lla'r  by  siitiirts, 
and  eoM  wftrt;r-<lt'esair)gfl  H]i]>lie(l  tn  it,  with  n  little  cixiiprpr^Mion. 
The  jiHtii-nt  icogvereil  rii|ii<Hy,  tlip  skin  ailhenn^j  chiscly  to  the 
jbooe^  M)  ti&  to  Ipfive  rjiiite  nn  csrawileil  h»iik  ti>  thuc  psirt  cif  the 
!.  There  H'N^  iiu  fiinul  |i;ti';tlysis  ;  hiil  the  imist'iil^Lr  jLCCiun 
nbuve  the  urbit,  nn  thn  right  ^iilf?,  AceiitMl  lodt  from  tho  nectiun 
ofihi'  ntrve^  diwinhut^l  lo  thut  imrt,  utnl  wns  in  whcmjj  (.MntrEist 
whli  ihe  muM'ulnr  uriivity  ilispliiyi-il  in\  lli*-  iij>|msiiti  teiiijile. 

Tlus  |iiiijeTLt  flietl  nlniut  ei^liteeiL  iiLunllis  after,  fnmi  (.-iinferoua 
dipenfte  Jirtni'kinif  tht  iniegiEtiicrjtri  i)t'  tfie  i)we,  in  frntit  of  ihe 
former  ullei'JJiin,   whli  ultcLtJaiit  cunAlituLiunul  (Ji^eiue. 

Cabb  CC:i.\X\\y.~Pninfid  Ttnuur.  n^vitjvnl.  ~  K 
hi?a]ihy  Inokinj^  olfl  womam.  (14  yeiirs  of  n^e,  einne   iitider  my 


..^ 


■j;:> 


SI 


cnre  ut  llie  r(i*!*pitn],  Jiint!  3,  1*^51.      Thirty-Cv%'0  years  before, 
she  Eind  the  inuinpa   on   the   right  side  of  lier  fAce.   unJ,  ivheu 


496 


TUMORS. 


llic  ewelllng  eub&ided.  a  pcrmnnent  tumor  was  left,  wliirh  gradu' 
a][y  enliir^^ed.  In  ten  yc^Li'd*  it  fiHil  uKnincil  L}ie  oiza*  of  a  snuiU 
orange  ;  jid(1  a  fem^ile  cuncor  doctor  waa  «]ipHed  to,  wlio  *'clrew 
it  out,"  leaving  an  open  evfrt.  AVlitii  this  healt-nl,  llic  lumur 
a*nln  ejikrgeti,  and  ftftcr  ISVJ  prew  rapidly. 

When  I  saw  [ier«  a  tumor,  euch  aa  is  represented  in  the  wtMid- 
cut,  ot'ciipied  tlie  right  side  of  tlie  face  and  neck.  Tlir  clinmHfr 
of  its  hate  waa  five  indiea  in  one  directiun,  und  fciur  In  the*  olW, 
Itfl  circumference  about  iIlc  base  wad  n  little  mure  t.linii  n  ftxil. 
It  waa  nomewKat  lohulnt^l^  and  vi^iy  elastic ;  the  sWm  of  it  vm 
railicr  strongly  marked  ity  veins,  and  scarred  by  iliu  Hp|dicA(uin* 
of  caustic.  It  waa  freely  movable  on  llie  &»bjac<?iit  pHrts,  ruiJ 
caused  a.  sense  i>f  unenMtJc^a,  railicr  ibau  ]Hiia. 

The  patient  bein;;:  etlieii^ed  ^Ith  chloric  ether,  two  vertii*d 
inciBioiis,  ecmilunar  in  .*liape,  were  made  over  the  tumor,  incJud' 
ing  the  cireiimacribed  akin,  which  waa  adherent.  Then,  cnm- 
nicncin^  iit  ita  lowcal  part,  il  was  partly  Jidaected*  antl  pardv 
peeled  out.  lu  adheeiona  to  neighboring'  parto  were  not  vctt 
firm;  but  it  was  exceedingly  vft&cular,  and  the  operation  ww 
frequently  intemiptal  to  tie  vesaelo.  The  jugulai-  vem  wb§ 
wounded,  and  the  sound  of  air  entering  waa  diatiDcrtlv  beflfil. 
The  vein  waa  severed,  to  prevent  further  ingresa  of  air.  At  this 
time,  ahe  became  quite  faint  from  loss  of  blocid. 

Afier  the  reinitval  of  the  tumor,  the  cai'otld  artery  wnp  found 
cip*i^  at  the  bottom  of  the  cavity.  The  reniaimnnr  fi^in  wnft 
not  8ui£cient  to  cover  thewound*  which  waa  therefore  (illeil  with 
lint. 

During  the  operation,  paits  of  the  tumor  were  so  soft  4u  tn 
be  pressed  out  between  the  fingcra.  This  matter  wha  nearfv 
flcah-culored,  and  of  the  eonsiateiicy  of  n  aoft  apple. 

On  cutting  into  it,  ihc  acetion  wn^  found  compoecj  of  aimilur 
matter  in  pari,  but  in  some  places  waa  quite  fibrous,  Undtr 
the  microacopCt  no  true  cancer-celia  could  be  found  :  it  a[>- 
peareJ  to  be  coinpoaetl  of  £brea,  with  granular  matter  intcf- 
flpcrsed, 

The  wound  grnnulatcd  rapidly,  and  healed  without  adv  tin- 
toward  ay mp torn. 


nEOUEHEKT  PAROTID   TUMOR. 


497 


Cape  CCLXXXV. — liecurrcnl    Tumor  of  the  ParoitH 

Hand.  —  A  lur^e,  powerful.  liiU-bit>i»iled  tnnw,  34  vcaw  of 

^  conaiilted  mc,  in  Maroh,  1847,  for  a  ttimdr  m  tlic  rl|;r]]t 
prii"i*ti<l  ^'l;;nd,  A  tumor  luivl  hcen  rcmovol  from  the  e/inic  spot 
twcDtv  j'envfl  beJ'ure,  wliith  ahorHy  ^ifccrwrvrda  re-nppe-irecl  in  tlie 
form  of  n  smtxW  hard  tubercle  uiidur  the  ear.  For  fifteen  yenra 
it  rcinjiLTicil  dtaljon.'Lrj',  and  then  ]>cg^n  (o  iiicrcnsc. 

It  wna  uhoiit  tho  eiac  of  u  Lcn's-cg^.  of  n  bhuah  coIi>r,  lobu- 
klcU,  anJ  having  a  Imrd  bitae  Biirroundcil  bj  smaU  cvjta.  The 
lobe  of  the  car  Wiia  pushed  upwnrd  by  the  ttiiuori,  wliich  ex- 
tencleil  mwnril,  and  fippareTUly  involved  ihc  lower  hnlf  uf  the 
pnrotid  glamh  The  p:Uie(it  was  very  dcrfiroua  of  an  operation, 
and  I  dctcnuincd  to  atlcmpl  its  removal  wilhoiil  iirdt  applying  a 
ligature  to  ihe  (;ari.>tld,  wliich  r*etmi;d  to  bo  involved  in  it.  l^rs. 
J.  C.  VV'ftrrcn,  George  Parktimn,  Samuel  Farkman,  Dr.  Brlgg^, 
tad  Dr-  D,  D,  Slnde,  were  prcBent  at  tho  operation]-  This  vra* 
one  of  the  early  rases  of  tho  iiao  of  ctficr,  which  wns  adminis- 
tered by  Dr.  ilorton  with  his  ftppamtua-  TJic  tumor  re- 
quired a  very  alow  and  carefal  dieficction.  The  base  of  it  was 
Ossified,  and  preascd  upon  the  foeial  nerve ;  and  this  had  caused 
A  partial  [laiidysis  of  ihat  6idc  of  the  face.  The  removal  of  It 
waa  aeconipUshed  without  tying  the  carotid  artery  ;  and  the 
patient  wad  aufficieully  recovered  in  n  week  to  return  home,  a 
distance  of  some  hundred  miletJ, 

Some  twelve  or  fifteen  year:*  after,  thia  patient  again  applied 
to  toG  witli  a  tumor  in  tho  same  situation;  ihc  faec  parti^dlv 
paralvKed  on  that  aide,  the  paralysis  increasing  as  the  ttinior 
became  liardcr. 

The  tumor  was  again  removed,  the  wound  healed,  and  the 
patient  remained  well  for  a  time.  A  few  yeara  afterwards,  ho 
appfiei^l  to  me  a  third  time^  and  came  into  the  Hospital,  with  a 
large  ulcerated  cancer*  whieii  had  retunieil  in  the  s^me  Dituatiou. 

On  conaultation,  it  was  decided  that  no  ojieration  was  advis- 
able. The  patient,  liuwevcr,  was  ^o  eolicitmis  that  1  ehould  do 
BDmetliing,  that  I  diaaccted  bjick  the  llaps  of  »kin  at  tiic  base  of 
the  tumor,  and  then  passed  two  double  ligatured,  the  size  of  a 
whJ[iLN>rd,  by  means  of  long  needlea  willi  handler,  at  right 
angles^  aa  fur  beneath  the  tumor  a^  pjsaible.    The  ligaturea  were 


4y8 


TUMORS. 


tlien  tied,  and  the  whole  masa  etran^ulaled.  AfU*r  it  a^paxalM, 
powcriul  citu^rLC  upplicfitioiie  were  madci  and  iho  niAn,  vihcu  I 
]net  saw  biro,  had  0  email  hcaltlij  wound,  in  pltice  of  the  offtn- 
Bive  tumor  which  he  wns  autftring  JTom  before  the  oi>erfllr(ici- 
Thia  tuinot*  therefore,  fVoin  Ita  <^omniencemciit  to  tlie  last  i)|>cra- 
tion^  Tlb^  a  course  of  between  thirty  nnd  forty  yeare,  Doriiig 
the  whoJo  of  this  period,  hia  gencmJ  health  was  ^od. 

Ca6£  CCLXXXVI, — lietnarkalle  Disappearance  c/ m 
Appiireiit  ScirrhoH»  Tumor  of  (he  ^ecJc*  —  December,  1*^6S. 
A  gentleman,  nbout  5U  years  of  age,  of  epare  hitbit  nnd  io  deJ> 
cate  health,  applied  to  me,  about  two  ycnta  eiocc,  wiiii  n  bard 
tumor  of  the  eize  of  a.  large  lien*B  eg^,  situnted  pardj  under  tU 
ear.  It  w.ifi  nlmo3t  entirely  eaveloped  iu  the  eubstaiice  of  tJ» 
8icmo-nm£told  nmtele,  whore  it  is  atliidied  to  iIl^  mastoid  W9- 
cess  of  the  temporal  bone- 

The  tumor  was  ovoid,  well  defined,  Jind  njjparcntlj  finniT 
fixed  to  the  hone :  the  skin  above  it  was  a  httlc  U]^'olt>red< 
There  was  no  tenderness  in  it,  and  no  timrke  of  an  active  influD' 
matory  character.  The  patient  ^aid  tlint  it  Lc^^n,  ahout  ^ 
months  betbi^e,  in  tlie  ^Libstance  of  the  muscle^  nnd  had  grA^u- 
ftUy  grown  to  the  above-mentioned  eize- 

I  had  no  question,  from  the  appearance  of  tlic  patient  VtA 
from  the  examinntien  of  the  tumor*  hut  that  it  wad  M"  a  mtSiT' 
nunt  ehamcter-  I  did  not  encourage  its  removal,  ae  it  invohcJ 
a  loBs  of  ekio  and  a  large  portion  of  tlie  muscle,  and  it  di&aevticJ 
from  the  bone,  with  every  probability  of  recurrence^  The  p*- 
tient  waa  much  averse  to  an  operation,  unless  1  could  Lironu<< 
him  a  perfect  certainty  of  cure  fntm  it,  1  advised  ium  »on» 
constitutional  reniediee  to  invigorato  hia  health,  nnd  esriei^iolJT 
to  avoid  having  the  tumor  hiuidleil  or  disturbed,  ns  1  Imie  ofkn 
seen  the  growth  of  tumors  accelerated  hy  repeated  mauipuU- 
tions. 

Widiin  a  few  days  of  writing  this,  agcntleman  stopptxl  me  10 
the  street  to  iliunk  mo  for  the  advice  I  liad  given  hijii^  ami  rr- 
called  hia  case  to  mc.  Ho  said  that,  ehortly  after  consulting  mti 
the  tumor  began  gradually  to  disappear,  and  finally  v.ns  entirclF 
abaorbedp      On   examining  the  spot  occupied  by  it,  1  found  dx 


TUMOK    OF    CHEiflK- 


499 


upper  pnrt  of  tlie  sromo-mfl^ioid  mustlc  eligliilv  bulbous,  as  if 
^1  mflated  with  nir.     The  par:,  however,  was  perlecily  soft^  *^*^ 
not  iho  filighlest  trace  of  the  tumor  remiunod* 


» 


i: 
I 


Case  CCLXXXVIL  —  Ttiitior  of  the  Ftire  m^  OrbU. 
HecovGi-'f.  —  The  pntient  wna  40  ycnra  olJ,  Fifteen  years  be- 
fore, n  siiinll  pimple,  followed  by  n,  ac^nl6f  appeared  on  hi!4  face, 
below  the  eyeliih  This  u'Jis  kept  aore  and  irntittofl  hy  beiny 
constanily  pickinl.  It  slowly  incrcaiw],  invaJiug  tlie  ii;ie<[u- 
ments  of  the  face,  cellular  membrftue,  muscles,  and  nppiu'ently 
the  malar  bone,  and  takiiij,^  partird  possession  of  (he  orbit,  *o  aa 
to  force  the  eye  backward  and  upwoni,  flnd  in  a  great  ineaaure 
conceal  it.  The  tumor  af)penrcd  perfectly  ibted,  as  if  involving 
the  mu-lar  jltuI  other  bonee  of  tJie  orbit  •  and  the  operation  wjia 
one  alter  stating  (o  the  pati:>nt  the  uncertiuuty  of  the  reanlt,  of 
which  he  seemeil  fully  inviu'ef  und  with  the  expec^tntion  of  the 
neceasity  of  reinuving  the  niivtar  bone  nod  ihe  obitAr  proceM  of 
the  superior  maxillary. 

The  tmnor  on  the  fiuro  being  circumscribed  by  an  incision,  and 
liie  diiiBeclion  comrueucwl,  it  was  found  pogslble,  while  using  tJie 
chisel  to  examine  the  stale  of  the  bone,  to  peel  up  the  Tumor 
with  it  irom  the  bitae  wichuut  removing  Any  of  the  bone  itaelf. 
The  discnec  evidently  had  token  hold  of  the  covering  of  the 
bone,  but  had  not  penetmted  its  structure.  AVith  much  diffi- 
culty and  patient  dissection^  (be  whole  periosieum  of  the  malar 
bonej  with  the  tumor  attiichedf  whs  removed,  nnd  the  dissection 
carried  deeply  into  the  orbit,  removing  the  disen^e  there  in  the 
siime  way  ;  the  whole  mass  coming  out  perfectly  clean  and 
smooth.  The  edge  of  tlie  eyelid  and  (he  mucoua  membrane 
were  left  ;  and  the  si^t  was  not  injured,  although  the  eyebil] 
had  been  much  compressed  and  forced  from  its  natural  position. 

A  microscopical  examination  of  the  disease,  afterward,  by 
Dr.  Ellis,  revealed  a  structure  composed  of  much  Eibroua  tissue ; 
but  no  cancer-eolls  could  be  detected.  The  patient  recovered 
well  after  the   ojjcmtion, 


Case  CCLXXXWIL  —  H^ctirrcni  Tumor  m  Cheek,  wlh 
Enxtite  Tissue.     li^jtiovat-      liecouety.  — A  young  gentle- 


500 


TUiions. 


man  from  Halifax.  N.S.,  16  ycrre  olil,  came  under  my  care  in 
Jiiiiujiry,  1847,  lur  &  tumi>r  siiuntMl  in  tlic  eubsljincc  of  the 
right  cheek.  One  of  a  aimilar  milure  hnd  been  rcmpvcd  from 
die  ^nijic  siiuatjoti  two  jeafs  bclur^},  but  hiKl  epucdily  re- 
tur:ic(l. 

^Vhcn  I  eaw  hira,  the  wliolc  of  tlic  right  eidc  of  bis  itict 
loohcd  larger  Ihnn  the  left.  The  veins  were  much  distended; 
and,  at  lii'et  flight^  a  midi^aat  disease  of  the  unti-uin  would 
ha\c  been  euepccted-  A  lobiilntcd  tumor  vas  found  deeply 
Bented  in  the  eubstancc  of  the  check,  juat  below  the  zygomatic 
arch,  And  nppnrently  CTctcndcd  up  under  it.  It  was  movnble  ftod 
hard*  A  large  voseulnr  polypuid  growth  occupied  the  right 
noetrll,  und  entirely  obstructed  the  breathing  on  that  eide. 

In   coiiEuhalion,   it   was   determined    to   reo^ove    iJic    tumor, 
which  was   dune    on  Jan.    2Hth.     Thia  wna  one   of    the  early 
cases  of  the  uae  of  ether,  whicli  waa  exhibited  by  Dr.    Morton 
with  \m  inhaler;  nod,  in  four  minutes,  the  palieut  wiis  quice  in- 
Bcusiblc.      The   polypoid  growth  in  the  no6Q  was  first  removed. 
A  li'nnsverse  ipcieion  was  then  niride   aloug  the  lower  €^gc  of 
the  zygoma ;    the  &kn\  and  musculnr  fiubBtiLiico  cut   through, 
vrhleh  txprjscd  iin  erectile  tissue  entirely  cavclo[nn^   the   tumor, 
and  intimaiely  connected  svitli  the  aurrounding  pnrt«-     In  divid- 
ing this,  in  order  to  arrive  at  the  body  of  the  tumor,  a  hemor- 
rhage hegnu,  which  y;rcatly  obdcurcd  the  diesoction  ;   and    it  wns 
only  by  compressing  the  carotid   that   the   oj^crntion    could    be 
continued.     The  tumor  was  now  diaeovcred  cstendin^  up  under 
the  zyg<^uui.tiu  nreli,  but  only  alt.iclied  there   by  n  looec   ccllulnr 
tissue;    behind,  it  dipped  down   in   the  ihrcctiun  uf  the  epheno- 
mttsillary  tisfiuro.     It  was  detaehcd  from  these  different  con- 
nections nfier  it  lun*^  diescction.     The  operation  wiis  ^uepeuded 
irom  lime  tu  time,  in  order  to  idlow  the  repetition  of  the   ether, 
whjth  waa  three  times  repeated,  at  the  request  ol'  the  patient. 
He  said  subecqucntly,  that  he  hud  cxpencnecd  no  pain,  and  that 
his  impreasioua  were  njjrcciihlc.     Hia  call  for  ether,  he  £DJd,  i>na 
jwrtly  from  the  pleaHUrc  of  taking  it,  and  not  entirely  on   ac- 
count of  tho  relief  it  atforded  him  from  sulfering. 

Ill  consequence  of  the  great  hemorrhago  fpoo^   the  whole   sur- 
face ot^  the  wouud,  it  W&6  found  ncceuBary  to  U6c  compression 


LEUtXJUYTH^HIO    TUMOR6> 


£01 


I 


with  *(pong;e3.  No  su!iflequent  Llt-edir*"^  took  plfice^  find  tlie  pa- 
tient recovered  without  any  had  symptom.  One  or  two  vvccks 
elftpfiwi,  however,  before  the  Bpongea  could  be  extricated  from 
the  Jeep  wound,  bo  firmly  were  they  embrar-ed  by  the  grnnu- 
ktbna ;  and  ut  length  removal  svaa  only  accomplii^hcd  by  tear- 
ing them  away  jnecemeal.  The  disense  nppefired  to  be  of  an 
en(*e|jhiLloid  character,  and  eDtirely  surrouDdeU  by  erectile  tia- 
Bue,  thedhittion  of  which  gnve  rise  to  the  hemorrhage.  With 
the  exeeption  of  the  aetaal  cautery,  the  u&e  of  sponges  seemed 
to  me  the  only  menna  of  stopping  the  flow  of  blood ;  and 
from  the  great  difficulty  in  removing  these  from  the  wound, 
I  think,  thnt,  in  a  fiiniilar  case,  I  should  give  the  preference  to 
the  forinern 

Notwithstanding  the  malignant  appearance  of  the  tumor,  the 
puticnt  entirely  recovered  ;  und  T  aitw  him  Bome  year*  afterward, 
grown  to  robust  manhood,  with  a  marked  evidence  on  liin  face 
of  the  severity  of  tlic  operaiiona  he  had  iindergoue. 

This  disease  was  dimbrle^s  a  polypoid  growth,  inrestcd  by 
erectile  tissue.  The  question  of  its  maJigmmcy  was  seiiled  by  its 
not  recurring.  I  have  seen  one  Instance  of  a  eiiiiilnr  growth 
■which  had  made  its  wny  out  from  the  posterior  nnrea  into  the 
zygomatic  foasn,  probably  by  abdurptiou  of  the  auiicriov  m:ucil- 
Jary  bone  ;  a  part  of  it  appearing  in  the  QOHtril  of  the  needed 
■kle. 


LEUCOCYTII.EMIA. 


Thia  subject  has  been  alrendy  alluded  to  In  the  Introdciction  to 
this  chapter.  Ttri  histury  ban  been  well  ilJitFitriLlcil  hv  Dr.  II.  F. 
Damon  of  ihi^  eity,  in  hia  "Prize  Kj^eay"  puhlii^hed  in  l^li4> 
An  excellent  pnpL'r  on  the  "  PoHey  or  rm|iohcy  of  removing 
Lem'orvtIijtmi[',  (.rlnndidar  Tumors,"  bv  Hr.  I).  W.  Chccver, 
WHS  published  in  the  Boston  "  Tiled ical  and  Surgical  Journal*' 
for  Ang.  2,  \Ht\t^, 

I  huve  iiad  two  or  three  CJiscd  of  leueocytha*nne  grovvihs,  where 
the  tumors  were  aa  extensive  —  occupying  one  or  both  aidcjt  of 
the  ncck-^lbnt  an  operation  seeme<]  tnimlvi^ablc.  riiesc  cnaea, 
uf  which  the  following  is  iin  example,  Imvc  been  much  benefited 


502 


TUMOfia. 


by  the  u?e  of  iron,  aea-ti^tUin^,  l^  iii^hly  noiirU1iin<^  diei, 
the  <fElicr  incEirti   usually  cniploycd  in  patients  cnUed  ficrofaliniH 
or  of  oibcr  diafinacB  of  lt>w  vitiJity, 


Case  CCLXXXIX.  —  Tumotofl^eek.—X  young  w^ 
IS  je^n  af  ngc,  with  scAnty  menetruiitlon,  and  aiwftye  of 
tieliuftte  conetirution,  four  yeupfl  before  I  saw  Iier  lind  a  »i 
tumor  ;i|>iM;ar  in  the  neck,  iindci'  the  left  eir,  This*  for  about 
two  yeatB,  accmed  to  iDcroase  tatd  climiniah  nt  intervals.  At  iW 
end  of  tlim  time,  tlie  tumor  befj^nn  to  p'ow  Isn-gor  ;  nnd  oitica? 
were  added  to  it,  until  tJie  wKuJe  Mg  of  ilie  tieck,  from  the  wt 
to  the  clavicle,  wne  filled  with  Jar^,  sofl,  ajid  oneUr  moTod 
tuiZLOFB.  The@e,  upon  any  exdtement,  became  enlarged,  and 
li^^htly  di  St  ended  wjtl;  bloini.  The  patient  was  modcmcdr 
fleshy,  hut  lind  n  Uvid.  uulieallhy  louk  ;  imis  tP(>nblc<l  with  piJ- 
pitation  of  the  heart,  nni]  dvbilitv ;  also  diorlnega  of  ]>rcMk 
on  Blifj;ht  exertion.  She  aiiffered  no  poin  in  the  tuomi-,  which 
seemed  to  dip  deeply  into  the  neck,  nnd  overhung  the  cbivirle: 
but  ehe  had  neurul;:i;ia  in  the  leH  &mi,  whieh  was  eumewlul 
ewullen.  Her  jijcneml  hedth  was  improved  hv  a  tonic  eourx 
of  trentmt^Eit,   but  the  tuniur  did  not  diminitih  in  aizc. 

Case  CCXC-  —  Tutratr  iff  JVeck.  Operation.  Jnicmai 
Jugular  Vein  cut  and  tieiL  lUcover^j.^  A.  grontlemati,  3* 
ycara  of  nge,  applied  to  rac  in  May,  1801^  for  nn  uicerdted 
tumor  on  the  left  eidc  of  the  neck,  oucujjying  the  grcuter  por- 
tion uf  the  Tc^oii  lietwccn  the  outer  part  of  thi'  stcrno-mustoiJ 
lUUdcle  and  the  ti-nchcn.  A  tumor  of  three  years'  gro\%th  W 
been  removeJ  from  this  fipot  in  May,  185!>.  The  sheath  of  \\%t 
great  vcsecla  had  been  cipoaod,  and  the  inft!?e  separated  nt  that 
point,  the  pcdiel^/  oppoiently  cxletiding  in  between  them  nesirU 
to  the  ccrvieal  vcrtebrre :  a  lipnturo  was  tied  nronnd  this  pctliclv 
before  the  maaB  wna  cot  off.  The  tumor  waa  of  an  encysted 
character,  and  contained  a  thick  fluid.  The  wound  hcaloil  well, 
but  shortly  nftcrward  the  tumor  began  to  rc-aftpcnr. 

When  he  coneultcd  me,  it  not  onlj'  occupied  a  good  part  of  tliBl 
loft  side  of  the  neck,  but  pressed  back  into  the  ihront  ami  on  [he 
trachea,  impeding  deglutition  and  respiration.     Although  I  w 


TTJMOll    OF    NECK. 


503 


extremely  imvillin^  to  operate,  vet,  at  the  urgent  eolidtalion 
of  the  pnlient  to  make  nn  eHViri  to  save  liia  Ijfe,  I  t'OTisenleil. 
The  tumor  waa  encirclwl  by  nn  incision  pxteiKling  niong  the 
lower  edge  of  the  jaw  ;  another  ir  front  of  the  Iiiimir,  between 
it  nnd  the  trachea  ;  one  below,  iti  a  line  with  the  clavicle ;  und  a 
'ourth  in  a  line  with  the  sterno-mnstoid.  The  opemtion  required 
R  long  Tind  laborious  dii«ection  of  nearly  two  hours.  In  di*- 
aeetiug  tlie  mnmr  from  thp  grpat  ve-^sel/*,  iht  intemil  jtigolnr  — 
which  w:i»4  pwriiidly  incorporated  with  it  —  hail  a  pjef^  necessar- 
»ily  cut  out  from  its  side.  The  aperture  in  the  vessel  beinp  i*eize<? 
with  two  forceps,  n  ligature  eloseil  the  npprtnre.  The  lunior, 
which  was  of  a  dainb-hell  shape,  cxpaniW  behia:!  the  great 
veeeela ;  nnd  that  portion  which  pressed  up  the  mucous  mem- 
brane of  the  pharynXj  and  could  be  seen  in  the  mnmh,  was 
removed  williuut  any  great  difticnlty,  no  inHammaiory  adhetiions 
binding  it. 

The  patient  auppoiled  the  operation  well,  being  Heated  in  a 
rfiair,  nnd  under  the  influeoee  of  ether  for  over  two  hour».  The 
symptoms  that  followed  were  not  sny  more  violent  than  could 
have  been  expected  from  sueh  nn  o[ieration.  He  was  kept  ex- 
tremely f|uiei  lor  a  numl>er  of  dnye,  for  fear  of  [lemorrhage  from 
the  ju^mlnT.  There  wua  much  sorcne^Ji^  of  the  thrfiat.,  nnd  eome 
nffeciion  of  liie  voice.  But  he  recovered  riipldly,  mill  woe  well 
enough  to  return  home  to  aniitW  State  on  the  2Sth  of  May, 
nbout  three  weeks  at\cr   the  ojx'ration, 

Dr,  Calvin^ti^ Ellis  kindly  giive  me  the  following  microscopic 
appearances  of  a  portion  of  the  tumor  sent  him  :  — 

■'The  gro^vlh  vrti9  flhout  thri!^  inches  in  dianieler^  and  compn^^iil  of 
umall  hibiile^,  clusti-'rii"  of  vhifh  appeared  to  be  rniitainetl  in  cyslSj 
which  tlicy  (piite  llllcJ,  The  color  of  tliwe  loliulcs  vtiried  wilh  the 
uuinbvj-  of  bloodvcfificlfl  corittiincd  williia  tlicio  ^  fionic  lii^in^  nvArly 
while,  while  oiliere  worts  of  a  tlotp-red  color.  These  vcHaeUj  after 
re&chiD^  the  |)eriphery  of  ihe  lobule,  relumed  in  the  form  of  loops. 
The  lobulca  were  uompoaeil  uf  deliculc  RbrouH  liaaue,  with  small  nu- 
clei, with^  for  the  uiaat  part,  cuiLipariuivoly  siaEdL  uud^i.  la  >ome 
parti,  these  nuclei  w«re  quite  irregular  lo  form-'* 

One  OT  two  year*  aftorwariU,  thja  patient  coneultod  me  for 
u  recurrence  of  thie  disea^Cf  fur  which  no  operation  wns  avail- 


504 


TUMOB8- 


able.     Ilia  ^ocraL  hcfllch,  aielcc  the  operation,  hnd  been  i^^ 
good. 


Case  CCXCI.^i-fi^^e  Tumor  of  Face  and  A'tfci".     Rf- 
niovaL     Rocoverrf.     J^f^currcjioe  afitr  three  ^crrv.      OfKm- 
Hon.     Dtath.  —  Feb.  liT,  184H.     A  aiiiii^  aged  47,  ftpplied  to 
mc  with  a  tiJinor  of  t^vo  years'  standing,  occupymfr  a  good  part 
of  the  left  fide  of  the  neck.      It  bcfrnn  as  a  niovnblc  luiiiLir  near 
tbe  anj^le  of  tlic  jaw,  and  incren^jcil  iiniil  it  extoiidcd   froni  the 
cnndyic  of  Iho  jaw  tu  within  un  inch  of  ilic  clavjcJc  uiideme>lJi 
tlio  sterno-maetoiil  mneclc,  and  bcyunU  the  nkedian    line   of  tJic 
neck^  farcing  the  trachea  before  it,  and  encrunchcd   apou  tlif 
mouth,  puttbin^'  the  tongue  over  to  the  rig:ht  side.      The  cBn>I]ii 
artery  waa  lost  in  the  tumor.     At  a  consultation,    Jt  Wft«  de- 
cided that  an  effort  to  remove  the  tumor  eliouJd   be  ninde*  al- 
thon^'h  the  entire  eKtir|iati'>n  of  it  waa  eonsid(*red  as  doubifuL 
The  patient  bcinj^  |daced  under  tlie  inftucnce  of  ether,  the  re- 
raovfll   was   etlceted,   after  a  lon^  and  careful  diSEcetioii  ;    that 
portion  of  the  tumor  which  projected  into  the  mouth  being  enu- 
cleated wilhotit  any  difficulty.      The  carotid  aricry  nod  jugular 
vein  were  huncd  in  a  doep  fissure  on  the  lower  part  of  tlie  tumor. 
ARet  ita  removal,  the  anatomy  of  the  wbok  neck  wne    bc.iuti^ 
fully  dieplayed,  jjartifnilarlv  the  Bniall   muflclcs   under    the   juw, 
and   the   ueriea  of  that   pai-t.      The  patient  recovered   nipidJv, 
and,  after  a  few  weeks,  left  the  Hospital  well.     The  tumor  had 
a  sfilid  bopo,  witli  an  innumerable  quantity  of  cvets,  ivbich    per- 
vaded its  pubslaneo  and  covered  ite  eut'liiee.     1  »uw  nothing   of 
this  man,  until  twQ  yeare  afcerwarda.     He  then   had,    in    the 
middle  of  his  neck,  under  tbe  skin,  a  aaiull  m^tvable  tuaior,  about 
the  size  of  a  nut,  which  could  he  lakea  up  between  tlie  finc^ersj 
and   might  Imve  been  easily  removed   by  a  tew  etroke*   of  the 
knife:  he,  however,  declined  to  have  it  done^     1  lost  eight  of 
him  nntil  the  s|irLu^  of  1851,  when  I  was  called  to  see  him,  and 
found  him  in  the  following  condition  :   The  entire  left  ■'ide  of  tho 
neck,  together  tvith  the  front  part,  ofi  far  as  tbe  clavicle  and 
etornum,   waa   oocupied  by  an  enofmoua   tnmor,   c^»vered    with 
largo  veins,  and  CKiendinp  up  into  hie  mouth.      Oaij  part  of  the 
aurtace  had  ulcerated^   and,  from  ihia  place,  there  had  been 


TUMOft  OF  FACE   AXD   NEOK, 


505 


I 


TCpeated  nnti  Hcvcrc  hemorrhn^jes.       ITg   tKoujjIit   he   Imd   lost, 
ont'c  or  twice,  nearly  a  <|tuirC  uf  blt>od  j  Imt  tliU  was  jn-obiiWy 

Under  trontmont,  llic  bleeding  was  nioricnlarily  etnvod;  but, 
tecurriiig  a<rnin.  nnd  threatf^nin;;  liis  life,  lie  woa  finnlly  inducted 
to  be  removed  to  iho  Hospitivl,  where  he  could  ho  carefully 
^vatohed,  nnd  means  inetantly  used  on  the  return  of  the  hemor- 
rhage. After  a  few  dnya'  treatment,  lio  i-evival  a  Utile ;  nad^ 
en  a  full  consultation  of  the  BU'^gcons  of  the  hLij<^>ilid,  it  wtiB 
decided  to  inform  the  patient,  chat,  if  he  chose  to  have  tin  openi^ 
tion  donv.,  it  was  barely  (>o*siblc  Chat  hU  life  might  be  saved, 
To  t\m  he  at  once  ctmjsentcdp  The  following  day,  his  stren^rth 
having;  icvived  a  litUe,  eiifficieut  Co  allow  of  an  nttompt  to 
remove  the  tumor,  it  nna  done  as  fulJowa,  under  otlior*  The 
Account  19  condentfod  from  the  llosjiitul  reeortb :  An  iuei^ioQ, 
more  than  a  foot  long,  was  made  over  the  tuinor,  ihroufjih  the 
skin,  from  the  mastoid  proeeee  to  the  opposito  side  of  the  nceh. 
Tlic  Cumor  waa  now  |iact!y  dwaecled,  nnd  partly  onuclenlcd 
with  the  fingci'fl  where  it  pasdcd  under  the  tongue.  The 
principal  adhesions  were  in  the  vicinity  of  the  great  vc^^eld  \ 
from  the  ehearh  of  which  the  tumor  liad  in  the  first  o[icraTion 
been  dia^cctedi  nnd  which  had  since  become  completely  in- 
corporated with  it.  There  was  no  difficulty  in  diHsnccia^  out 
the  enrotid;  hut  thia  was  not  so  with  regard  to  the  jn^^'ular, 
wbicli  was  involved  in  a  nia^s  of  inHaunnatory  material,  nnd 
its  outlines  with  difficulty  di^lin^'uished.  This  vein  wiii^  \v't\ii}d- 
cd»  nnd  the  opening  into  it  followed  by  a  great  gia^h  of  blood. 
It  wnfl  at  once  scizi^l,  and  tied  on  the  side.  The  heinorrhjigc 
elsewhere  waa  pnncipnlly  venoua,  coming  from  the  lar^'c  vcine 
which  everywhere  covered  the  aurfaee  of  the  tumor.  The  whole 
time  occupied  in  sweeping  out  —  if  it  can  be  ho  cidleil -— this 
great  mtifts,  waa  hut  a  few  minutes;  aa.  after  the  firat  incialons^ 
every  moment  of  lime  that  could  be  »ivcd  wad  preeloua :  the 
surface  being  &o  e:itensivc,  it  w&ij  uacIcbs  io  atop  to  tic  vessels, 

Ou  the  completion  of  the  operation,  the  ]>atlent  fainted ;  but 
eoon  rcvited,  on  taking  a  few  drops  of  the  epiritfl  of  ammonia. 
The  wound  being  closed  nnd  di-csscd,  he  was  carried  to  Wi«  bed, 
and  seemed  pi'Ctty  comfortable.     Towards  evening,  lie  had  a 

&4 


isofi 


TUMOHB, 


reinni  of  r-ollnps^.  ami  tViefi  sudilonl}'-  He  had,  in  ibe  moR 
dtteruiinpil  nmnnpr,  rcfiiBeil  —  nWer  the  operation ,  nnd  ninit  h^ 
for^  it  — the  use  of  ditfuftble  MimulaQl!^.  froTn  batvinff  tak^nilu 
pli?()g<^  ftn^;iiTi^t  inloximliiiu;  i.ln»k8.  Substitutes  iverc  used.  W 
InetfectLLAlly  ;  and  It  is  diiubttul  wltetber  nay  dung  NrouU  ln" 
nlti^reil  llie  ret* u It, 


Case  CCXCTT,  —  Larf/e  Euci/Rtud  Thyroid  Tumor  of  ikt 
J^eck.  Incuion.  Jif.ctii'try.  —  A  lirtle,  lieflrty  ol*!  ladT*  «ppl 
d6t  entered  tlie  Hosjiitnl  on  June  11,  I8fi0,  whli  u  larf^  tniuur 
ocpnpying  ihe  whole  front  of  tha  nerk.  PXfRiidhi^  from  the  <iif 
to  the  sternum,  projct^Iing  uul  beyond  the  cbin  in  front.  It  wi' 
evidently  &  §&<?,  but  so  distended  th&t  nl  Hcut  it  mi^ht  eofiJv  I' 
mieraken  for  a  tioIiJ  tumor.  It  begjin  in  the  mtddlv  of  the  nwk. 
wben  elie  wiu*  only  two  years  of  a^,  and  inerensed  elowlv  iintJ 
June,  1859,  Since  then,  it  had  nearly  doubled  in  eixc,  Hir 
*ikin  over  it  was  red,  bnt  moved  freely  on  the  eubjaccnt  parW- 
It  WTU  not  tranxlucent,  and  no  flnt'tuntion  rould  be  f^lt  in  it 
Thero  waa  nr>  jtnarmin.  She  e<jni|>lmne<]  of  fulno^d  in  the  hc^J. 
apparently  owmg^  tn  the  obatruetJon  of  hlood  from  pressure  «o 
the  great  vesfleU.  On  the  IJllh  of  Juni*,  I  punetured  the  tu- 
mor with  n  pniTill  trnenr,  nnd  dretv  off  twelve  nuneeg  of  dark- 
ihin,  chcM^olnle-colored  fltijil.  The  ranula  was  left  in  the  wound; 
but  it  escaped  in  the  night,  owing  to  the  wanr  of  nppo^iljou  '*' 
tween  the  wound  in  the  skin  nnd  the  ^nc,  nt^er  the  escape  of  tbc 
fluid.  I  did  not  mnke  an  incision  into  the  tumor  at  this  timL 
wishing  fi]>t  to  te«t  (he  hemorrhai^ic  tendency  in  it ;  as  1  hiil 
once  or  twi<:e  brfore  observed,  in  these  eases,  that,  after  tlif 
pressure  of  the  fluid  wa«  taken  off  from  the  internal  pnrt  of  thf 
Rae,  A  troublesome  blectling  look  plHce  from  the  ere<Hi]c  ti»«lK 
pervadinjj;  It,  On  thi^  20(h  of  Jime,  I  mnde  a  fn»e  inctBiun  inii> 
the  tninor.  on  the  median  line,  tmd  evaeiiad^d  tn-veml  ounorf  vf 
bloody  serum.  A  tent  was  then  introdoeed,  and  rctnintMJ  it 
position  by  adhesive  pliisier.  On  the  3Isl,  the  putient  w»» 
comfortable,  biJt  ha*]  a  sli^^ht  fenssition  of  gidiline<iB.  The  dis- 
charge waa  of  a  purnleiit  nature,  nnd  grailtially  increased,  fn-it 
d^y  to  day,  in  (jijantity,  becoming  very  offensive;  eo  that  *^ii 
June  30th,  finding  her  suffering  from  great  prostration  aud  diitf^ 


507 

jtea,  1  ttgtih\  freclv  incbed  tfic  aac,  and  covered  h  with  a  large 
totilticc.      Slic  was  llicii  put  upuD  u  course  of  quinine.      On  tlie 
f.£<l  of  July,  thci-c  wuft  cuaaMi^raljIe  li  enictrrhEi<^e  i\\,m  tli^  wouDil, 
'liich  vrtiA  checked  by  expi>dLire  to  the  air.     Oq  tlie  f  »llowi[ig 
fday.  am*clier  eli^ht  heinorrlmge  took   place*  and  a  tliird  one  un 
[the   Gtli  July.      L^upptirntlon  was  free   from   the   sac,  and   of  a 
latural  4;onaUtencr.     After  this  time  »he  improved,  and,  un 
July  10th,  waft   ftdviacd  to  leave  the  Ilciapital,  and  go  into  the 
country.    I  did  uot  KoJtr  frum  Lhi«  (luiient  ai^'aiii  uiiIlI  Nov.  :f4th, 
rhen  her  physii^uui  wrote  mc  "  ihat  the  tumor  liad  cntirelr  dia- 
dpj>eared,  and  the  wound  healed  up." 

P  Cabb  CCXCUL  —  T/iijroid  Tumor.  Tuilct  removed.— 
A  woman,  35  year^  of  age,  noticed,  in  October,  1840,  a  email 
aivclKng  in  the  nei;k  on  the  right  side  of  the  trachea.  In  No- 
vember, 1851,  tliifl  havln*;  become  very  painful,  I  removed  it, 
at^cr  a  long  and  careful  dtseection.  It  proved  to  be  a  cyst  in 
the  right  loltc  of  the  thyroid  glandn  Four  moiiths  after,  another 
tumor  a|jpeaml  in  the  game  situation,  nnd  slowly  increased  until 
May,  IJJ.jS,  when  it  was  the  size  of  an  apple.  It  was  flnctu- 
ating,  and  unaccompanied  by  pain;  but  respiration  waa  im- 
peded by  Its  preasin^'  on  the  larynx. 

The  patient  being  ctlierizedi  &  vertical  incision  was  made  over 
the  tumor  down  to  the  aac,  whidi  waa  then  laid  o|>cn.  About 
ei^fit  ounces  of  a  dark-brown  fluid  eacai>ed.  Considerable 
liemorrhagc  ensued  from  the  interior  of  tlic  aac,  proceeding  from 
vcsaelfl  which  it  was  found  iniposaible  to  flccureH  A  otrong  U^- 
LuL'c  was  tlierefore  applied  to  the  mouth  of  the  aaC|  and  the 
patient  removal  to  her  bed.  It  was  found  that  the  sac  occu- 
[lied  the  poniiion  of  the  rl^ht  lobe  of  the  thyroid  gland. 

The  ffnc  at  once  HUeil  again,  and  tho  ligature  v\hich  con6ned 
the  mouth  of  it  tlirCiitened  lo  give  way,  but  for(unjitely  did  uot 
until  suppuration  took  place.  For  five  daya  al'icr  the  operation, 
there  were  repeated  hemorrhaged  from  the  eupcrficial  vcAsela, 
vrhicli  were  greatly  cngor^ied,  and  which  were  checked  by  ti»e 
application  of  a  solution  of  the  pcrchloride  of  iron.  Ihe  suppu- 
riitlvo  proccoa  obliterated  the  aac,  and  she  waa  di6char<^  per- 
manently cured  in  four  weeks,  and  1  have  aeeu  her  fre<|ucntly 
5iac€,  in  good  hcalUi. 


SOS 


TLNORfi. 


ThyroM  tumors,  t\a  aur^eons  well  know,  ore  altrnjs  trouhl<> 
Bomc  to  deal  witli.  Tlic  trcatracnt  by  &(*ti>rj  ia  not  uiialtcniW 
with  tlangci-,  and  I  hnvc  seen  serious  hemorrhages  resolt  frt>m 
ita  UPC.  In  one  p&liont,  a  very  inurkwl  protnifiion  of  ihc  e^o 
(eiophllmliuud)  co-exbtcd  with  it,  ac<iornpriiiit.>(l  by  an  anaemic 
condilioti  and  sonic  ccrcbnil  dielurbfltice.  This  patient  urf<mlJif 
dcflirctl  an  operalion,  bul  I  did  not  eoo  llic  way  clear  to  ju*Uf' 
inc  in  inicrterin^  with  iho  tumor.  The  treatment  of  ihei^eiu- 
more,  whether  solid  or  encyelcd,  with  the  long-continueii  intcnttl 
or  external  uec  of  iodine,  requires  judgment  and  CAution. 


f 


Case  CCXCIV.  —  Titmr^r  of  the  Neck^  involving  the  Aril- 
larif  PU^ne  cf  Nerv€«.  Jiemovnl.  — A  woman.  4t>  year*  flf 
ngc,  Jipjtlicd  to  me  in  Oetober,  18135,  for  a  peculiar-looking; 
tumor  of  tie  neck,  i>f  thirteen  yeara'  fliandinir-  Some  time  be- 
fore, she  hod  been  run  over.  A  hiirfte  etnick  her  with  IiIa  hciid. 
knocking  her  d^twn,  anil  the  wheel  of  a  carnnse  pnasoii  over  hfif 
sLouliler.  Shctrtly  after  the  uei^ident,  ti  aniidJ  hard  tumor  ap- 
peared, above  the  left  clavicle,  very  near  the  ncFomion,  This 
c<viitinuei.l  to  grow  until  it  nltuined  the  eiiEe  of  a  ^ose-cgg.  It 
prcfduccd  much  pain  in  bcr  arm,  and  partially  pnralvzed  it. 
It  Inv  Tery  deep  in  the  outer  triangle  of  the  neck,  wo^  a  Hide 
moTftble,  and  fili^^htlj  fluctviatinjj  on  prcesurc. 

In  order  t^>  remove  it,  a  criieiol  incision  was  made  fio  as  tD 
freely  ejipoae  the  tumor.  Tliii^  was  eompoeed  of  a  thick  mCy 
which  was  partially  embraced  ly  filaments  and  nervca  of  UkC 
braehiai  plexuSi  By  a  very  rareful  dieeectlon,  the  nerves  vrtrt 
gradually  detached  from  the  tumor,  and  tlie  biie  di6:dectc<]  oat, 
leaviiLjf  the  hracliial  picxua  exfjoeed-  The  hemorrhage  %vne  quite 
free,  and  tome  large  ^eesela  re<]iiiroJ  the  li;:ratiire- 

The  ^ac  eontaii)ed  a  ttirlid,  ^croue  Hujd>  In  the  inttaini 
tory  pn*co«a  which  ensued  for  the  reparation  of  the  vvoiind,  tlie 
pain  in  the  arm  waa  temporarily  a-^crnivated,  iiccampanicd  ivilB 
crampa  in  the  thumb,  index  and  midille  lin^orf. 

She  gradually  recovered,  and  waa  diselairged  in  about  threo 
weeks,  I  saw  her  some  monlliB  afterward,  ontl  preeoribcd  for 
her  a  number  uf  times;  the  power  in  the  arm  becoming  i^-ad- 
ually  restored  ofler  the  remoral  of  the  tumor. 


CYSTIC    TUMOlt    OF    BREAST,  509 

Tlie  €Xtt(^t  wny  in  vrhk-h  the  p.isenije  of  the  wheel  over  the 
ihouMcr  cniucd  the  lumor  is  diHicuh  ii>  exjikiii,  cjicept  that 
\t  was  hy  soma  e'^tsum  of  IiIochI  iLt  the  tmie,  under  llie  fuacifl. 

Case  CCXCV.  —  iftfihoceh  of  the  JWci-.  Lj^ffrtmmn- 
tion.  Suppuration.  Itmnoval  of  Sac.  —  Ayoun^'umn*  28 
yenre  of  Bfj^,  hud,  for  a  yeiir»  a  tumor  in  tbe  lower  trinn^le  of 
the  neck.  It  tomment-'eJ  quite  emiill,  juat  nbove  the  ':ln\'i<:le. 
^Vhl;ll  I  fiL^^t  j^nw  hiiu,  it  hnd  int^rensctl  t^u  as  to  oct^iipy  nearly 
the  whole  of  one  side  of  the  neck  ;  extending  from  th(^  c^kvicle 
to  the  mneloid  procoae,  nnd  from  the  (rnchesi.  uiidornenth  the 
stcrnci-mn^toiU  uiti-^clf],  to  the  back  of  the  neck.  It  omi&eil  him 
much  pain,  and,  from  the  pressure  on  the  trnchen,  difficulty  ct 
respirution.  By  my  direction,  he  enlere<l  the  Hosjiitftl  for 
treatujent.  Shortly  nfter>  it  suddenly  became  tenae  fuid  jifiin- 
ful,  and  the  spot  on  its  tiiirfHt-e  red  ;  ahoAving  indi(rftliona  of  suj>- 
pumdon.  It  w&fi  chcre(^>re  lipened,  nnd  n  gi-cHt  tjiinntity  ot 
sero-purulent  matter  dischiir^ej.  It  hml  once  before  hoen 
opene<l,  and  n  qimnttly  of  mtlky  aenim  evncu^iieJ. 

Tlie  tumor  uow  "^adimlly  contrneted,  and  the  pniient  hnd 
mni'h  relief.  At  the  end  of  iihoia  three  weeka^  it  hiid  contnicted 
to  ihe  size  of  a  largo  apple,  and  It  wua  dctenmneil  to  attempt  to 
remove  it, 

Tlie  dijisectlon  wns  very  long  nnd  Uboriouj^,  iraplicntinjj  most 
of  the  large  hloiwlveaaela  and  ncrvcfi  of  tlio  neck;  the  Jofliimmn- 
tion,  wliioh  h^iJ  iMken  jtlno^  in  the  sic,  having  glued  il  to  t)ie 
surrounding  pnrts.  A  e^mplom  which  occurred  during  its  re- 
inovnl  19  worthy  of  notice,  whirh  I  have  obi^erved  before  in 
removing  impirtfint  turaora  involving  the  nerves  of  the  neck. 
Whenever  the  tumor  wiia  drngjpcd  upon,  respiration  was  ao  mitch 
affected  that  it  was  necessary  to  suspend  the  operation  for  n 
time. 

He  remained  <;uite  depressed  for  nn  hour  after  iho  operation, 
ntthough  he  lost  but  Utile  blood.  The  recovery,  however,  wns 
good. 

Case  CCXCVI.  —  CysnV  Tumor  of  S^^ea^t-  Jl^jnoiaL 
— Aprit,  lSi3(}.     A  stout,  henlthy-looking  German  womim,  45 


510 


TUMORS. 


* 


yfora  uf  age,  (ttMere<l  the  Ilogpitnl  for  a  tnroor  <ri'  the  bmA. 
of  wliidi  aho  gftve  llie  loU^wiiig  hi^lory  :  Eighteen  ytftra  UW. 
af\er  her  tirfil  (^onfiii^ment,  ahe  applied  a  piippv  to  hor  brcaui  h> 
draw  ofT  the  milt-  In^tend  of  drawing  off  the  milk,  he  bil  of 
the  nijiple  t^t  tyim|"leiely  that  the  milk  could  nt^t  be  drnva  a 
alJ,  Soon  after,  the  hreasi  In?giin  to  swell  ;  and,  ut  ti*e  eod^ 
three  months,  hroke. 

After  this  hfl'l  hejilod,  a  smnll  hard  bunoh  wus  notioMi  m 
Eulj^dmoj?  of  the  ^HufiJ,  insiJe  of  iho  position  of  tlje  uiiiiJf. 
With  the  hirth  of  eo^h  one  of  her  children  eub8c<}iicntlr,  sU 
hnd  a  jiiinlliir  n-bspesa  in  the  bjv-asf :  and  the  tumor  alowk 
iocreiis^jd  in  i*ize.  Dunnn;  this  period,  her  ^eiicnil  JtesUtli  rr- 
mnined  very  good?  nnJ  ahe  suflered  no  pain  in  the  breast,  ti- 
cept  at  the  IJine  when  it  wtis  distendttl  with  mi.Ik»  and  brxikco. 
In  ihe  early  pnrt  of  March,  18<^fi,  nftei*  exposure  I41  rovtw 
weftlher,  thp  hrenst  becanip  swollen;  and,  to  relieve  it,  ^ 
applied,  by  the  aJviee  of  an  M  wonj.in,  a  strong  CAuetic  jtrrp- 
nration,  which  was  kept  on  until  cliree  duys  before  ooming  to  dv 
HofipiCaL 

On  entrnnce.  the  breast  presentett  the  following  np|>eHnitJcc8£ 
It  was  very  niiM-h  enlarij^ovl,  and  rlie  akin  ilennded  for  n  apaoc  ol 
six  indies  in  drciimrerpnce  in  the  centrCj  where  a  pedunciilaicJ, 
ovoid,  bleeding  maas,  the  sizo  of  an  orange,  protvnticd-  Insulo 
of  this,  covered  by  the  t^liin,  a  hard  lump,  the  size  of  a  hen'* 
egg,  r^ould  he  felt.  The  patient  staieil,  that  a  etnull  maM* 
nttadied  to  the  larger  one,  had  douglied  nway  6ve  dAj^  beTon. 
She  had  no  pnJn  at  any  time,  oxr<?pl  from  the  use  of  tlie  caus- 
tic. The  skin  cf  the  ghnd,  outside  of  the  denuded  poriioD« 
was  not  di5f?i>loi'ed. 

The  piiiient  being  etherized,  the  ttimoi'fl,  with  the  surrouadin" 
glaiid-tiAfiue.  wore  rnmoved.  Very  plight  hemorrhage  eQau«d, 
requiring  fonr  ligatures.  The  tmnora  were  found  to  be  coin' 
poised  of  proliferous  cysts. 

The  wound  united  wltnoat  by  the  first  inlention  ;  ^^d  tlic 
patient  letl  the  Hospital,  well,  in  the  course  of  a  few  w^ck&. 


Case  CCXCVll.  — Erectile  Tumor  0/ B reus t.     Jtvuioval, 
—  July,  l*i62,  a  hoalthy  woman,  47  years  of  age,  entered  the 


TUMOR    OK    RHEAST. 


fill 


^Hospilnl  fur  n  mmor  of  the  brenaf.  It  B|j|ieEired,  twc*  j'Oaw 
bt^furt^,  as  n  smuH,  linrd,  painless  lu[np  In  the  rii^Kt  bron^l,  near 
Lo  nipple,  find  mOTGnsed  in  site  elowly.  In  June^  186^,  nftcr 
an  PXJJininiuion,  jisiin  wjia  iir*t  felt ;  and  for  ibe  folluvvmg  tnonih 
tlicrc  were,  nt  times,  severe  Innctnaring  piuna  in  tlie  breast, 
wliich  WHS  iibout  doitblc  tho  naturid  sizc^  nud  m(Kl(?r:iicl/  bnrd 
on  pressure. 

The  pnrient  wfls  etherized,  nnd  the  hnnlness  entirely  subsided. 
An  eiqilorntory  inoi-iion  wna  tht!n  nmde  over  the  mnn>r ;  and, 
after  dissecting  thi-ough  the  ekin  snd  adipose  tiesue,  a  durk-bhie 
AubstEitiee  was  found,  whic'h  pi^vcd  to  be  q  iiieiss  of  dilntod  veins, 
flbrnit  the  size  of  the  little  finger.  The  rL^ai  of  the  tumor  wft» 
then  earerul]y  dissected  out,  and  found  to  be  of  &n  ereeiile  ehur- 
noxer,  occupying  the  entire  gknd.  The  whole  msiss  was  removed, 
a  few  smiill  arteries  re([uiring  ligature.  The  pnticiit  made  a 
rapid  recovery. 

Case  CCXCVIII. — Chronic  laflantmat ion  of  the  Breast, 
re»e7nbtiti^  Scirrhiis.  lietuovnl.  —  A  woman,  bom  in  Eng- 
land, appnrently  of  Jewish  origin,  appheil  to  me  in  January, 
18ijU  for  a  tumor  of  the  right  breii*(,  which>  fo  the  ti»M<^h.  gave 
the  ordinary  aeneatlon  of  Ecirrhufi.  Her  physician,  n  die^tin- 
guiebed  prnetitioner  in  ft  neighbormj^  town,  bnd  exumined  it, 
and  adviaod  its  removnl.  !5he  was  twonty-tive  years  of  age  1 
with  an  exntrniely  delicate  and  tninspftrent  skin.  Her  heidlh 
bnd  generally  been  good.  She  had  boon  twiee  eoufined,  and 
had  bnd  one  or  two  uiiscarnagea  ;  bLit,  although  well  developed 
in  every  reapeet,  nevci'  bad  any  milk.  Nino  months  before,  she 
WHS  confined,  wbtn  a  swdling  look  plaire  of  both  hrea^itB,  but 
without  nry  uiilk  in  cither.  The  right  brerist  suppurated,  and 
was  opened  in  Iwo  or  thive  placcj^ ;  it  remained  in  n  »<orc  e1;i[e 
for  two  monilis,  when  It  healed,  leaving  an  induration-  This 
enlarged  from  that  time,  and  became  more  nnd  more  trouble- 
some. 

A  turnor  of  the  sizq  of  a  small  potato  was  discovered  in  the 
axillary  side  of  (he  breast.  It  was  (jnilo  movable  :  the  skin  over 
it  wfl*  retracted,  and  adherent  in  one  or  two  places  i  the  nipple 
•0  deeply  dmwn  in  as  to  have  entirely  disappeared.     The  tumor 


A!2 


TUMOK8- 


coiild  not  he  diHtin^iiLFiheil  frum  scirrhns  ;   still,    thfi  hit 
tlii^  ciisc  anil  nge  nf  [Im  pnticnt  eceuiud  a-^aiD^t   it;   but  m 
breast  wji»  entirely  tt^elcris,  And  ns  ii  wns   the  sourcse  of 
imfiuiun   to   lier,   I  ndvUpd  its  reinovul. 

Tlie  tumor  waa  reniuvol,  together  with  the  nippEe  find  «dl 
cdC  skin.  The  Jrody  uf  tlic  tumor  was  coin]>osed  of  a  tranvpaiiii^ 
fibrous  tissue,  which  creaked  under  the  eealpeL  Near  the 
fiice  wu.i  nn  abaceBs,  tibnut  the  j^ize  of  n  cherrv*  fillod 
unhealthy  Wking  [iuh.  Althoiiglt.  when  trxpitted,  the  Iudv 
filill  gnve  to  the  finger  tlie  Bengnliun  of  Beiirhus,  yot,  on  exmniia- 
tion  with  the  niir.'ro?4i^ip8,  no  esineer^ella  could  lie  fViiind  in  ll 

The  [kit ( on t  hnd  n  gotid  recovery,  and  was  ecco,  ia 
186S,  in  H  state  cf  perfect  health. 


»f 


Case  CCXCIX.  —  Cancerofthe  Breaxt.  IiejitovttL—\ 
the  £7th  Deecniberf  1801,  I  ujiernteit  on  ihe  f<dlowiii^  cnee :  Tl^ 
lady  wita  40  years  of  age,  unnutrried,  and  very  dcUcute. 
or  two  of  lier  family  haj  died  of  eancer  of  the  tilerue.  And 
now  has  a  cancer  of  the  breast.  She  perceived  xUc  tumor  r* 
ibe  ftxiLnry  side  of  the  left  breast  four  years  before;  it  tlw 
beiD_^  rjuite  small  and  movable.  One  year  before,  it  enlArr^. 
adhered  to  the  skin;  and  xvas  just  on  the  point  of  tilcenti't 
when  I  operated-  Sbe  had  pain  in  the  tumor,  nnd  in  ihe  hns 
of  that  eiJe.  I  rernuved  tho  tumor,  the  nminmnrv  gland  I* 
whit'h  it  waji  nttnchtd,  nnd  the  ,^kin  over  it.  The  wound  wa*ap- 
proximaieil  by  sutures  and  adhesive  stra|>s,  nnd  a  buti<lage  apiilioL 

On  cutiing  o]H?rL  the  tiunor,  it  was  found  to  be  n  scirrlioai 
lump,  iiiToIvin^  the  edge  of  the  mammary  gland  ;  the  skin  owr 
It  being  destroyed  and  the  edges  ol"  the  skin  ineorporiitctl  wilK 
it.  The  wound  healed  well,  A  slight  imtntion,  and  ^^xudatiun 
from  the  eurfnee  of  the  scar,  however^  continued  for  eomi 
monrlift.  She  then  improved  in  henltb,  aud  now,  at  tlie  end  of 
five  yenrsi  is  perfectly  well- 

Casr  CCC.  —  Cancer  of  ike  Brtattt,  folio  win  fr  tmm^i- 
ttUlif  an  Niir»iiig.  Paltiaiive  Ofiertitian,  icith  Iter.urrtnct 
of  Didf^rtfte.  —  A   lady  was   brought   to   nie  hy   her    i>hvsjriau. 

with  a  Beirrlmus  enlnrgezneut  of  the  left  breast ;   the  ekin    \mr\z 


CANCER   OF  BRBAST. 


fil3 


covered  with  cunccrous  tu!>erclea.  There  wii3  also  a  eli^ht 
enlar^ment  of  the  glnrtct:i  in  the  nxillii.  The  tum^ir  wiia  quite 
painfuJ,  as  was  tho  arm  of  the  same  &iJc,  nnd  @Icc|)  ititer- 
ftred  with  from  thi^  chubc.  There  wns  aleo  a  slight  eough. 
She  was  a  smnll,  rnther  delicate  w-iman.  ri>rt_v"-fivc  ycnrs  old,  and 
the  mother  of  eijjht  ehildreu ;  the  diaeiise  having  appcitred  nlout 
four  months  before,  immediately  after  wcaninir  tlic  Inst  child. 
The  operation  for  il^  romovnl  was  perfoTmt^l  on  the  7th  of  De- 
cember, IHOl.  The  hreaet,  with  the  skin  over  it,  anJ  the 
dieensed  glaud  in  tho  ascilln.  being  removed,  eufticiciit  intcgimicnt 
remained  to  allow  of  the  appn>ximation  of  the  cil^es  of  the 
wound.  The  hemorrhngc  wim  eonsidcrable,  as  is  fhc  oji^e  in 
most  of  these  tumors  of  an  active  growth.  As  the  vvoman  was 
thin,  I  determined  to  make  nti  attempt  for  union  by  the  fir^t 
intention  :  the  ed^ee  of  the  wound  wore  therefore  nieely  approxi- 
mated by  menna  of  ejturca  ami  filaetcr.  For  the  first  two  or 
three  daye,  fthe  had  a  fehrile  Action,  apparently  dejjciiding,  in  a 
£pi3iit  mco^nre,  on  the  efFcel  of  tfic  ether. 

The  wound  united,  almost  by  the  firnt  intention  :  a  part  of 
tlie  ekin,  however,  in  its  centre,  where  tlio  traction  waA  ttie 
g-reatcat,  elonj^'hcd,  Abont  the  tenth  day,  ehc  was  able  to  eiC  up 
and  take  solid  tuod,  and  on  the  fourteentli  wa^  able  to  g-n  out 
for  a  abort  walii.  Shortly  a^tar^  ebe  left  the  llospitnl  with  her 
wound  nearly  healed,  the  pain  relieved,  and  her  cough  entirely 
gone. 

I  saw  her  again  a  few  montlie  after,  with  a  recurrence  of  the 
tittieaao  in  the  eiciUrtx-  I  should  have  stateil  Wfore,  that  J  had 
infi>rmcd  the  patient's  friends,  previoua  (o  the  fir,*t  operation, 
that  curicer  occurring  in  thia  way,  either  dui'ing  or  immediately 
after  nursing,  ie  generally  of  the  most  Lintavorable  dciseription, 
and  is  almost  certain  to  refrur :  if,  however,  ihcy  elmse  to  have 
an  operation  performed,  to  relieve  her  sufferings  and  to  give  her 
a  Icmjwrnry  respite,  J  aaw  no  objection.  The  operation  did 
have  tiiia  effect,  and  also  relieved  her  cou^^h.  Her  health  had 
been  unite  guod  after  the  healing  uf  the  wound.  I  did  ni>t 
advice  a  rcpeEition  of  [he  operation,  aa  I  ahould  Iiave  dime 
under  other  circumstances. 


314 


TIMORS- 


Case  CCCL — Confer  of  Br^u*t  Mekite  yurtin^.  h 
moval.  —  A  iady,  26  yenre  of  ftge,  of  ^ood  shape,  ut^  »)n? 
heultby,  wna  delivered  of  her  firai  child  in  185!*,  In  Au;* 
18tiO,  she  |»«rceivc<1  iliAt  lier  nglit  bi-c^rii  wt^s  fiwollen,  boi  a» 
tinued  to  nur^e,  and  in  January  iipplicd  to  me  n-itb  u  ofi^ 
trated  caneer  ol"  tlw?  whole  of  tKe  glnnd.  It  did  not  thco^ 
her  much  pniiif  but  her  hcallh  was  t'hdhig,  J  advieed  vratat 
her  child  at  ctnce.  SuhAcqiicudy,  ahe  came  Co  nte  ik^^ti,  tii 
the  (li^wflse  in  i\n  ntlvnnced  suie  ot"  'levelopmont-  Tbe* 
brenst  wns  solid,  nnd  migliF  well  be  trailed  ^^Irrhou^.  Tht  ^ 
was  oovcred  with  cancerous  tubercles:  tb^re  wns  no  enlwyti 
glnnd  under  the  Asilk,  The  pnin  in  itwn«  exceeeivc,  ofn 
ing,  stinging  cbnrao(er,  ntid  dnnbg  up  throu"-)!  tlio  nerves 
the  shoul Jer-jiiint .  She  was  \ery  dcr^iroua  of  liaviti"  tht 
ensc  removed,  and  I  finnlly  ngrccd  to  do  it,  in  order  to 
her  n  tempomry  relief:  at  the  same  timp,  mnkiii**  her  fidlv 
doratand  that  diat  wiia  idl  she  could  e^jJOf^t  ri»ui  it,  When 
cnme  to  the  opernlion,  her  courage  failed,  utid  the  dctenDiiM^ 
to  nbnndon  the  idcn  of  hf>ving  it  removetl.  I  cUd  not  see  bcr 
ngnin  for  two  or  three  week*,  when  »he  called  on  mc,  and  ^^ 
tlmt  the  pnin  had  become  so  intonseT  nnd  of  such  a  btiniui<r, 
grinding  character,  as  to  deprive  her  of  «le(>p,  nnd  rtxtAs 
life  intolerable.  She  begged,  therefore,  to  have  the  opcmllaa 
done  J  otherwise,  she  feiired  ibjit  she  fihould  die  from  excessive 
pain.  The  whole  buhsiance  of  the  breaet,  together  with  thi 
skin,  waa  of  the  most  excessive  h;irdres9 :  \l  nppeare<l  eolidW 
tuLherent  to  the  ribs.  The  |>:uient  had  a  hluUh  and  idiui^^ 
asphyxiated  look,  but  waa  still  in  tolerable  fleah,  and  nj^| 
pretty  strotig.  She  wns  fully  etherized,  and  the  whaJo  tunoc 
encircled  by  an  inciaioii.  A  little  dissection  Avas  now  mnde 
under  the  lower  edge  of  the  mass,  bo  na  to  afford  n  good  hold 
Upon  it!  nnd  the  flepanition  was  completed,  partly  by  tearing, 
and  partly  by  the  handle  of  the  knife  and  the  fingei's;  this 
being  considered  the  more  effectiud  way  of  goiiing  rid  of 
tliseoHed  tissue.  The  siirfiice  expoBcd  waa  about  the  size  of 
common  dinner-plale.  Tho  hletding  after  the  opemtion  wne 
excessive;  but,  tvhile  engaged  in  taking  up  the  ves^ela  whi 
required  ligatures,  the  pulse  failed,  and  the  pnlieot  was    seea   to 


ttlLS 

i 


CANCER   OF 


515 


»e  111  a  state  of  crlla[>we:,  requiring  the  applicntion  of  ammonia  to 
the  nostrils,  frictions,  ^.,  under  wlncli  Irentment  slie  rcvivcil, 
I  have  oQCC  or  twice  observed  this  condifion,  wlicii  exteoffivc 
wounds  over  the  region  of  the  heart  have  been  expoj^ed  to  the 
air.  In  the  present  insinnoc,  theae  snme  syruptoma  recurred  a* 
Boon  na  the  wholly  surface  of  the  wound  waa  agiam  exposed^  The 
[vcmaimng  vcascb  were  therefore  secured,  taking  care  to  uncover 
'only  JL  fimall  surfiure  of  the  wound  nt  Ji  time.  In  the  subsequent 
Idressingfl,  inatead  of  uftiuj^  cerate,  flour  woe  applied  to  the  whole 
^eurface,  which  waa  removed  from  dnj  to  day.  as  appeared  to  be 
required.  This  method  I  have  frequently  adopted  in  dreaeing 
Terr  large  wounds  reauUing  from  the  removal  of  the  breaat, 
when  it  is  im|:ortaiit  to  avoid  tbe  daily  exposure  of  the  aurftice 
in  drcaeing.  The  eecretions  are  afjoorbed  by  ilic  ilour;  and  the 
email  masr^es  iUns  formed  roll  off  from  the  wound*  and  can  be 
easily  removed,  and  replaced  by  freah  applieatlona.  She  waa 
■ftt  onoe  relieved  by  the  operation,  and  wa«  placed  in  a  atate  of 
comfort,  when  compared  with  her  previous  condition  of  torment. 
It  required  three  or  four  weeks  for  her  to  i-ecover  so  aa  to  be 
*«ble  lo  go  home.  Tlic  v^ound  waa  then  Iwo-lhlrds  healed.  I 
never  hcanl  from  her  afterward,  but  have  no  doubt  that  the  die- 
eaee  returned. 

Case  CCCII,  —  Cancer  of  the  Brtat^L  Operation.  Rt- 
nppenrtincf  of  Cancer  iit  oth^r  ptirtii  cf  the  Ji'jd^.  It'^ptnUd 
Operation.  —  A  lady,  45  years  of  age,  of  fine  development, 
who  had  alwa,v0  enjoyed  good  health,  called  on  me  in  June, 
1858,  with  n  tumor  in  the  right  hrcnet,  of  a  year's  standing.  It 
was  evidently  scirrlious,  and  was  rapidly  npproacliing  the  surface, 
I  removed  the  whole  breast.  The  tumor  being  large,  many 
ligatures  were  required  :  the  wound  healed  kindly,  with  the  ex- 
ception of  ore  spot,  where  there  was  much  irritation,  whJch. 
after  five  or  sijc  weeks,  almost  gave  rise  to  the  idea  that  there 
waa  a  recurrence  of  the  diseaae ;  hut  thid  wa*  finally  relieved  by 
the  discliai-ge  of  the  knot  of  a  ligature.  In  October,  18511,  I 
waa  called  U^  see  her^  to  examine  a  large,  hard,  scirrhous  masd 
in  the  axilla  of  the  same  fiide,  of  the  sj^e  of  a  double  6sC,  quilo 
tnovablei  but  evidently  implicating  the  nervea  and  the  axilJarj 


xrwoKS. 


artery,      I  ^Jviseil  an  op^mtion,  anO,  ufter  making  the  pjiIctdI 
inciBions,  removed   the  Uieejifle  prindpjiJly    by   CDiicleatioD  wflfc 
the  fingers ;  exposing  all  the  great  nenee,  arlcrj,  and  ^dat  o 
the  aiilla.     The  patient  remained  quite  well  until  Augunt,  W>, 
when,   Ql'rer   tnudi    fuirgue   from   travellinp-,    an     ulceratioa  K- 
curretl  in  ihe  axilla,  which  I  at  first  fcnred  wae  a  return  i-f  tk 
dibeaBc,  but  whieh  healed  up  kindly,  leAvin^    no    iadximwt 
January,    ISGl,   I  was  requested  to  mc   Jicr   on     accoui:!  lii 
swelling  jiiirtly  over  the  epinoua  process  of   one    of  the  dord 
vertebne.     I  at  onoe  detwied  a  eoin-hous   lump   there.     Sht, 
clI   this   time,   wa^   complaining   of  ncural;riG    pmna    in  the  left 
ehoulder  and  axilla.      The  eicntrijt  of  the  breast  and  axilla  wij 
perfectly  sound.     The  tumor  at  first  fleemed  quite  indeGuiti!,  bia 
jp^dually,  after  some  weeks,  became  delineil ;    and.    nl   hct  rr- 
quesl,   I  proceeded  to  reiuove  it.     The  diseacM^   eeeined  alaKM 
confined  to  the  fascia  over  the  veriebrro,  and  came  out  in  a  wlai 
disc  of  About  tlie  size  of  a  dollar.     It  waa  about  an  inch  ihtd 
in  the  centre,  and  Capered  oflf  towards  the  ednr-a  ;    the  t^kin  ■» 
not   imphcalod;  and,  after  the  removal  of   the   diseased   niasi, 
the  flurrouuding  parts  were  fonnd  to   be  quite   healthy.      Thr 
wound  healed  well,  and  there  was  no  return   of  tlte   diaea^e  Ir 
cally.     On  the  Itth  of  T>eceniber,  l^<il,  after  evJiuplrtininif  for 
two  or  three  weeks  of  a  sen^e  of  numbne^d,  ntteaUed  wrih  noi- 
ralgic  pains  in  the  muscles  of  the  thighjj,  toother  \rith  a  uniwl 
paralyeis  of  the  fleior  muscles  of  the  n^ht  ihigh,  she  wua  telixA 
with  an  epileptic  convulsion,  which  lasted  betvrccn   one  and  t^ 
hours,  in  the  course  of  which  the  right  thiph  was  broken  nrar 
ila  upper  third.      The  cerehrtJ  irritation  sub&idcd    darinu  the 
course  of  the  night,  bo  tliat  on  the  next  day  hut  little  evident 
of  it  remained.     She  did  not,  however,  for  a  week  after    com- 
plain of  her  broken  (high,     1  did  not  think  it  worth  while  to 
apply  any  appnratua  lo  the  limb,  and  she  did  not  discover  vhtX 
had  occurred,  but  simply  placed  it  on  a  pillow  ;    in  ^hicli  noa- 
tion^  with  the  toes  a  littk  everted,   it  united  ia  a  couple  of 
months.     During  thia  period^  ahe  hnd  two  or  three   epileptic 
attacks,  whose  violence  was  mitigated  t>y  the  inhalation  of  ether. 
On  the  7th  of  March,  1862,  she  had  an  attack  which  Wti-d  i\a 
greater  part  of  die  night,  leaving  her  tnind  in   a    wandeiiii^ 


CAN C Eli    OF    BKEAST. 


517 


Btntc,  in  which  condition  ehc  remnineU  *il  tho  date  of  the  present 
[record  (Marcli  lllli)»  recognizijiK  tVicnJi*  with  a  smile,  but 
MHifTcrinn;  from  nn  entire  loss  of  mcm<>ry.  She  haa  now  a.  cno- 
'Ceroua  luberolc  under  the  ekJr,  uvcr  iho  ripht  acnpuln,  and  a 
>canccrou8  mnse  in  front  of  the  left  ernpulti,  on  the  buck.  Dur- 
iin(^  the  whole  of  thi^  long  period,  ehe  has  never  hnd  dje  sli^hlcst 
dn,  ftnd  hoa  submitted  to  tho  Tnnous  opcratiooB  with  for- 

titndo   nnd   rp^it^tititjon,   And*   in   fiu.1,   wn^  never  aware  of  tlie 

exiiet  nature  of  Jicr  ditJeo&e. 

She  sank  nhortJy  nfter,  and  died  without  aufieringp 

C\SE  CCCIII. —  liecurrajii  Omxcer,  Lonp-coniinued  Se- 
cretion of  Milk*  — -I  wne  reque»te<l  in  Fehnmry,  1851,  to  eea 
a  woman,  64  years  of  n*^e,  from  wlioin  I  had  removed  the  lelt 
breast  ten  resirs  before,  for  a  csiiicerous  tumor  of  two  yeu.rfl' 
stundin^-  She  was  tlicn  n  widow,  and  her  youngest  child  waa 
35  years  old.  After  weanin;*  this  chDd,  she  had  milk  in  tha 
breast  which  afterward?  became  dleeosed*  for  throe  years.  She 
had  renmined  well  after  tlie  iir&t  0[>eraiion  until  1850,  when  two 
Jumps  appeared,  one  over  the  pectoral  mnaele,  and  one  in  the 
iL^illa  ;  the  former  heja^  lullicreat  to  the  skiOf  and  hod  been 
tampered  witli  by  caustics-  These  lumorj  were  thoroughly  re- 
moved. 

1  saw  iier  a  year  afterAvards,  in  a  good  *lnte  of  healcli,  and 
with  no  return  of  cancer. 

Thia  patient  had  been  subject,  for  many  years,  to  obstinate 
constipation,  often  going  sijctecn  days  wiihout  an  action  of  the 
bow^cls*  This  condition  had  lately  been  completely  relieved  by 
tho  use  of  a  ^lass  of  wine  daily,  with  a  Bmnll  quantity  of  tlie 
sulphate  of  magnesia  in  it. 


Case  CCCIV.  —  Cancer  of  the  Breast.  Long-coyitinued 
Secretion  nf  Mifir.  ~ln  1852,  1  operuted  on  a  woman,  60 
years  cf  a<;e,  to  remove  a  small  cancerous  tumor  of  the  ri^lit 
breast,  of  a  year  and  a  half  standing-  This  patient  had  con- 
tinued to  have  milk  in  both  breasts  since  the  birth  of  her  first 
cbild,  thirty-seveu  years  before.  Her  mother  had  died  of  can- 
cer of  the  breast,  and  one  of  her  sisters  of  a  cancerous  ulcer-* 
ation  of  the  nose. 


518 

In  iinother  inst;Lnce,  I  rt^iacivi^tl  a  cnriccroiia   breast,  in  whi(^ 
the  milk  li:id  Ih-e^d  i-etalned  <jn  tL^jt  aide  fur  twcntv  veara. 


Case  CUCV, —  Tumor  of  MnU  Breast.  Rcmovrtf^  Hr- 
coverif.  — A  mnn*  G3  ye^ra  of  nge,  enlcr^l  the  Ho»pitAl,  Jane 
16i  1865,  \y]\i.i,  ^ibrriit  fuur  inontlis  befarc,  had  noticed  u  jiiiinll, 
hard  tumor,  nhuve  and  to  the  outaide  of  the  rio^ht  nipple. 
Far  the  firat  mouth  after  it*  appearance,  ihe  only  tienr^Tttion  in  it 
was  one  of  itching.  It  ifterwnrds  rapidly  inciL^asetl  in  siic, 
becoming  softer,  and  ut  limes  puinful.  It  vt-aa  nbcjut  the  size  at 
an  egg,  circumscribed  and  movable :  there  were  no  external 
eigns  of  inflnmmatory  nction.      He  had  geuemlly  i>een  lienllhv, 

Abrjut  fifteen  years  befi^re.  Dr.  J.  C.  Warren  rcnki>vo<!  n  can- 
cer from  hie  right  lower  eyelid.  He  aaid  that  an  uncle  of  hi^ 
hnd  a  large  cancer  on  his  lip,  which  de*tn\Tcd  him. 

The  patient  being  placed  under  ether,  the  tumor  waa  removed 
by  two  ellipticiii  incisiona.  On  examination  by  the  microscope, 
it  proved  not  to  be  malignant,  but  consisted  of  a  hypt^rirophlfll 
glandular  »tructure>  The  patient  did  well,  the  wound  hcnlln*' 
up  very  rapidly. 

Cabe  CCCVJ.  —  Ittmttrhtible  'rtimot-in  the  A^jtMUi ^  coming 

on  after  JVftrflnjr;.  —  A  delicate  lady,  about  30  y^enn*  of  »^. 
ailer  the  birth  of  her  second  child,  had  a  tumor,  one  and  s.  quar- 
ter inchea  wide,  and  three  inches  lcng»  appear  in  earh  aiillan 
region  aa  aoon  aa  the  milk  began  to  be  secreted  in  the  brea^u. 
Thcae  were  oblong,  flabby,  and  not  unlike  the  breast  itself  in 
a  flaccid  state,  but  without  any  thing  corresponding  to  a  nipple. 
and  were  especially  eularged  duriug  lactation.  On  tiie  milk  drr- 
ing  up,  the  turaora  diaappeared  in  a  great  measure,  Icavin^r. 
however,  distinct  rudimcnta  in  their  site.  At  her  next  eonfiais 
tnent,  ahc  waa  delivered  of  u  stillborn  t^hild.  The  secretion  of 
milk  which  cnaued  waa  attended  with  aimilar  phenomena  in  ihv 
axillic,  the  awcllirg  being  much  greater  on  the  right  eitle  Htun 
on  the  lefl.  In  addilioHf  on  the  right  side,  a  amall,  hard  li^rhi- 
gray  tumor,  of  the  size  cf  a  pea,  ftirmcd  upon  the  apex  of  Ui* 
Gwelling.  Thia  soon  became  the  ee&t  of  the  most  intolorable 
lancinating  paina,  particularly  at  the  men&trual  periods^  attended 


I 

I 


TUMOR  OF  AitM.  515 

Uh  fl  ajmpathetic  fiffection  of  the  oiher  nxilU,  and  ainiiUr  pnlns 
f  n  severe  charnctcr  in  the  region  oi^  both  ovuriee.  My  friend, 
r,  Charlee  G,  Putnam,  her  physician,  who  hns  hod  a  rery  ex- 
uaive  eTtpenence  in  affvctiona  connected  with  prc*;nancy,  had 
never  seen  any  thing  ainiilar  to  this  i  mid  he  rctjucated  me  to  visit 
&e  case  with  him  in  conaultntlon,  thinking  that  pc^albly  it  mi^ht 
be  on€  of  the  pnitkfitl  aubcutimeoi.L'*  lubercle»  uLich  arc  often  so 
much  aggrnvntcd  during  or  prccedi^ig  the  piicqicral  Mate*  The 
whole  tmnov  t'ecmtxl  to  be  compo.scd.  6rst,  of  the  ti^hby  tkin  ; 
ihcn  of  a  collection  of  glatidsj,  eo  *ofl  us  ecnrcely  to  be  distin- 
guL^hcJ  from  the  cclluhir  tiaauc  ;  and,  imjihiiiteci  in  the  apex,  the 
einnll,  hard,  nnd  paiiifnl  lubcicle  juat  referred  Uu  From  my 
cxpcricQCO  of  the  painful  BubculjEneous  tubcrde,  often  faund 
in  the  cxTrcmiticfl,  1  was  confident  thut  this  tiuncr  wns  not  of 
that  character,  and  dctenuined  to  make  an  incision  in  it.  When 
thia  wni  done,  a  quantity  of  milky  Hulcl  was  projected  with  vio- 
lence n  (iietmicc  of  eevernl  feet,  and  the  tumor  wholly  eubjiidedt 
On  ihc  folluwin^  day,  she  was  entirely  free  from  pain* 

From  thnt  time,  the  neuralgic  condititm  of  JijTcrent  parts  of 
the  hody,  which  aecmed  to  emanate  from  tliis  ^mall  eyet  on  the 
apex  of  the  axilbiry  tumor,  cejwed;  nnd  she  very  mpidly  re- 
covered her  henUh. 

Ca3&  CCUV'II,  —  Lutrj^  Tumor  oj'  tfc:  Ana  (ace  woodcut). 
Thifl  old  lady,  75  years  of  age,  inlbrmed  me  that,  twenty  years 
before,  her  huabimd,  while  in  a  state  of  iartonity,  threw  nt  her  a 
caimou'haiL  which  hit  her  on  the  nnn,  near  the  axilhi^  Slmrtly 
afterward,  the  tntnor  be^MU  lu  make  ltd  appearance,  uud  in- 
crenacd  until  it  attained  an  cnormoua  elze.  It  oppcnrcd  tu  be  uf 
B  fibro-collular  eharaeter,  and  of  aUml  twenty  pounds  weight; 
hanging  down  so  ihul,  when  the  nnn  vsas  licld  nt  n  ri;:lit  nn;:le 
with  the  body,  it  rested  on  the  flcal  on  whioli  she  *al,  drugging 
down  the  integnmenta  and  other  a  true  tu  res  in  ita  vicinity.  Ver/ 
Inrgc  TCaaela  entered  it  from  the  axilla,  and  could  he  diatitigiiiahcd 
pulsating  in  its  fluhfltnnce.  The  tun»or  wa*  earned  by  the  pii- 
iicnt  in  a  large  sleeve  ;  nnd,  when  I  aaw  It  Grat,  it  Itod  an  uleer^ 
alion  on  the  aurfaet,  caused  by  being  prcycetctl  from  her  alee^e 
upon  the  grate^  while  ehe  wua  ihrowin^j;  amia  upon  the  tire>     Sli? 


had  a  second  iQmor,  ftp[tareiitly  of  a.  simUar  description,  on 
ber  face. 

A  verv  atrlknkg  daguerrot^pe  waa  takea  of  this  patient  aD<I 
the  tumor. 

Prom  some  BupEratitious  feeling  connected  with  its  removalj 
she  derlioi:d  iiiivinv  jt  upcrnted  on  ;  und  it  la  pnncipally  from 
tilt  lonnner  tjf  its  occurreni^»  lis  apparent  8truchirp,  and  its 
uncucuiiLou  Mze  in  thld  fiituntioii,  that  I  have  tliuught  it  wortJi 
wliile  to  reliiie  it,  and  have  it  depicted. 

Case  CCCVTII.  —  Unchondroma  of  th^  First  Phnt'tn^  nf 
the  Middle  Fiiujtr*  Ampiitattoti.  — Miiy,  1850-  The  aul>- 
jeot  of  llic  di^enae  ivaa  a  girl,  13  yenrd  old.  When  two  yc4uv 
of  agCt  a  small,  hard  awclliag  zLppeured  uii  thtr  innur  aide  of  the 


ADIPOSE   TtTMOn. 


£21 


Irst  ]>lml!mx  ()r  the  mulUle  finger,     Thia  elowlr  increased,  and 
jrotluced  no  inconvtnicDce,  cxce|)t  ironi  its   aize,  wtiicb  more  or 
)&$  iiitcrfcYcl  with  tit?  nioduQ  of  the  Jinnd. 
At  the  time  of  tlio  opcrntion,  tbc  tumor  waa  the  size  of  tk 
ill  npp!e,  involving  the  whole  bone  of  the  firat  phalanx,  And 
t>t'  the  ^cctjiul.     The  finjj^crwas  ibrced  out  of  its  pUicc,  nrd 
ly  dirt^ndly  acrosa  the  little  and  ring  finger.      A  emnll   tumor 
|i>f  eimilar  description  occupied  the  lower  phnliin^  of  the  fc»ro- 
iiijrer.      On   the  ring:-fin^r  waa  another,   ii  etill  smuilcr  oae, 
'iniT  under  and  concealed  hy  the  l^r^r  tumor. 
The  finj^cr  was  reinove<l.  nnd  the   heud  of  the  metnciirpul 
bone  flawed  o9'  to  alluw  of  the  iicee^eitry  upprujsimjUion  of  the 
Esdgea  of  the  wound. 

A  section  of  the  cxci^  iMirt  showed  n  uniform  appeamnce, 
like  the  interior  uf  a  tipc  apple.  The  pcriphtrv  wns  somcwhnt 
elliptic,  like  the  more  deiicntc  layer  of  l>one  or  cnrtilugc.  A  few 
epicjln?  of  bone  were  iiitcrHperaed  through  the  iatorior*  The 
elinft  of  the  bone  had  dtfta[ipenred>  The  metacarpal  extremitj 
remained. 


Case  CCCIX, —  Cnse  of  larg^  Adipose  Tttmor  betice^n 
tfte  TAitntb  and  I'^orejiii^er. — A.  woman,  73  years  of  nge, 
entered  tlie  Hospital,  April  0,  18U5.  for  a  tumor,  the  uiae  of  a 
billiard-ball,  of  thirt_r-iiv-e  ycara'  ^landing,  ^raaped,  a»  it  were, 
between  the  thumb  and  forefinger  of  the  left  hand.  When  first 
noticed,  it  wra  the  si^o  of  a  bean,  and  inerpiucd  until  it  at- 
tained the  above  dimensions;  becoming  trouhleaome,  nnd  pre- 
venting llic  use  of  the  fingers.  The  skin  over  it  was  thin, 
dry,  and  wrinkled.  It  waa  caaily  removed,  jieclin^  off  rcftdil/ 
from  the  mitecleSt  and  not  involving  any  important  vcascia  or 
ner\'Ci9.     The   wound   healed   well. 

An  adipose  fimior  in  this  situation  ia  rare :  and  I  remember 
Imving  Been  only  one  other,  which  was  in  a  child,  and  auirounded 
the  firflt  phalanx  of  one  of  the  fingers. 

It  had  ;:rown  very  rnpidly^  entirely  enveloped  the  bone,  wwM 
round,  cCafltie,  <|uite  painful,  and  was  «uppo£ed  to  be  (afler 
repealled  cxnminationa  by  cxpcrienceil  surgeon*)  malignautp  An 
inciz^ion  into  it  eecmed  to  justify  thia  opinion ;  nod  it  was  de- 


52£  TITUORS. 

cklc<l  to  remove  the  fin^jer  oi  ihc  joint,  whifli  wna  dune.  On 
cxnniinationi  it  prov^  to  he  an  adipoBe  tumor,  etjrroundin^ 
find  ^Un^iii^  l>^ht  to  the  bone.  The  pressure  of  the  tendoaa  finU 
iflfcin  over  it  hod  coDiprcssetl  it  in  «uch  a  way  ua  To  pvc  il  lh« 
appearance  of  n  cancer  when  explored-  Amputation,  however, 
^vn»  tlic  imly  remcJy.  The  operniion  was  nijt  perToriiLed  haatUy. 
hut  after  the  patient  hod  been  under  obeervfttiOQ  foine  time. 
The  finger  was  accordingly  amputated,  but  one  vessel  r«quirin^ 
hgfllute. 

Case  CCCX,—  Cy^>  Tftr^tor  of  the  Hemi.  nf  the  Tibia. 
AwputfTiion,  —  A  man,  3<J  ycflrs  of  age,  camo  undor  my  care 
in  May,  1853.  Eijrhtecn  montha  before,  he  rcceivcii  a  ^ei^re 
blow  on  the  upper  part  of  the  ri^lit  filmla>  [iroducnng  nn  in- 
Haromation  and  e^iellin^  there.  After  the  iirai  fiyiiiptoms  had 
FuhfliUcU,  a  hard  Bwellin;,'  v*'»6  diecovorcd,  which  ^julually  in- 
creased. In  March,  Ifi^^U,  ho  enid  that  the  tumoL-  waft  «bcmt 
hjiir  the  eizc  of  an  apple;  "that  it  had  the  elastic  feid  of  a 
wimigal)/'  nnd  aeoracd  to  liim  n^  if,  with  slight  pressure,  he 
oould  force  in  its  walla  like  etiff  paper-  Biiatcre  were  applied  to 
it,  whii.'h  inHnmcd  its  eurfaec.  In  April,  an  h&%\c  was  eir- 
ployed,  whicb  nia'lc  an  opening  into  St,  from  which  ven&  di*- 
chnrged  about  hidf  a  teacup  o£  clear  aerum,  followe*!  bv  niort 
or  leas  blood. 

When  I  first  aaw  him.  his  ffcncrnJ  hcaltb  was  rpiitG  good.  He 
was  able  to  widk  witli  some  limping,  [he  knee  being  very  ^ligUtlr 
bentp  The  upper  and  anterior  part  of  the  leg  wae  occupied 
by  a  hninl  swelling,  which  entirely  ubeeurcil  the  course  tjf  ilie 
upper  third  of  the  fibula.  The  surface  of  the  tumor  waa  covertil 
by  an  iuHamcd  akin  from  the  application  of  vesicating  eiibatances 
in  the  centre  of  which  was  a  small  openinjj,  obstructed  bjr  h 
alough.  Upon  prefigure  on  iho  limb,  a  quautity  of  ecru-puni- 
lent  inatCer  run  out.  The  forefinger,  being  ini?inuateU  vcrr 
slowly  flud  carefully  into  thia  ajiorture,  tnivcrsed  the  tuiuor 
through  a  mnHS  of  loose  granulated  aubfitanee,  ami  brought 
up  agjiinst  the  iilna,  ^vhith  ielE  quite  smooth,  \is  if  covered  by  i 
Bcroua  membrane;  and,  the  finger  being  swept  around,  co- 
countered  an  elevated  eup  of  bone.     The  hejid  of  the  fibula  wv 


CYSTIC    lUMOR    OF    TIBIA. 


523 


nowTiere  to  be  dieoovercil :  and  thavi^h,  nl  one  part  iyf  the  tibia, 
a  Jittlc  ronglinc^Jd  coiilil  be  detecicd,  na  Kmt^e  ^pioulu;  of  bone 
were  anywhere  to  be  obaei'vetJ.  The  tioger  being  withdrawn, 
a.  slow  stream  of  venous  blood  ftjilowed,  and  continued  lo  flow 
for  one  or  two  ininuU'^. 

I  inforrni?d  [he  pniient  of  the  nntnre  of  tbe  di8C:iae,  and  ih^i: 
the  only  remedy  waa  nmiJutmion,  —  na  o]nnion  agreed  in  by  the 
other  BLirgcoik^  of  the  Ho^pjinl.  who  suw  him  on  tbe  (Jilluwing 
day.  I  mv^clf  iTither  inclined  to  favor  the  ideiL  that  the  disease 
was  what  hns  been  called  spina  ventoaa;  and  that  tlie  sup- 
piimdon  of  the  tumor  ami  the  rrranidated  cont^nie  were  to  be 
attributed  to  the  infliimmntory  action  bTtniii;ht  on  by  the  iasue, 
thna  giving  It  n  midignant  aspect,  — an  idea  which  some  of  the 
gentle  men  favored, 

Jn  n<ldiiion  to  what  has  l>cen  stated  above.  In  regard  to  the 
use  of  the  limb,  it  may  he  mided,  that  the  power  of  flesion  of 
the  foot  was  entirely  destroyed,  ao  that  it  htrng  loose  in  walking  ; 
Q  fact  whieli  was  explained  afterwnrtU  hv  the  entire  destruction 
of  the  bcniiea  of  the  musdea  hy  the  pressure  of  the  lunior. 

The  o|>enilion  was  done  on  Saturday,  May  lith.  The  pa- 
tient hein^  etherized,  the  tiimof  was  fin^t  s!ic  open,  in  accordance 
with  A  promise  made  Eo  hJin :  and,  the  upper  pun  of  the  iibula 
being  found  to  be  destroyed,  together  with  the  miucles  in  front 
of  it,  amputation  was  at  once  prot^eeded  to.  In  onlcr  to  obtain 
n  long  htumpj  the  firt^t  Incislona  through  the  tkin  were  made 
ju.flt  over  the  upper  edge  oi'  the  piitelln.  There  wm  very  little 
hemorrhiige,  and  not  more  thwn  lialf  n  dozen  ve*iaels  required 
ligatures.  Four  euturoa  were  inirodin^ed  in  the  flaps^  but  not 
tied,  smd  the  wound   left  open   lih   the  ntlernoon. 

The  diaease  presented  very  curious  and  interesting  phcnomena- 
The  tikiii,  being  disjieoted  back,  disclosed  a  large  cavity,  filled 
apparently  with  old  coagjia.  These  being  reniove<l,  at  tJie  bot- 
tom were  portions  of  the  sac,  of  the  color  and  consisiencc  of 
that  of  an  nnourism.  The  lower  part  of  tlu^  sac  wna  formed  by 
the  upper  pnrt  of  that  poi'tion  of  the  fibula  wliich  had  been  left, 
ihrcp  inehos  of  it  having  been  destroyefl  hy  disease.  The  por- 
tion alluded  lo  was  lined  by  a  smooth  tnembrane  in  its  centre, 
expanded   and  rough   on  its  edges.      At  the  upper  part  of  the 


ENCEPHALOII>    TL'MOR. 


525 


I 


mor,  on  the  otiteide  of  tlic  liciul  of  llie  libiii  of  tlie  nrrht  log, 
wiih  nil  opening  <■«  its  cxioninl  pnrt.  The  diiieaso  begun  fivo 
months  before  by  a  severe  ^>ain  tleo|j  in  ibo  limb,  wluoh  j^rudu- 
ally  increivflt»<l,  ant]  at  tbt;  SJiinu  time  ibc  bone  enhir<reil  nl  ihnt 
point.  About  tive  weeks  belbro,  tho  tumor  had  acquiiXMl  the 
aisc  of  a  krge  a|>[jle^  nnd^  the  pain  beiny  vurv  eevcie,  tbej 
Applied  to  n  fiUrgeoD,  who  mnde  a  tree  incision  into  it,  %vitlL 
partial  ivliof  fur  the  lime. 

Wht^n  1  ^aw  him,  the  limb  had  become  contracted  and  u^e- 
lese:  the  pain  was  very  severe,  requiring  the  use  of  opiates, 
And  hi 0  henlthu'na  b^ginnin^  to  fail.  I  informotl  h]^  parents 
tluLt  tiie  only  remedy  wnti  :im|iutation,  and  that  tlie  didi>!ieo  wha 
probablv  nf  a  muli<;nant  charac-ter.  The  parenia  consented  to 
the  operation ;  unri  the  patient  entered  the  Hu^pittil,  where  the 
operation  wrtE  dune  on  Nov,  4tli, 

After  he  was  put  under  the  inKuont^e  of  ether,  J  first  ipude  an 
incision  into  the  tumor,  in  order  to  verity  ihe  diHguoais,  which  I 
fonnti  to  be  correct.  The  limb  wna  therefore  removed  juet  above 
the  knuo. 

Ofi  making  a  eootioTi  of  tlie  tumor,  the  greater  portion  of  the 
bony  enlibre  of  The  tibia  was  tbund  dct^tr^ived,  and  its  place 
oceupiL'J  by  a  large  cncepliuloiil  mnsa,  iiitcrtf|K.'r:i<'U  evcrrvrherc 
with  .HmalJ  grnnulci^  of  bone,  foi-niing  a  disease  wbicli,  under 
the  old   nomenclature*  would   bo  dcnignntcd  as  o^teimareuina. 

On  thu  day  tblkjwiug  the  operation,  he  was  ^jcricotly  cumfort- 
abli: ;  atiJ  he  Ukado  a  I'apid  reeovery. 


Case  CCCXir.  —  jE^ucep/inloitl  ViimQr'  commenciiig  In  thi^ 

I*<rptileftl    S/f'tce..        A-riffttitiifiou,       Hecoi'ery.  —  A    hvdv,    *i2 

yQnr9  of  age,  requested  me  Co  see  her,  in  coneidtation  with  her 
]ihy£LL*ian,  in  August,  1853,  About  three  ycnta  previously, 
being  then  in  good  heidth,  ahe  percoivod  a  smidl  tumor  in  iho 
pi>pti1eiil  epacD  af  Ifie  left  leg.  This*  slowly  increasing,  pro- 
duetHJ  more  or  le^^  pin,  and  embarritdHment  in  the  motions  of 
ihe  limb  ;  and  finrdly,  when  1  saw  her,  hjtd  ntluiucd  tnormoua 
dimensions,  extending  up  on  the  thigfi,  and  nearly  dciwii  to  tho 
ftnkle.  The  tumor  wa»  tenee,  elastic,  and  the  surlaec  of  it  covered 
with  largely  di  In  ted  veiim.     A  eertnin  amount  of  pulsation  was 


( 


fiS4  TUHGRB. 

wound  WAR  n  iiTnall  pTC<!4*  of  the  hend  of  the  fibulu,  iKis? 
eighth  of  an  inch  in  iliiokncfls^  wEiirh   siill  rciuAtoed  itudp^' 
lh(!  lidirl  iif  ihi-  (iiiia.      The  inTier  pnrr   of  the   cavitr  ici^  ToT 
ri^riut.'r]  Jiv  ihr  tihin,  onvcrLxl   hy  n  smoDlh   tueDibrane,  at  <^\ 
before,  iind  Ra?me(l  to  he  nf  a  fomenhac  fluttenod  cup  eiui|ie,  Ti»| 
rciniiintkT  of  the   tsac    in  front,   on    ihe    outijide   aud  tjMwfaw>| 
yk'nis  furmed  hy  thf;  inle^iiments  and  de^enoratetl  tDU£CukrtsA 
intL^raiiET^ciI  with  i>\ecea  of  Lone, 

Some  of  the  genllemen  who  esamioej    the    jimb   Bocmri  ^ 
think  the  disesiae   ini^ht  po^isihly  have    heon    na    nncuri^RMl  t* 
mor  uf   the  bone ;    n^lthough   ihe   wunt    of   tVi]>e    urtCfial  bea^ 
rhuge,  wh«ii  tt  wafi  upeoLi],  iliJ  not  fiivcir  thnt    ideft.      AcanM 
loic^roBfopit'  exjiminntion,  mndc  nflcrwrinJa    by    Or,  EUis*  llilT< 
n  new  li^ht  upon   it,  nml  seemed  to  verify  lb«   noctimcr  of  tk 
fir^t  diii^noitU,     Till;  apjmrent  LTmirutA,  boiiii;   plaoeil  in  focK- 
were  found   to  consist  nJuiost  enth-ety  of  jn^'eloid  etruc(urv,  tJ^ 
the  whitish-yellow  aiibstnneo   iniers|ieT>ed   with     it,    and  ntoct 
might  eitsily  hnve  been  t^i.ken  for  erirfphidoid  matter,  woa  fntA 
tu  he  oomposed  of  fat  globiilea.      Mr.   Paget,    io   his   ^  SurEjicaJ 
Piitholoyy/'   mentiunj*   an  almost   siniiUrly   det?ept*ve    c^c,  is 
thvev   words  :  — 

'*None  who  exammpcl  tliis  ilisEft^  with  »he  nnkM  eye  «lont;  ftlt  bjtt 
doubt  lliat  It  wuA  an  example  of  mfUuElury  cniiccr,  with  r v»(rs  fibunJa;!!- 
ly  formed  in  ii-  l^lt,  oo  minuter  iikv<'^'ilipitir>EiT  none  but  the  flvni'-nis 
Vfb'ich  I  flJiJilJ  pJ-eaeniJy  dsjcjibe  aa  cLn rwctcr Jsiii^  oi'  Liae  nay^eJoni  (uiD^n 
could  be  found  in  jt.  Thest;,  copiously  embedded  in  a  dimlj  gnmukr 
substance,  appeared  to  form  the  aubetance  of  the  cyst-walls,  and  of 
whatever  EoUd  material  existed  between  tbem.  The  white,  braiD-hke 
masfl  was  apparently  composed  of  similar  elements,  in  an  advanced 
fatty  degeneration  :  neither  in  it,  nor  in  any  other  part,  could  I  find  a 
semblance  of  cancer^eells.*^ 

The  pntienl  recovered  well  ;  and  bo  far  as  I  know,  had  no  re- 
currence of  the  disease. 

Case  CCCXL  —  Encephaloid  Tumor  of  the  Z/efid  of  the 
Hight  Tibia.     Amputation.  —  Ahoy,  16  years  of  age,  of  deli- 
cate complexion  and   light  hair,  was  brought  to  me  on  Nov.  1 
1859,  by  his  futher.     He  was  suffering  at  the  time  from  a  Jorge 


ENTEPHALOID    XrWOR. 


535 


imor,  on  the  outside  of  the  lionJ  of  ilie  ilbia  of  the  ri^ht  l*^'' 


O' 


I  with  an  opeiiinir  oo  ilB  eKtermJ  \'aTt-  The  (lisoase  bcg:m  five 
DionCh^  before  by  a  severe  pain  doop  in  tlie  limb,  nhich  grnJu- 
fclly  incre!t^o<],  niid  hI  the  ^nitic  time  the  bone  enlur^ed  Lit  tlint 
point.  Almut  five  weeki^  beforet  the  tumor  bad  aoquireiL  tha 
BlEC  of  a.  hirge  apple;  nnd,  the  pain  being  very  severer  ihey 
applied  to  a  nur^eon,  who  tim^e  a  free  incision  into  it,  with 
partial   rcbof  for  the  lime. 

When  I  saw  hini,  the  limb  had  become  contrncted  and  uae- 
^lo0E :  the  pfttn  was  very  severe,  requiring  the  use  of  opiates, 
and  his  hejtllb  w!ls  bo*fiiinin^  To  fnil-  I  iiiformed  hi^  imrenis 
thnt  the  only  remedy  wna  imputation,  and  ihut  the  di^eiise  waa 
probablv  of  a  inulignnut  eharaaer*  The  parenta  coaficntcH)  to 
tlio  operation;  ami  the  patient  entered  the  Hospilnl,  where  the 
operation  was  JtHie  on  Nov<  4ih. 

Al^er  he  wus  put  nndor  the  inrtiience  of  ether,  I  first  made  an 
inciiiion  into  tiw  tumor,  in  order  to  verify  the  diajjuosia,  wliieh  I 
fonnd  t(i  be  eorrect.  The  limb  woe  therefore  removed  just  above 
the  kntP- 
B  On  mnkinfT  a  Bcetjon  of  the  tumor,  the  greater  portion  of  the 
H  bonv  ralibro  of  the  tibia  was  found  dciilrovcd,  nnd  its  plocc 
H  occupied  by  a  large  cnecphnloiil  ntuss,  interctpcrded  everywhere 
I  with  ^mull  <;rntLitIca  of  bone,  forming  a  dieeaee  whieli,  under 
I  the  old  nomenclature,  would  he  designated  as  oatoodureuma. 
^t  On  tlie  ditv  following  the  openition,  he  was  perfectlv^  eomfort- 
^p'tUe;  and  lie  made  n  I'npid  i-ec-ovcry. 

Case  CCCXII. — EnGcphahid  Tnmcr  eommen'^ttig  tti  thf. 
Poplit^rd  Sp'fc^.  A'ltpfttfiiion^  Heeovsry*  —  A  lady,  \i-2 
yeare  of  &^e,  refjiiealed  me  to  eec  Ler,  in  eonenltation  with  her 
lihyaician,  in  Au^'iiet,  JJ*^3.  About  three  yeara  previously, 
bcin-;  then  In  good  health,  alie  perceived  a  small  tumor  in  the 
popliteal  apace  of  the  left  lejj.  This,  elowly  increasing,  pro- 
duein]  more  cir  lesd  pain,  and  cmbnrra^fment  in  the  motions  of 
the  limb  ;  and  finally,  when  I  ^aw  her,  had  attained  enormous 
din»enaions,  estendirig  up  on  the  thi;;b,  and  nearly  down  tu  the 
ankle.  The  tumor  waa  tense,  elnetie,  and  the  anrfaee  of  it  isovered 
with  largely  dilated  vcias,     A  certain  amount  of  puldation  waa 


536 


TUMORS. 


obeervcd  in  it,  wludi  at  first.  It-i]  In  tliR  siippoi^iitiiin  tliat  it 
an  Bueiirifjn  ;  i>iLt,  im  rni^f'iil  eMiEiuiuctirin,  jiiiil  lon^-oi^iu^nuotl 
pressure  on  the  fenKirnl  artery,  which  ilid  not  at  b1]  lUruiBub 
lis  size,  I  fdt  cuiitident  llint  the;  pul^atiiin  nrn^(.>  fnitn  the  ooii- 
tiucmirut  uf  the  luiiLc>r  by  tlic  fu^clci  i^vrr  tiic  poulitenl  art^TT, 
which  cunuiiuuicutetl  ili^  impulHC  to  it.  The  jinln  id  it  veos 
e^tt^cHMve,  and  extenUetl  duwn  the  I'lnih  to  the  foot,  and  could 
be  ftJIeviiittjJ  fm\y  by  opiates,  nud  waa  gnuluHlly  wearing  her 
out. 

Tlje  (lcci(»icin  arrived  at  »aa,  thiit  ihc  afl'ectinn  was  nmU<fTmM. 
and  afa|jiitiitinii  of  the  tliigh  the  only  remedy*  lu  view  of  the 
slight  liupu  uf  recoveiy  to  he  ci|.>eoted  iVum  removal  of  the  limb, 
tlie  [ULtieiit  wuH  ut  first  undcridiid  whjit  course  to  pursue  ;  but,  nl 
the  end  of  u  month,  bui[i;^  nearly  worn  tiut  by  coniinuod  and 
LEicrt^aalug  pdii.  b\iG  demaud^d  t]je  opi^rutlou.  Tlii»  wns  \»^' 
formed  on  Sept.  ^4th, 

Tl;e  Ihiib  bein^  removed  about  hrtlf-wiiy  up  tlie  thioh,  niKl  at 
some  diatuucc  beyond  the  tuiuor,  it  >\JLfi  foujiil  tlmi  rlie  trrcaf 
icti^ds  v>erc  matled  together  by  iiiHuoiinaliim  ;  niul  iho  arierv, 
being  ^jarateil  aad  tied  twice,  broke  tlirough  under  the  lii;nliir«. 
so  tliat  it  was  found  necessary  to  plun^^e  ii  needle,  iirraed  wilJi  i 
li^^atujc,  deeply  iDto  the  muscles,  und  tie  tiie  artery^  vein,  ttuil 
mnseulai'  siib:ft;iuce  in  one  Luasj^. 

la  *pile  of  tlie  uiifavomble  nature  of  the  operation,  ciie  patient 
had  a  ^ood  rccu\ery,  though  ihcr  lij^ature  ilJd  not  come  away  till 
after  the  kpse  of  etffht  luontha.  On  diasection  of  the  tumor, 
after  its  removal,  it  waa  found  to  spring  from  the  neighborhood 
of  the  tibia,  wha'h  was  more  or  Ivso  disejiacd.  witTj  bony  pri^ 
ceases  projecting^  from  it,  Tlic  l^jwer  |Mirt  of  llie  femur,  on  irhidh 
tJie  tumor  Iftv,  wiia  more  or  leas  eroded.  The  body  of  tbe  tumor 
was  composed  of  a  lardaccou^  hiuking  Aubatanee,  in  I  em  periled 
with  bony  spicukc.  in  the  eent]~e  of  whieii  was  a  eavity  coniainitiJ! 
fibrinous  clotdf  vi'ith  walla  reaenibliag  an  aneurisinal  caviTT. 
The  iHJplilcal  artery  was  found  Jn  the  back  part  of  the  tumor, 
whdc  ihc  nerves  had  beea  forcibly  pressed  from  their  nstiund 
position,  and  so  dra.gfrcd  upon  as  to  explain  the  torlurintr  pnin* 
xvliich  had  so  much  c.^hanstcd  her.  The  tanior,  being  csamlnal 
by  Dr,  J.  B.  8,  Jackson,  was  by  him  pronounced  iimlignaEi; 


C*NCEH  OF  FEMUR. 


5S7 


iJ,  bein^  emrained  by  Dr.  Sbiiw  with  the  microsoopeT  he  made 

le  followiTi^'  report :  — 

''^  Composed  of  vrell-miirkcd  caaccr  eli^moQls.  a,n*\  n'oulfiinm^  a  lar^o 
[Uanlily  of  fat  in  Iho  canccr-rclls,  la  the  poriiflU  of  iho  uimor  from 
tr.  J^ickeoiu  which  I  Huppoi^o  lo  lia  \\\g  Bnmc,  a  i^iimlar  BLnn^Uirc  vrns 
tund  t:oiilainiii^  nu  cDornioiis  quaniily  of  fnf,  so  as  lo  ob,=L"ure  ihe 
[View  of  ilic  cells  at  first  Ai^Lt :  thU  porliuD  was  wLiEer  tht&a  thftl  which 
rou  eoDt  mc.'^ 

Ittnutt'ks,  —  From  the  m&lignant  chnrocter  of  the  tumor,  I 
hftd  but  little  bope  of  the  tiltimate  reoovery  of  tliis  ^intictit,  am] 
vas  much  surpmcrl  on  a  visit  to  Lrnn,  aix  yciire  atterward,  at 
beirg  lolU  ebe  waa  in  a  state  of  perfect  hcnith.  Though  I  had 
been  cojK^tanllv  in  her  vicinity  bcft^rc.  I  had  not  inquired  nfrer 
her,  tnkiii^  it  fur  gnmtod  that  ahc  Lad  succumbed  to  the  Jiaease. 
|0n  ft  vbit  to  perform  on  operation,  two  months  afterwardi  I 
took  ocovflion  to  call  M\^yix  her,  I  found  her  in  good  health 
ftnd  epiritfl,  and  greatly  increased  in  weight,  bo  as  to  be  from 
ecventy  to  eighty  [lounds  heavier  than  at  the  time  of  tlie  oper- 
[ttdon.  The  Htump  I  examined,  and  found  in  a  pcHcctly  healthy 
condition. 

The  case  \&  oti  inetruclLire  one,  aa  Bhovrin^  iv  good  recovery 
imJ  stftte  of  hedtb  at  the  end  of  bia  years,  atfter  an  npparenllj 
desperate  operation  for  tlie  cure  of  a  malignmit  diaeuae, 

Case  CCCXIIL  — j1/(i/^;h««^  Tumor  of  ihe  Condyhs  of 
iht  Ft:iaur.  AntjmUilion.  —  A  bdwrer,  35  yeara  of  age,  en- 
Icretl  the  llo^piliil  on  March  l»t.  185E^,  for  a  ftwelliog  uf  the 
kneo-joinl,  whieh  he  etuled  had  been  of  four  month*'  dunuion* 
It  firtft  came  on  after  &  severe  blow  received  by  the  p!ip(>ing  of 
a  block  of  iee,  rthieh  slmck  hhu  on  the  lower  purt  of  iIil'  thigh. 
ThU  confiui^d  biLM  to  ihe  houjw  for  a  few  iky&,  niid  be  wa^  then 
able  to  limp  about  till  nearly  the  titne  of  hia  cnlrunce  to  the 
Hospital,  FiiiJilIy,  he  wa*  obliged  to  rclinr|uiflii  walkin;;.  and 
conbne  hJmaelf  Iei  the  betl*  on  aeeount  of  lameness  und  CAccsaive 
pain  in  the  kn^e-joint. 

When  he  entered  the  Ilot^jiilnl,  the  wlnde  knee-joint  wiia  oc- 
cupied  by   a   hard   tumor:    the   leg   waa   fllightly    bent   on    the 


H 


628  TUUO&B. 

thigh,  the  lower  end  of  the  Temur  projecting  a  little  fbmrdi, 
as  if  displaced  from  iu  natural  appoaitioD  with  the  tibift.  Bdow, 
and  on  eitch  aide  of  the  patella,  wu  some  elasticity ;  aboft.  It 
wofl  quite  hard.  Various  appUcationB  were  made  to  the  joint; 
itd  motions  were  restrained  hj  a  splint;  and,  finally,  two  deep 
iaauea  were  applied  in  ita  neighborhood,  and  the  aurftoea  spria- 
kled  every  night  with  half  a  grain  of  the  aulphate  of  moqdiiM* 
Ail  these  means  did  not  have  the  slightest  effect  in  nTi*tg**^ 
the  pain,  and  he  expressed  himself  as  uni^Ie  to  bear  any  further 
the  excessive  suffering  from  the  dieeaae. 

A  conaultation  of  the  aurgeons  of  the  Hospit^  being  called,  m 
is  usual  in  such  caaes  before  proceeding  to  extremities*  the  fbl* 
lowing  suggestions  were  made ;  That,  from  the  -excesaire  aaf- 
femg,  the  diaeode  might  be  an  ulceration  of  the  cartilagee  of  lb 
joint,  or  poaaiblj  it  might  be  of  a  malignant  character ;  and  tfait 
an  inctalon  should  be  made  into  the  joint,  and  its  condition  ei' 
plored.  If  it  proved  to  he  an  ulceration  of  the  cartilage,  tlat 
the  ends  of  the  bone  should  be  removed  ;  otherwise,  ampotatioa 
of  the  limb  should  at  once  be  performed. 

On  being  informed  of  the  nature  of  the  ca«e,  he  agreed  to 
have  done  what  was  thought  proper.  Hie  following  open- 
tion  was  therefore  done  on  Wednesday,  March  80th  ;  preparation 
having  been  made  beforehand  of  a  aplint,  well  moulded,  to  ie- 
ceive  the  limb  In  caae  the  joint  should  be  e&ciaed.  Bein^  ether- 
ized in  his  bed,  to  save  him  from  the  pain  likely  to  be  caused 
by  his  removal  to  the  operating  room,  he  was  carried  up  stalre. 
A  firm  pillow  was  placed  under  the  joint,  ao  as  to  aupport  it 
in  a  bent  |K>sitLOD ;  and  an  inciaion  wna  mode,  commencing  tX 
the  inner  condyle  of  the  femur,  carried  down  with  a  semi- 
circular sweep  over  the  tubercle  of  the  tibia,  and  terminated 
opposite  the  outer  condyle.  The  llgnment  of  the  patella  wis 
now  cut  through,  and  the  joint  partiiilly  exposed  ;  a  g:reat  mah 
of  Huid  titking  p[ace  as  the  capsule  was  opened*  The  head 
of  the  tibia  came  into  vietv  hi  a  perfeotly  lienllhy  condition.  The 
flap  bcin^  raided,  a  most  beautiful  and  highly  colored  tumor, 
covered  with  delicate  synovial  inembrnueT  having  lar^  vessel? 
running  in  every  direction  over  its  surface,  very  much  Uiettendedt 
and  formed   by  tlie  lower   end  of  the   femur,   was    seen.      The 


TUMOR   OF  SAnTOBlUS  MUSCLE. 


N 


tumor  extended  quite  up  lo  the  lop  of  the  flvnovinl  saf..  There 
being  no  question  aa  to  ita  mflligiJiincy,  the  [mtient  woe  inimoji- 
atcly  sli|ipcil  down  upon  the  table,  and  hia  thigh  ampuluttMl 
about  the  ntiddle.  More  iLrtcriee  roi^uirod  li^^ture  tbfin  in  enit- 
nary  casea  of  nmpulation  from  ftcciiicnl ;  a  \'act  which  Is  fre- 
quently obacTved,  when  n  hnih  has  hcen  amputaleJ  for  mnhgnnnt 
diseiiae.  The  bleeding  having  been  checked,  and  the  eurfacfl 
teiiig  quite  dry,  tlic  wound  was  brijught  to^tlier  wilh  two  or 
three  sutures  ;  and  a,  ci>rnpi-cdSt  with  hauduge,  earet'ully  applied, 
to  givG  the  stump  support. 

lu  the  afternoon  oud  evening,  the  atump  hecanic  distended 
and  painful,  so  that  it  wiis  ucccesary  to  open  the  wound  ii^uin, 
find  upplj  one  or  two  li;:;nturc8.  It  wae  tbrmerly  my  habit  at 
the  lloapltal,  m  order  to  avoid  an  occurrence  like  the  present, 
to  leave  the  wound  open  for  fire  or  Btx  houra,  and  then  Imve  the 
dreefling  done  niter  all  oozing  of  bJoo(J  hud  ceaeetl.  My  reneon 
for  relinquL^hing  this  practieo  was  the  excea«ive  aenrtLiivcne^s  of 
'patients  fur  a  lew  hours  after  operations,  ju^t  ae  they  recovered 
from  the  etFeeta  of  ether,  and  their  uuvvillingneaa  to  bo  interfered 
■with,  But  where  there  i&  evidently  luueh  dnnger  of  bleeding, 
J  consider  the  dchiy  a  lesacr  evil  than  the  re-opening  of  the 
stump,  aejirching  for  the  bleeding  vcbbcIs,  and  perhaps  opening 
fre^h  ones*  while  clearing  the  wound  from  coagula,  at  the  same 
time  nmning  the  rl^k  of  eubeeqiictit  suppuration,  and  sometimea 
of  an  ill-formed  atump. 

The  patient  made  a  good  recovery. 


Cash  CCCSFV,  —  Tutiior  connecied  u-ith  tfte  Sartortna 
Musoie^  ^condary  to  Cmicer  of  tho  Breast*  Op'^rntioH.  En- 
fniHCO  of  Air  into  the  Fetw-  Jlceovcrif,- — This  patient*  30 
years  of  age,  had  a  tumor  of  the  breaat  removed  five  year  a  before- 
One  of  her  sifters  had  nJ^o  been  aubjcetcd  to  an  o}terntion  of  tlio 
breast  for  an  cnccpholoid  tumor,  and  svaa  well,  and  present  at 
the  operation.      Another  aister  atso  had  a  tumor  of  the  breaat* 

The  tumor  in  question  appeared  about  a  year  and  a  half  be- 
fore; and,  when  I  saw  it,  was  four  inches  long  and  three  iriehes 
wide,  commendng  ju^t  below  Foupart'a  ligament,  and  extending 
down  the  thigh. 

67 


I  ' 11  III 


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nLolIuD  <rf  the  limb. 

On  tbe  upi^r  &&(!  inner  siik  of  tbe  ihi^i  was  aWgr,' 
Acribed,  movable  lumor.  ^itoaud  deeply  iu  ihe  llab,  «^' 
citenaor  uiJ  adductor  muocJcA  aiul   ^^r^nt    "resHti*.     ll  Wl 

deep  MtLiation- 

Thc  j>atient  being  etherized,  tbe  thtgli  waa  ratmieA  «ir*i*| 
and  partjj^  flexed  oa  tbe  abdumeD.      An  mciaum,  eigbt  id^M 
Icn^tSi,  WIL0  DOW  made,  over  the  middle  of  tbe  tucmiTi  ikMl 
the  skin.      Tbe  i'ascin  waa  iheti  divided,  which   i^pond  1^^ 
ductor  longue  nnd  ^raciliB  rousetctf,  eprend  over  tbe  Ciuaor&f> 
fan.     The    adductiir   l.mgua   lw?mg   cut    Uirotiglt.    tlje 
ma^ue  waaesposed,  wliidi,  being  divideij,  brinighl  the 
into  view,  with  its   layers  of  ccJIalar  mcnibraiir.      It  ^"v 
Jaid  bare,  and  gradually  dU9C<^tcd  or  sepantted.  vritb  the 
and  fingers,  from  ite  invcdtinenta ;  U^e  heinorrbage  bciti^|l^' 
lilac,  Dininly  from  lar^  TeDoua  lrunkr<,   »oiug   of  which  hd^ 
be  tjed.     An  oozing  of  hjood  contintiitkff,    the  uiteriijr«fA> 
wound  wofl  lightly  li^ucbcd  wUb  a  aolufion  of  the  pcrchtoride' 
iron,   iitid   a  ti[H>ngei    enveloped   tn  ji   linen    clotli.   t4rj]i|MMtf4r 
IniroUiiccd  to  fill  up  the  large  cavity  and  produce  coiuprimtfj 

Tilt  turakjr  was  found  to  be  fibroua.     ll  vraa  »p|ierir&]  in  ^htfc- 
about  Uie  size  of  a  large  cocon-nut*      It  Iny  agaio^t  the  boacrt 
itfl  inner  side,  prc^sinj^  the  vetieeL^  outvarda.     Towanla  tlir  Inlitf  | 
part  uf  tlic  operation,  the  circulution   became   much   i1oimt»(4, 
and  the  face  very  sallow,     Under  tlic  use  of  sliiuiiliuit*.  in  tk 
courae  of  a  few   hours  tiie  circulatiur   wne  fully   restuirvd.     1» 
three  or  four  days,  there  wa*  coneiderable  swelling  in  die  th!^ 
which  waa  relieved  by  a  free  suppuration.     The  wnund,  aftff 
tliia^  healed  well;  and,  at  the  end   i>f  &\x  weeks   tVnju   the  tlmC 
of  ibe  operation,  he  returned  home  [*erfeetJy  rcstortN],  in  )a^ 
sptnta,  taking  bia  tumor  witJi  bim. 

Case  CCCXVm  —  Uncommon  Tunwrof  Thit/it,     Urcot 
trtf. — A  gentleman   applieil   to  nie   iu   Junuriry,    J81JG,    for 
tumor  of  the  leg,  which  hud  njipciLrLMl  under  tJic  foUurt'lij^r  L-ir-| 
cuuiatanccfi;    About  three  luontlid  bcl'orc,  be  wiu  token  nitha. 


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2 


PAEffFCL  CUTANEOUS   TUBERCLE.  S35 

of   veflaelsT    principolly    venous,    projccied   tdrough   the 
ind.      These,   together   with   the   body   of  tlie  tufoor,   were 
lisaectPtl  out,  with  some  [ipinorrhnge.      The  opi^mtion  waa  »p- 
linntotl  by  Dmhrflcirg  with  a  llgnttire  the  base  of  this  cnngeries 
lof  veaaeU.      A   severe  ottnck   of  mtinmnittCion   followed,  which 
uumtcd  in  an  abscess  lu  the  f^hcck.     He  left  the  Hospital 
LweU,  in  A  fortnight.     The  nucleus  of  tlie  tumor  wns  composed 
of  n  fulty  siibstjince,  quite  finn  U'fore  romovitK  hut  cnsily  broken 
lip  by  the  fingers  nfler  it  wiw  dissected  out.     The  greater  por- 
tion of  it  was  made  Up  of  erectile  ti^^eue. 

Cask  CCCXX.  —  Painful  Cufaveont  Tufiercfe.  —  A  wo~ 
\KD,  30  years  of  age,  had  a  smalt,  projecting,  nipple-bhnped 
tumor  on  the  skin  of  the  right  nrite^.  Ir  waa  of  five  yenrfl* 
itAuding ;  nnd  she  complained  greatly  of  the  suffering  occusioucd 
by  it,  which  wiw  of  the  most  in*iuj>fmnnble  kind,  nnd  occurred 
in  paroTysmB.  At  these  periods^  she  would  uot  allow  any  per* 
son  to  come  nenr  her. 

The  wound  was  examined,  after  the  excision  of  the  tubercle, 
for  the  purpose  of  discovering  if  any  nervous  filament  had  been 
pressed  uj>on  by  it ;  hut  none  could  he  detected.  Its  tcxmre 
was  librous ;  at)U  no  cancer-celU  coald  be  found  in  it,  under 
the  microiicope-  The  character  of  the  pniin  waa  the  same  as  that 
obiorved  in  the  suhcutaneoutt  painful  tubercle.  Entire  relief 
followed  ita  removul. 

The  subjoined  tables  give  the  immcdinte  result  in  one  hun^ 
dred  and  fifly-five  cases  of  midignnnt  diaeaae,  operated  on  hy 
myself  during  a  |>eriod  of  twenty-six  years.  The  tahio,  for 
the  last  thirteen  years,  consists  only  of  Hospital  cases:  and 
the  whole  table  eomprieea  only  those  patients  who  remidued  for 
a  time  under  treatment ;  many  who  submillod  to  minor  opera- 
tions, auch  na  cuncer  of  the  lip  and  of  the  inleguroenta,  leaving 
immediately  after  the  operation,  am)  no  record  of  tliem  being 
preserved. 

The  cases  up  to  1852  wore  collected  from  the  Hospital  re- 
cord*, by  Dr.  Albert  A,  Sawyer,  and  tlio  remainder,  by  my  *on, 
Dr,  J-  C.  Wairen,  formerly  houae-aurgecns  at  the  Hospital. 


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CHAPTER   XIL 


GUNSHOT     WOUND  S. 


Since  iho  Ente  war,  gunshot  wounds,  nnd   other  wounds  p- 

diiPCtl  by  warlike  vpcopons,  hnvc  received  an  iurrcased  inittft*- 
anJ  are  now  bcinp  extensively  illujstrnteti  by  tlie  elaborate  "iirt* 
published  by  Surgeon -General  Barnes,  under  the  fliTectii>a  ^ 
llio  American  GovcrniucnL  Some  of  iho  beFiutiful  photo^ptiit 
illuatrutione  of  important  surgical  cn&cs  ond  oj>crntIonB,  by  Dr. 
George  A.  Olis»  Surgeon  CS.  Volnnteore,  and  Curator  of  thf 
Army  Medical  Milium,  which  surpass  in  the  art  ativ  thing  <i 
the  kind  which  hns  thufi  far  been  QCf^oiiipUshcd^  ha^e  dre^dv 
appciircd.  Circular  Nu.  U  —  being  tlie  prcliiuinary-  fiUTgioI 
rep£>rt  of  Dr.  Olis  tg  ihe  Surgeon-General  —  ia  of  raftai 
vnlue.  The  annie  may  be  eftid  of  the  medical  report  by  Dr.  J. 
J,  WotfJ^viird.  ^The  bnttle-field  liJsls  of  nounded,  for  the  ycin 
1864-S,  irclude  over  114,000  names." 

To  ^ivc  an  idea  of  the  nEnoiint  of  material  wliioli  iireEeaU 
itaelf  for  ub^crvntion,  1  mrike  the  following  quotation  from  Dr. 
Oua*fl  vnJunble  report  i  — 

*'In  comptiriftg  (he  numbers  ofcnaes  of  some  important  injury,  a*. 
for  ox»inpLo^  guoflhot  frnoUiroa  of  tha  femnr,  it  i^  found,  thnu  ■□  iba 
Frendi  Crinie»n  nrmy,  iliere  were  459  such  injuriea,  nad,  ia  iho  Edj- 
liflh  army,  194  -.  whili-  iiver  fl,000  such  cnaes  hai-o  been  reported  to 
ihia  office.  Or,  if  one  of  th^i  mnjor  nperatfcms  \p  et-lecf^d  for  wia- 
purieoQ,  na  <^xcii^\oii  of  the  htiul  of  [lie  Lullutu^i  tlin  Critut^nn  reiunu 
ghtt  IG  of  iliege  exci^ion&  in  the  Bntisli,  nnd  38  in  tlio  KrcDcU  array; 
but  ihe  ri:'r[s[f!rH  of  Llii^  [ilTiec  ronijiin  the  rieliiilcd  bi^lorics  of  o7* 
sucli  opcraiiODS." 

The  Crimean  war  gave  rise  to  ore  or  two  valuable  works 
bringing  the  subject  more  particularly  before  the  public  thao  it 


/S 


WOUKD    OF    HEAD.  543 

nt\  been  since  the  splentliil  ivork  of  Lirrey^  and  tho&e  of  Gu- 

rio,  Honnen,  mid  others  during  tliG  war8  of  Nn-polpon. 

In  regnril  to  the  destruction  of  life,  eniised  by  tlie-  pasHn*'e  of 

rojectilcB   from   Hrp-armn  nenr   tlie  hni\y  wlEhoiit  ttiurhing  it, 

ere  hna  long  esisied  a  popithir  duljsion.      In  iminr  rn^c^,  it  lina 

heen  prf>ved  by  dissectii>ri,  llnu  the  hndy  Ima  boen  fitnick  by  the 

tall,  whicb  left  no  externnl  mark*  *if  its  passnge.      Lnrge  effii- 

ions  of  blnod  liiive  iK'.en  fuiiiid  in   the  thoracic  and   nbdoniinal 

Cflvities,  organs  riiptin'e<l,  mid  bone*   ftrul   muscles  diflorg!nii:£od, 

ichout  any  abnvaion  of  the  inte^nm^nt  outside,  to  indicAte 

the  paint  where  ibe  misMfe  struck.      Tliis  is  the  result   of  ibe 

^elastidty  of  the  skin,  vvhlch  in  itself  offers  but  little  resislan<"e, 

jielding  to  a  great  degree,  vrhile  t)ie  Hrmer  texture  uf  the  Imnea, 

muaeles,  nnd  orgnna,  does  not  permit  of  .so  mnclt  relaxniion.     It 

Uiny  fairly  be  sjijd  that  no  one  was  evor  killed  by  the  wind  of  a 

cnnnon-bnih 

These  n?m;irkB  nre  confirmeil  by  conversaliiinp  wilh  rnililiiry 
ftnd  n!iv:d  aiirgeona  who  liave  bati  the  pxporienee  of  tlio  whole 
wnr^  and  who  have  hjul  nn  oppi>rtLinily  of  \vit^Le^sing  imd  learn- 
ing, by  personal  experience,  the  etfeet  of  the  pnssngp,  near  the 
y,  of  pmjectilcs  of  a  larger  «i7G  llian  any  ever  used  in  war- 
before.  The  testimony  of  o^k^tk  and  soldiers  is  to  tbe 
sunie  effect. 

In  tbe  enrly  port  of  the  war,  fipfiire  the  subject  bai]  received 
much  ntfeniion  in  tbi?i  couniry^  I  published  some  casps  of  gun- 
fthoT  wcmnds,  also  of  injiiries  iti'  the  nerves  from  weapons;  ihe 
restilta  of  treatment  of  the  bitter,  at  that  ilme^  being  very 
mongre,  A  few  of  the  fonner  cjwefl.  wirh  aidditiunnl  ones^  nre 
here  presenleJ.      The  latter  have  Jilrendy  been  given. 

Cask  CCCXXL  —  Bullet  spJK  htj  romhtg  in  ConMct  with 
Bonf*.  — An  occurrence  vrry  r^iuitnou  wirh  the  or«lin:iry  spheri- 
enl  bullet  is  to  sjilit  on  eaming  in  contnet  with  bone.  The  fol- 
lowing case  occurred  at  the  biitrlr  of  Bull  Run  t  Lmufcnunt 
B-  was  struck  on  the  left  side  of  the  os  frontia  with  a  round 
bail,  nod  WHS  supposed  by  hia  eornradca  io  be  mortally 
wounded.  He  was  ninrle  prisoner,  and  taken  to  Richmond,  A 
prcijeetion  wna  felt  under  the  «ca1p>  about  four  indies  from  the 


J  wound  in  the  integuments,  and  fto  inciaion  made  over  it*  frtm 

which  half  of  the  bullet,  with  ft  highly  polished  cut  Aurlkoe,  m 
removed*  He  retnained  seven  months  a  prisoner  at  KchtnoDd, 
during  which  time  the  wound  in  his  forehead  continued  open, 
and  suppurated  freelj.  He  was  troubled  with  acme  uneasineN 
iu  the  head,  and  occasional  headache.  On  his  arrival  at  Fortmi 
Monroe,  after  his  release,  this  discharge  atiH  fx»ntinuing,  b« 
WAS  examined  by  Dr.  Cuyler,  United-States  Army,  who  ^ 
eovered  a  metallic  substance  deep  in  the  wonnd.  This  vai 
skilfully  extracted.  The  patient  states  a  small  portion  of  brun 
escaped  at  the  time.  On  examination,  the  extracted  bo^ 
proved  to  be  the  other  half  of  the  ball,  flattened  on  both  Aukfli 
and  having  embedded  in  it  a  portion  of  the  skull.  On  the  not 
day,  a  piece  of  the  inner  table  of  the  skull,  which  had  ben 
driven  before  the  ball  into  the  brain,  was  also  extracted*  Afta 
the  removal  of  theee  substances,  the  wound  healed. 

The  patient  afterwards  came  under  my  care,  and  t«muDd 
for  some  time  in  delicate  health. 

Dr.  Fox,  of  the  Naval  Hospital  at  Chelsea,  show^  me  a  case 
in  which  a  ball  pcnetmtecl  in  the  middle  of  the  arm,  and  mi 
cut  out  over  the  scapula.  In  ita  passage,  it  struck  the  edge</ 
the  scapula ;  the  ball  being  cut  nearly  in  halves,  and  flattdwd 
out  in  thi^  position* 

In  ahnoat  every  instance  I  hnve  met  with,  when  the  round 
ball  encountered  bone,  it  was  cither  flattened,  or,  if  it  met  ll« 
j  edge  of  a  bone,  as  of  the  jaw  or  rib,  it  was  split. 

I  f  Case  CCCXXlh—GunnhotWoutid  in  the  ^eck, At  die 

i  battle  of  Bull  Run,  a  man  was  struck  in  the  neck,  just  bebiad 

}  the  angle  of  the  jaw,  over  the  point  of  bifurcation  of  the  carotid 

I  artery.     The  ahot  bein^  fired  from  below,  the  bnl]  penetmted  in 

?  nn  upward  direction,  and  struck  the  edge  of  the  juw,  which  cut 

it  in  two,  one  portion  rcmnining  in  the  neck.      The  other   and 

larger  part,  pnsscd  through  the  base  of  the  tonf^uo     carrid 

away  a  portion  of  the  alveolar  process  of  the  up]>er  jaw,  and 

escaped  tlirough  the  check.     The  hemorrhage  from  the  wound 

was  at  first  rather  profuse,  hut  waa  checked  by  pressure  with* 

]iatjdkei^:hicr,  and  did  not  recur.     The  wound:)  healed  kindir: 


W0USI>  OK   0»  CALCIft. 


545 


nit  an  Mbscesfl  fi>iTHftl  in  the  neck,  wluoh  wns  opened*  and  por- 
tions of  lead  and  spioula  of  bone  wore  reimjveil  from  it.  After 
tne  or  two  ahsceeaes  of  tlu«  kind  hiul  formed,  he  recovered. 

Case  CCCXKIU.—  Gutu^hot  Wound  in  the  Leg, — A  mun, 

27  yeara  of  age,  was  hit  by  a  bullet  on  the  inside  <jf  che  left  le*, 
ibout  its  middte-  The  bnll  pnaaed  llirough  tlie  tibia,  producing 
eonipimnd  fracture  of  the  hone.  The  frjieruri?  united  rtficr  a 
■verv  lonjj  time,  aa  nho  tUe  wound  of  entrance,  X'he  wound  of 
exit,  lnjwever,  reinnined  open,  and  when  I  saw  him,  eight  month* 
ftl^er  the  rei."eipt  uf  the  injurv,  W'.is  of  the  size  of  a  hnlf-dnlljir, 
And  Ijod  on  unhealthy  look,  re^einhling  cpitheiial  ciuicer.  The 
l^es  of  the  wound  had  alreudy  been  dlejaectcd  up,  in  the  hope 
of  relieving  lenBion,  Jind  produchig  si  heiililiy  8(ale  of  (he  wound, 
I  determine<l  to  die»iect  out  the  entire  ulcer,  ivhich  was  done- 
,In  the  centre  of  the  wound,  and  between  the  bones,  a  black  suli- 
ftanee  was  diA(^overed  in  an  encysted  state,  Thi»  was  at  Hrst 
'thought  to  l>e  powder,  but  wna  afterwanla  e^tplained  by  the  pa- 
itient  fltating,  that  when  in  lUehnumd.  on  aecoimt  of  a  aloi-jtrhy 
oonditiou  of  the  wound,  be  had  been  tu  the  habit  of  flprinkling 
it  vviili  ^'harcojd,  ^Joine  of  the  granules  of  whicli  hud  been  covered 
up,  and  reijiiiied  there.  The  wound,  after  the  operation,  look 
en  a  healthy  netien,  and  soon  closed. 

Case  CCCXXTV.  —  Gm^shol  Wound  throvi^h  /I,*  O-  C'al- 
CX9.  —  The  following  case  exemplilies  the  very  slow  way  in  which 
w^ounde  of  a  spongy  bone  take  on  the  healing  process :  Richard 
Roe.  a  private  in  the  First  Regiment  JljLs*;achueGtia  VciluniecrH> 
was  struck  by  a  bdl  in  the  lefl  heel  ;  the  ball  jtik^^ing  ruund  the 
OS  calds,  and  coming  out  on  the  other  side-  The  enemy  were 
firing  up  fn>m  a  hill,  a  little  below.  SliTirtly  afterwanl^,  he  ex- 
posed (he  other  foot^  when  another  ball  struck  him  iu  exactly 
the  same  spot  on  that  foot,  past^ing  through  the  o«  culcU,  He 
was  carried  a  prisoner  to  Richuiond,  where  he  was  under  the 
care  of  Dr.  Charles  Bell  Gibfcon,  of  the  Confederate  Anur.  In- 
flammatiiU]  was  so  extensive,  and  the  pain  so  severe,  that  ho  at 
one  time  rcquesTL>d  Dr.  Gibson  to  ampututc  the  foot,  which  he 
very  properly  deeJmed  to  do.     The  patient  came  under  my  euro 


about  m  monlhs  uft^rwartU,  having  regnioed  hi^  Zihertr. 
pruLin^  the  wuund,  I  discovered  a  lar^^e  piece  of  dclachetl  b^| 
The  wound  wns  pnlnrped,  and  q  portion  cif  bonp,  th<*  eiM  oR 
cUei^tniit,  rtpmovcU  ;  mid  th^  bone,  ntiicb  wue.  rou^h  in  ono 
Dinde  emtxith.  Al^er  this,  the  wound  ^rsdutiJly  healed,  £4> 
at  one  time,  he  rjitild  use  his  foot  in  wfllking.  If  ihen 
inlJsiTiied  nfjuiui  ^nd  began  to  diachtir^e,  1  ndvUed  him  to 
the  IL>^pjt:df  two  monihA  alter  the  fir£t  operation-  tTlic  boM 
waa  then  ex|>o^ed  by  a  large  incision,  and  the  whole  mtcrior  oi 
tlie  cnvity  ex(*a^ated  uilb  a  chisel  nod  drill.  The  mouth  of  (k 
aperture  in  the  bono  \mib  unide  niLch  wider  ihnn  the  inienW 
In  April,  1862,  nearly  nine  nionrhs  of^er  iho  aceident^fl 
wound  was  nearly  healed,  but  ttill  painful  if  he  Aticnipto^i 
walk  ;  and  it  was  difficult  to  say  whether  he  \^-ould  rceov^r  with- 
out the  removal  of  the  whole  bone.  The  rest  of  tl>e  foot  wai  ift 
n  perfectly  heahhy  state.  In  June,  1862,  the  wound  hnd  wb- 
ti-ncted  to  SL  smnll  point,  there  was  n  serous  exudation  froi 
and  be  wae  able  to  walk  nbout.  Now,  IStiT,  it  is  pcrfccUv 
In  moat  cuees  where  1  hnve  had  to  operate  for  caries  ofj 
OS  CftleiBf  reiwQted  operalious  huve  Iweu  require^!. 


Case  CCCXXV-  —  G^tnahol  Wcuud  m  the  Thi^k. 

Trnee  oftJiG  Bail  at  first  to  be  discorertd ^Injor8., 

lit  the  heiul  of  bia  re^inieuE  at  tlie  battle  of  iXew-bcrn.  recci^ 
hall  in  the  upper  and  front  part  of  the  thigb,  nhout  two  iLdiQ 
below  Poupart^s  lifraracrt.      The  whole  regiment,  at   the 
were  in   the   aJvunce,  and  were  expoeed  In  an   open  field. 
reclining  position,  firing  on  the  enemy,  who,  in  return, 
firing  down  upon  them  from  breastworks.     He  fell  a  h|oi 
the   leg   na   if  from   a  stone,   nnd  was  not  awnre   thjit   he 
wounded,  until,  on  ren»ovin<:  hJs  eont,  he  ^aw  iho  bloml  doi 
freely.     He  went  on  j,^iving  his  ordera  until  he  boc«iac  faint,] 
waj*   t:iken   to   the  renr.      The  wnuml,  being  probed  bv  the  nP- 
geon,  wfiH  hmnd  to  extend  in  mlirectioii  downward   and    lui 
for  three  or  four  inches-     The  bail  could  not  be  found  id 
wound,  nor  could  any  irai^e  of  it  he  deleeted  ekcwhere, 
only  eensaUon  he  folt,  in  addition  to  a  general  w^ant  of  powi 
the  liiub,  woB  that  of  slight  numbness  in  the  calf  of  the  1^  aoi 


] 


in  the  foot.  Perf«cl  rest  of  llie  limh  was  enjoined 
inn  mm;  and,  Jihijrtly  aft^rwnj-d,  he  was  Ijr(nj;r|it  linme  m  a. 
transjjikrt  ve^^el,  with  i»(lier  woitniird  soliJierA.  1  enw  him,  la 
|DOtiipuny  with  h]6  phv^it^Ian,  Dr.  ChiLrlea  Gurdoti,  itbout  three 
^weekrt  aAcr  the  date  af  the  injiirv.  An  extrtvated  ulcer,  of  the 
BLzc  of  it  quiki'ter  of  u  dollnr,  nturkeil  die  nitunlioii  of  the  entrnnoe 
(if  tlie   hail.      IJodeniealh  it,  in  die  celluliir  membrBDC,  was  a 

IdepOMt  uf  lyjiipli,  wliiuh,  on  being  moved  tif  imd  fro  over  tlie 
muectea,  gnvc  u,t  iirst  the  ^eii^fition  of  the  picj^ncc  of  a  ball  at 
tliat  .4jiot.  A  HmaJl  piidiole  In  tlie  centre,  from  which  issued  a 
serous  fluid,  at  first  eeenied  to  conSrm  this  view  :  the  history  of 

I  the  wound,  however,  was  oppo^eil  to  ft.  A  probe,  bein;;  ^titly 
pressed  into  the  openji]<r,  ciiuouutercd  uo  forei-rn  subatauce.  The 
pntieiit  beiu^'  of  £iie  phyalciL]  development,  nud  quite  free  from 
fat,  the  coulimr  of  the  various  uiu^clea  waa  strongly  marked.  A 
careful  exaiiunallon  was  uow  tiiJidc  of  the  whole  liiuh,  coiu- 
mencing  at  the  toea  a,ad  guing*  up  to  the  ^roin^  Enakiiig  such 
limni|iulutIo]is  \is  to  Imve  no  one  of  the  uiu?^ctes  or  iuterniuaculEtr 
Bpciccfl  unexplored.  Xot  the  sli-rhtesl  pam  could  be  pr">duceJ, 
or  indor:Ltiijn  felt,  to  mark  the  pre«cnue  of  the  concealed  bullet. 
Finding  no  tmee  of  thu  ball,  JL  wus  decided  to  allow  the  patient 
to  uftfi  the  Ihiih.  On  fir^t  making'  an  alti^mpt  tij  jit:iud,  he  found 
much  dilfit;u1ty  in  Join^  IH^,  bi:itb  from  the  stillness  of  the  ivound 
^feaud  from  tlie  dir^nse  of  the  Hmb  ;  but,  heiug  supported  by  twu 
persons*  and  making  an  eiFort,  he  wa^  gradually  enabled  to 
move  EU'ouiid  the  room-  1  advised  \i  tontiiiuauce  cf  this  eser- 
^P  cise,  ID  order  that  he  might  re-^^in,  aa  sogu  &a  poAMble,  the  power 
of  the  niu.^t^les,  :md  wUh  the  hope*  Dliat  the  muafudar  Jietinn  would 

Ibriug  the  hall  from  its  hidiug-plnee>  TIuk  proved  to  he  the 
Giiae  ;  for,  iu  al)out  ft  eouple  uf  weeks,  a  hiird,  movable  sub- 
fitance,  which  felt  like  half  a,  sphere,  was  found  trnvelling  np 
the  limb.  The  bullet,  it  was  hoped,  would  follow  up  the  trac^k 
(if  tlie  woLuul  ;  but  it  wa.*  wjon  di*^c^^vc^ed  that  it  was  very  mova- 
ble, quite  under  the  reclns  muscle,  and  eoidd  not  be  distinguisfied 
Int  all  uht'n  this  niufi<'le  was  rontraetod.  After  arriving  iiiiiler 
the  oEd  winuid^  it  was  thought  jHissible  that  it  might  re&t  there; 
but  it  was  found  that  its  disposition  was  upwards,  towards  tlie 
groin.  Major  S,,  being  very  desirou?  to  gel  rid  ol'  it,  and  re- 
joLi  his  regiment*  decided  to  have  it  removed. 


548  GUNSHOT  WOUNDS- 

The  ether  being  given,  the  patient  waa  placed  on  a  table,  wit 
the  light  from  above ;  anJ  an  incUion  was  made  through  ^ 
skin,  cellular  membrane,  and  faecia,  and  the  muacle  uncovered 
No  cicatrix  could  be  found  further,  ae  a  guide.  The  ball  wa 
now  fixed  by  an  aid,  and  the  muaele  careJully  cut  thronirh; 
veaeel  tliat  ran  across  it  being  tied,  so  aa  to  prevent  any  deep 
seated  effusion  of  blood.  The  ball,  from  its  coDstant  dispositia 
to  change  ita  position  for  an  inch  or  more,  caused  some  embu 
rassnient.  It  was  felt  to  be  resting  on  the  bone,  and  wa«  tbo 
fixed  by  two  fingers  in  the  deep  wound,  and  the  muscular  fibre 
over  it  cut,  and  its  blue  coJor  was  seen  through  the  delicate  b 
vesting  sac.  It  was  uecessary  to  divide  this  in  several  direction, 
before  it  could  be  pushed  out  with  a  director.  It  >ras  a  roonJ 
bullet,  flattened  on  one  side,  as  if  it  had  struck  the  bone,  ud 
then  glanced  down  the  limb.  The  bone,  not  denuded,  coald  be 
felt  beneath.  The  wound  was  brought  together  by  adhetdn 
straps,  and  a  cold  water-dressing  placed  over  it-  The  mo* 
rigid  quiet  was  enjoined.  The  limb,  on  the  fbllovving  day,  wia 
aore  and  swollen  ;  and,  on  the  fourth  day,  an  ahscesa  formeda 
the  situation  of  the  sac  which  contained  the  buJlet,  and  ^ 
charged  itself  through  the  wounds  By  continued  rest  of  the 
limb,  and  absence  of  muscular  motion,  any  eflusion  of  pue  under 
the  muscle  was  prevented.      The  patient  completely  recovered. 

In  the  present  instance,  and  in  one  or  two  similar  onee,  n<^ 
tenderness  in  the  trnok  of  the  ball  pointed  out  the  course  whidi 
it  had  tnkcn ;  and  this  fact  is  important,  as  the  want  of  ina- 
bility iu  the  track  taken  by  it  is  occasionally  given  aa  an  anzu- 
mcnt  that  it  has  not  entered  at  alL  As  before  stated  a  pjJr 
was  felt  in  the  calf  of  the  log,  at  the  time  the  wound  wasiv- 
ceived ;  also  a  numbness  of  the  foot,  and  soreness  about  ii» 
ankle.  The  former  disappeared  after  a  time  ;  but  the  sorenes? 
of  the  ankle  continued  until  the  extraction  of  the  ball. 

Cask  CCCXXVf. —  Gunshot  Wound  front  a  Conical  Bul- 
let in  (he  Cajf  of  the  Leg.  —  Lieutenant  C. ,  of  the  Second  Mi*- 
eachusetta,  whose  regiment  had  fought  ilurin^  the  whole  da^^ 
as  rear-guard  iti  retreat,  the  ilay  before  ihe  battle  at  Winchesier, 
and  probably  saved  the  army,  arrived  in  canip  at  twelve  o'dix* 


at  nig'ht.  haying  cuftrdied  thlrty-fiyc  miles  without  food  itnd 
drink,  eic^efrt  tlie  muJJy  water  of  liie  rcHulelde-      Lieutenant  <J, 

that!  char^^G  uf  tlie  ca^nip-gLinrd  i'oc  tfie  night.  At  four  o'clock 
in  tbe  mornlnj^,  llie  battle  begnn,  anil  looted  four  hours;  and, 
when  the  re^^iiiicut  was  in  danger  of  being  auvrcuudcil,  the  onlcr 
for  retreat  waa  given.  The  re^jimcnt  fjnued,  and  niaruhtJ 
ckiwn  tbe  luJl  into  Winchester,  regftrdJea^  of  the  enemj  in  full 
pursuit,  wlitMverc  firing  intc^  them.      Lieutenant  C-  was  in  coin- 

»niaad  of  the  reur  company ;  in  faet,  the  [ast  pcraon  brintring 
Up  the  rear.  He  received  at  tliid  time  a  shot  ia  the  cnlf  of  tlie 
leg,  diC  aenanliun  bcin^^^  that  i»f  a  violent  blow  with  a  cliih,  which 
kiiock&d  Iiim  di>v\-n.  lie  attempted  to  ri^e,  but,  after  sturubliiig 
a  few  etc|>s,  itil  headhjn^.  By  this  time,  forlnnatelj ,  tbe  ecr- 
tgcant  of  Ilia  company  perceived  his  eituatiant  und,  being  a  nixa 
of  great  size  and  alren^'th,  took  him  in  bis  arras,  larricd  liitn 
about  two  hundred  yarda  into  tbe  alrccta  of  Winchester,  :ind 
idcptiBitral  him  in  the  only  ambulance- wa^on  that  happened  to 
be  there.  A.  nmnber  oC  other  wounded  men  were  put  into  the 
,Bame  wagon,  some  of  ihcm  lying  upon  Wim.  He  contrived  to 
MLt  bi^  head  out  of  the  front  of  the  rehielc,  t4o  aa  to  ^t  air ;  and, 
in  thi6  position,  with  \i  cnaji  lying  on  hia  wounded  log,  remained 
intil  tliey  arrived  in  W ill  ianie port,  on  the  following  morning, 
\- — aomc  twenty  houi^e.  He  waa  ho  completely  pinneil  to  tlie 
^apot,  that  he  was  unable  to  ebenthc  his  eword,  which  lay  drnvni 
'by  liifl  side,  juat  iia  he  w&a  placed  with  it  \n  the  ombulance. 

On    the    paeeage    through    U'inchetlei",   a    shell,    apjurenlly 

Lhrown  at  the  ambulance,  which,  if  it  had   penetratcdi  would 

have  di^fltroyed  all  the  wounded  within-  killed  a  man  lying  within 

two  feet  of  Lieutenant  C.     On  the  afternoon  of  the  following 

tyi  Lieutenant  0.  hatl  hia  wound  exunined*     It  waa  found 

fthat  the  ball  hud  penetrated  at  the  outer  and   upper  part  of  the 

left  leg,  passing  through  the  belly  of  the  gaatrocntndue  muscle, 

in  the  vicinity  ^ji"^  the  great  vessels,  and  had  been   stop|icil   by 

le  bone.     It   had  carried  in  with  it  a  patch  of  the  troueera 

^ftnd  the  drawer^i,  which  were  of  tbit;k  knit  woollen*  wiihoiit 

taring  tliem.      From   tlie  swelling  of  the  wound,  the  whole  of 

khis  plug,  nearly  ua  large  as  the  cork  of  n  quart  boltle,  had 

been  eomplctcly  wedged  iato  It,  ao  aa  L>aly  to  be  witlidrawn  by 


550  ouuaiiOT  woi7?ffi>8- 

free  incisiuni*.  The  wi>iiri(l  remainwl  quite  jwiioftil  for  iff 
dnya,  until  supjinrjition  hai\  trnmmcnc^  ;  nnd,  after  (K*  M' 
fi  immth,  sfi)wl\'  lienlfnl,  fhv!  ]i;ilitiit  ^i>ttiri^  nbout  on  enrr^ 
TUii  W'^  ^\i^A  ^omEwlifit  lM-nt«  uml  could  not  en^ilv  bc  litsv^  < 
tlte  Htjor,  isn  aooount  of  the  cimtraction  of  thc^  injut^  mu-^ 

The  CJUP  ii*  ^ivpti  9(:»m*?whaf  in  detnil,  to  ehow  to  irful  rcn 
the  ac»l(Jier  U  cxpoaed,  iptkpeadciitJy  n*"  the  daDjrcr  frw  t* 
wimndji.  Thrit  a  yoiinj^  man,  scarcely  ei^htee?i,  dtuuld  br  b 
tr>  mjirr-h  thirty-fivp  milrs  with  hi;*  re^ment^  con^ianilr  f sfc^ 
mill  uirlimji  t5ioil,  Icwp  jTimril  nil  ni^hr,  en^ra^'^  ia  i  i^' 
liiwi.in^j;  tuiir  hfiun*  tlie  next  riKirning,  be  w^oumlo<J,  and,  "'-j 
suftenng  and  blpedin;^.  lie  twenty  bi*iir«  with  m.  mun  on  hi*  '■■' 
Ji*n  linib^  villi  rMtlhin^  to  Kn^^uiii  hiTii^  cxrept  t^ti  th*;  M^ind  '^' 
n  iWftilow  nf  wiiinki'j,  —  shows  htiw  mndi  the  human  inm'^ 
1>ctir  when  nM^UEpd  hy  H]>irii  und  deieriiiinaiinn. 

"fliifl  [mlh*nt  wnfi  jilUTWHrilH  wonmlcHl  in  the  unn,  injiinnirTy 
nerve  ;  and  the  ense  is  reluttnl  in  rlio  chapter  on  injuries  i^  cv 
nerves.  SuhBeqiientlvi  he  waa  twice  under  my  ran;  willi  *»ni^ 
gunahnt  wfiunds.  It  is  a  curinu!*  fin-t.  thar,  }>oforc  the  WMf  i 
hnd  hiin  iti  chnrjre  three  tiuitu,  willi  thu'tiire  of  (he  li'tr  ■*'  *"^ 
being  am  uncommon  in^tane^^  lA'  ri'peaied  itijiiric^  r^uirin"  ^^ 
gical  dAfiisTnnee.  He  finalU'  ffll  n  victim  to  the  resuiu  of  flP* 
sure,  iTiourrtti  during  SherrnHn's  <?aiu[wugn_ 

Cask  CCCXXVU.— Wound  in  Chent  ft-om  Orap^^ghoL- 

A  s<»hlier.  3M  years  of  Ji^e,  wan  hron^liL  irilu  the  Ilospititl  on  ■* 
count  ijf  a  wniiEid  in  [Im  rfim-nv,  rt?(?eivi?d  «  weefc  before  si  ti» 
battle  oF  Newhern.  The  bnllj  whieh  wm  an  iron  one,  wci^itt 
Rix  ami  a  half  ouneeH,  ^tnii'k  liiin,  ^is  he  wa«  in  tt  Etoopinif  poii 
tion,  in  the  left  axilla^  wuuniJing  the  tle^hy  pnrt  of  the  anc 
wliicf]  was  hi  cmilJK't  with  tiic  side.  It  foiled  in  the  nbtJ,  utd 
ahl^  ran  between  the  tjkin  and  the  parletes  of  the  thorv 
and  made  its  uppearanee  under  the  nkin  iif  the  8lorniim  whei 
it  wnts  (Mit  out.  The  rihs  were  hmken  at  iheir  juiictidii  wil 
the  fiteriiutu;  the  lunga  wnundei.1,  and  he  e^^pef^tckr^ted  blooi 
In  wliat  innnner  the  wound  in  the  luai_rs  was  prothiccd  it  v, 
iinpnssilile  to  sav,  —  wheilu'r  hy  the  liall  ur  ihe  fractured  rib 
When  he  entered  the   Hofipilal,  nu   teudeniesa  or   IqcilJ    nppca: 


WOUND    OF    PELVIS, 


551 


Eanct!  indica-led  tlie  track  of  the  bnll ;  eo  ihut  it  cnuld  not  be 
,4ftiil  whether  it  hnd  gone  througli  the  cliesi,  or  had  run  along 
[on  the  outside  of  the  rib».  The  wound  in  tlie  axilla  healed 
rajiiiilly,  bnt  on  the  Btemum  very  slowly.  There  wna  no  fia- 
tiiUnjB  0[>eDinir  loft,  itnJ  no  discharge  of  bone.  The  patient 
recovered  alowly,  his  principal  Hympiom  being  gvent  debility. 


Case    CCCXXVIII.  —  Bulht  iu  Pthis.      Excruciating 
hiti  in  /Sciatic  ^erve.      Operation.      Redef. — J.  Y.,  aged 
S,  received  two  balla  at  the  buttle  of  Williamsburg.     One  struel; 
m  on  the  upper  and  hnok  pan  of  the  left  arm,  nnd  went  hobind 
the  U>ne,  cotiung  out  in  front  ot  the  chest.    The  other  entered  iin 
inch  above  a  line  drawn  midway  between  the  trochanter  major 
and   middlo   of  the  Bacnim,  in    tlie   letl   hip,   nnd   di^nppi^ared 
there.      He  wns  disabled,  lliougb  not  in   great  piun  at  first.      A 
week  flfter,  he  wiw  seised  with  the  moj^c  exertieiatiiig  pain  in  the 
course  of  the  sciatic  nerve  of  that  side.     He  was  taken  to  Balti- 
more, from  wliich  plnoe  be  wna  brongliC  on  to  Boston  by  steani- 
ibcat   and    railroad,    being  curried  oWavs   in   his  father's  arms, 
\to  lessen  the  jar  fi'om  tlie  motion  of  imvel.     I  saw  him  about 
ten  day?   after  the  reoeipt  of   ibe  wmmd.      His   left   limb   wna 
drnwn  up,  nnd  he  could  not  make  the  slightest  movement  witlj- 
out  severe  p^in.     A  probe,  passed  into  the  wound,  penetr^ited 
'three  inches,  when  a  hard  suljstance  was  encounicreil.     Whether 
fit  was  bone,  or  the  bullet  crushed  ngaitiat  the  bone,  could  not  be 
determined. 

The  following  day,  I  had  him  removed  the  Hospital,  &n<l 
■niiide  an  exploratory  examination  under  ether.  The  external 
wound  beinrf  enlarged,  the  finger  passed  through  the  gluteita 
|jnaximii8,  under  which  was  a  t^avity.  Sdll  farther  on,  through 
a  narrow  ^[iaoej  the  pelvis  wns  reached,  and  a  smooth  opening 
which  appeared  to  be  the  sciatic  nott^h.  On  the  inner  side  of 
Fthe  notch  was  a  hole,  through  which  the  hnll  had  penetrated  into 
the  pelvis ;  ilie  apieula  of  bone  lying  loose  in  the  neighborhood 
of  the  sciatic  nerve.      These  wore   removed.      Another  smooth 

ioavity,  which  would  hold  an  ounce  of  fluid,  had  been  formed 
under  the  deep  raoscles,  A  probe  passed  easily  two-thirds 
through  the  pelvie  cavity^  without  encouatering  the  ball.    A\'uter- 


552 


GUXSnOT  WOtTKDS. 


ilreesiniTfli,  find  a  poulli^^  iif)«rwnrr1s.  irere  pat  on  tlw  viV 
and  tho  pnlipnt  vvas  rnudt  rolicvcJ  b_v  the  operation.  TVp 
pipul  k^aiii^f<  iit'  imtatiim  apponrai  tu  bo  the  fnk^^meste  ni^ 
]yin^  on  the  ^rctit  nerve-  The  sitiiiLtion  of  the  ball  tk^*' 
appear.  The  patient  rorurnetl  home  f^rrontlv  relieved;  wL 
fur  OB  I  fi»va  ](<arm-<],  tie  bull  never  tuodo  tie  mpttmR^' 
causi^d  him  farther  tninblt. 

Case  CCCXXIX,  — .V^^*r  Toff  A  iodfft'.ff  in  tJtfTfm 
—  A  floldipr,  about  20  yeftrA  of  fli^r.  entered  the  Ho»prld<*>' 
len  ilius  uficr   the  batelo  of  Williflniwbur^,    havio"  TT«ii« 
wound  fr<»m  a  JjuUh*  whM^h  "Tnn'k  the   ri^ht   eido  of  the  ^ 
jaw,  aud  passed  "iit  Throuijh  the  iippor  lip.       Tfio  jaw  ww* 
tered ;   nnd,  wht-n  he  onterwl  Tl»f*  lliispital,  there  wcrr  puwt 
d<?|>oBiH    cornicctiiiff  with   \\w   nock   PMi?rnally-    nm!    lJ«'  »■ 
internally.      Tht- pmieTit  was  etherized;    hikI,    ihr  vrrtunil  ^ 
eiplortxl,  pieces  of  bone  wvm  found  evcry-whcre  burji^  b 
Miih^tiLnc^i^  of  the  Hieek  and  the  snrronrtdiiiir   poft   i>jtrt'>    T^ 
n'erc  ('i:triicied,    and   thi?  waiiad   liealod    rapidU-,      Some »" 
afterward,  lie  prp8ente<l  biin^Of  nl  the  Hospital,  with  »  ivfiUi 
ill   Mio  lonrriic,  the  wlffe  of  whiob  bad  h^eii  xvoundcd  hv  iJm  ^ 
let,   nnd  whi^^h^  unnl   lately,  ho  had   Iteen   unabJc   to   pTfiDi'i 
On  examination,  a  Lard  hody  was  found  emb<^ded   in  the  <^ 
etnnce  of  the  orfran,  whioh,  on  being  cut  U]jcin,  pr(>vcil  lo  t*' 
molrtr  loolli,  which  had  !.>ecn  knocked  out  of  the  jaw,  and  ht^ 
in  the  tonp;uG. 


Cxm  CCCXXX.^BvUet  lod^p,d  in   th^    Oorpus  OiOf 

nosroii.  —  I  wae  invited  by  the  late  Dr.  Fox,  8iir^oa  of* 
L^ni  led -Slates  Naval  Hoapital  at  Chelaea,  to  see  the  followia^ii 
lereflting  m-^'.y  anil  operaifim  :  iin  30th  May,  1862,  a  miui  abna 
;ilj  years  of  n^^e.  while  enga^l  In  a  boat  attack  in  Florida  w* 
tired  upon  by  a  party  from  ahore.  One  bullet  puaaed  ihniu^ 
the  loft  leg  near  the  ealf,  and  was  cut  out  on  the  opp(>siie  ok 
Another  struok  liirn  at  the  outer  and  upper  part  of  the  wn 
iinib.  p!U(J*efl  rhroogh  the  thigh,  eruergiui;  near  the  root  of  ti 
i^crotuin  in  the  fold  of  tbe  thit^h.  It  then  entered  attain  no 
the  same  spot,  and  dir^appc!arcd,  and  he  had  no   hirther  trooh 


WOUND   OF    VERTEBRAL    ARTERY-  55S 

m  It  For  the  timo.  He  rcturneil  liomi*,  nmi  came  under  the 
arge  of  I>r,  Fux.      Afti?rwftrUs,  the  bull  wiis  discovered  at  the 

'-rooi  fjf  rhe  pema,  in  (he  corjni*  cflvemoaum  of  the  left  Bide,  from 

,  which  |ihiL*e  it  gradHftlly  worked  over  ro  the  right.  The  mun  hml 
no  ditticulty  iu  uritintini;,  and  ito  [mui  durinn;  erection.  The  point 
of  the  hiillct,  which  wns  si  .\Hni*?   one,  was  lownrds  the   bodr. 

^St  wan  firmly  heU  by  the  fingerit,  niiil  then  cut  down  upon.  The 
akin  wiLs  first  divitlt^l,  then  the  Rtrong^  fibmits  coi'erlng  of  the 
cflTcrtiiius  bi.)dv  :  nnd,  allhou<;h  the  inciaion  was  qmic  free, 
the  foreign  Buh^taiice  re*ifited  the  use  of  ordinary  forcep*,  the 
elastic  finfe  nnd  eueiion  of  some  crf  the  ti^siiefl  operating  to  pre- 

,  vent  its  extractjou-  The  wuund  being  held  well  opeo,  a  pair 
of  bullet  fon^eps  iraa  introduced^  and  the  bid]  slowly  extracted, 
OS  if  frnm  a  l«vl  of  India-rubber.  There  was  no  violent  rush  of 
blood  from  ih^  QTcctih  il-wiie,  l>ut  a  slow -continued  disdmrge 
afi  from  R  large  vein.  This  was  c<mtrolled  by  means  of  a  apon^rt* 
and  bandage.  A  graulnal  Kupptjrniion,  with  apjinrcot  elimi- 
nation  of  the   sac*  whii'.h   Uad   formed  nronnd  or   been   pushed 

'  before  the  foreign  ho<ly,  fulloweil  t  and  the  patient  recovered 
in  the  most  satisfactory  manner.  The  cnee  m  important  from 
U»  rarity,  and  for  ihc  practical  flirts  which  it.  tenches  in  rcgnrtj  to 

'    the  danger  from  interference  with   ihc   erectile  tissue,  which  at 

^  first  woLild  appt^r  likely  to  be  more  con^^idenible. 

^^   Cask    COCXXXI,  —  Gttintkot     Wound,     cutting    off    the 
^B^ertehrul  Artenj.  —  Corueliu»  Mahoney,  1 1  years  of  age,  was 
^■fought  into  the   Hoapilnl  on   Lho  "llnU  of  Mav,  liStil,  having 
^TBCeivc[l  the  cJiarijc  of  a  pistol,  loaded  with   stones,  acciilentallv 
fireil  by  a  com  pan  Inn.     One  of  the  atones  gnizud  liis  forehead,  a 
neotnd  stnick  him  on  tlie  cheek,  and  \\.  thinl  penetrated  the  neck, 
jibout  half  an  inch  below  tlie  niastoid  process  of  the  tern|toral 
bone.      He  received  the  charge  wbtle  in  a  stooping  posture,  and 
was  taken  up  bleeding  profusely.      When  brought  inti>  the  Hos- 
pital, iho  bleeding  w»«  nearly  checkwl ;   watcr-dreusings  were 
applieil,  Lind  the  patient  kept  vet^  (piict.      1  saw  blin  on  the  ful- 
hiwiiig  morning  ;   and,  as  there  wa«  a  dirtpOKitJou  La  heuiorrha^, 
lie  was  eiherized,  wiih  the  object  of  removing  tJje  foreign  bo<ly, 
if  there  wua  one,  and  cliecking  the  bleedbg.     A  fioger  passed 

70 


cess  of  the  second  or  tiiini  cervical  vertebra.  The 
now  returned  violenlly,  antl  but  little  doubt  exist 
vertebral  artery  had  been  cut  off,  A  systematic  ph 
small  bits  of  eponge  waa  made,  and  the  bleeding  chi 
questioning  the  father  of  the  boy,  it  was  ascertained, 
they  were  engaged  in  arresting  the  bleeding-  at  his 
a  handkerchief,  a  small  pebble  was  discharged  into  it 
by  the  great  force  with  which  the  blood  gushed  forth 

29th. — He  had  passed  a  pretty  good  night,  an 
from  pain,  except  in  his  lefl  shoulder,  Pulse  re< 
from  140  to  120.  Towards  evening,  he  became 
dehrious.  He  remained  in  tlii»  condition  for  eight  <j 
ranging  from  120  to  140,  feverish^  and  at  times 
head-  On  the  4th  of  June,  be  was  somewhat  b< 
bandages  had  been  cut  off,  and  the  spoogea  remove 
wound,  on  the  2d.  On  the  ai^moon  of  the  4th, 
hemorrhage  took  place  from  the  wound,  anaountiii 
ounces,  and  producing  great  depression :  aaaistance 
tained,  it  was  checked  at  once  by  plugging  with  a| 

On  the  6th,  at  two  o^clock  in  the  morning,  a  tliir 
occurred,  which  was  promptly  stopped,  about  two 
blood  only  being  lost-  Some  of  the  old  sponges  wen 
and  replaced  by  fresh  ones,  dipped  in  the  solutiou  c 
chloride  of  iron-  From  this  time,  he  lost  no  more 
the  wound  suppurated  well,  the  sponges  being  all  r< 
the  10th-  From  the  attendant  inflammatory  action 
was  drawn  down  to  that  side,  but  gradually  rightet 
wound  had  fully  healed.  Before  he  lefi  the  Hospital, 
on  the  2id,  a  piece  of  bone  was  discharged,  which. 


UASE  CCCXXXII. —  CompQUii'l  urarture  of  ;^f:iut  from 
l*i»iol-nhoi,  Xjosh  nf  C'Grvhral  Substance!.  Death  jii^s 
datfa  after.  June  4,  1^51,  a  man,  54  y&tra  old,  won  foucd 
lying  in  a  ehopf  liavin^  ntlf^inplcd  euLude  wiEli  a  pUtol.  The 
boll  Ii!lU  entered  tha  hend  at  abi^ut  the  middle  of  the  nght 
temporal  foesa,  luiikinrj  a  lar^e,  irregular  wouud- 

Under  ether,  siit  hours  after  the  wound  waa  received,  efforts 

were  made  to   find   the   ball,  and   remove  it.      The  wound  waa 

^enlar^wl,  aud  a  pair  ot'  dresaing  foreeps   passed  in,  whieh   met 

'ith  no  reaigtance  until  the  opposite  aide  of  the  eranium  waa 

►ached-      The  bdl   could  not  he  found,      A  piet^e  of  ihe  roof 

|of  the  ri^'ht  orbit,    howovei",   was   extracted,  whic;l»  had  been 

Iriven  into  the  brain.     The  examination  woa  made  with  great 

ire,  and  occupied  but  a  brief  time. 

After  the  effect  of  the  erher  liatl  (jaseed  away,  the  patient 
remniacd  in  a  ecmi-oonjscious  condition,  but  answered  quej^tious 
rationaliy  when  nrouaed-  There  were  no  flip;ns  of  local  or  gen- 
eral pamlyais^  except  in  the  upper  ovelide,  which  were  fallen, 
and  the  eyea,  which  were  pvoirudiug  and  fixed.  The  lu'ine  was 
paaaed  without  diffieully.  The  patient  stated  that  he  could  eee. 
In  the  evening,  the  ejelids  became  verv  much  Gcchrmo.4od  and 
Bwollen  ;  and  about  a  tablespoonful  of  eerebral  substance  wuB 
discharged  from  the  wound.  During  the  nigljt,  he  had  sev- 
eral nltackfi  of  general  subsultus :  pul^e  ISO,  soft  and  reguhir. 
P Brandy  and  water  was  given. 
I  5th.  The  subauliujd  diwinit^hed  in  frequency  and  severity; 
pulse  22t  mind  clearer.  Has  taken  notliing  but  brandy  and 
water. 

*!ih-     Fflsaed  a  cpiiet  night ;  pulao  100,  mitk-ptmeh  ordered. 
^P      7lh.      Uat her  weaker  last  night;   pulise   100,  ret^pimtion  36, 
flubi^ultus  inoreaf^ingf  enema  ordered- 

Slh,  Very  rostless  lost  nir^ht,  tr>'ing  to  n^et  out  of  bed; 
aubsultus  lefijj,  pul*e  112,  respiration  28,  tonguo  dry  j  etill  eaya 
tliat  he  can  see,  but  unable  to  raise  eyelids.  In  the  evening, 
he  began  to  grow  weaker,  nnd  aank  into  a  comatose  condition* 
After  hve  o'cloek  the  next  morning,  he  failed  rapidly,  and  died 
at  hall-past  seven. 

The  foltowing  U  the  report  of  the  autopsy,  made  by  Dr. 


deeply,  lacerated ;  a  thin  layer  only  being  soflened 
on  the  confinefl  of  the  injury.  A  small  fragment 
a  bullet  were  found  in  the  bruised  Inyer. 

"  A  small  portion  of  the  Left  hemisphere  outeide  < 
the  lateral  ventricles  was  soAened,  and  filled  with 
A  large  opening  cxiated  above  the  right  zygoata. 
orbital  plate  of  the  frontal  bone  was  nearly  destroy 
left  badly  fractured. 

**  The  surface  of  the  ethmoid  bone  waa  also  injur 
regular  portion  of  lead  was  found  among  the   fr^gji 
left  orbit-     A  fracture  extended  Irom  the    large 
the  right  side,  across  the  frontal  bone/* 


Case  CCCXXXUJ.  —  EemarkahhCase  aft^j 
lodged  in  the  Nasal  Fo^aa  for  a  great  ien^t 
Fissure  of  the  Hard  Palate.  Operation^  C?ur^. 
35  years  old,  came  under  my  care,  who,  seven  y 
while  shooting,  had  his  gun  explode;  the  breech-pi 
and  penetrating  the  head,  producing  a  severe  woundn 
ball  was  destroyed,  the  upper  part  of  the  socket  en 
as  to  expoae  the  brain,  and  an  opening  made  in  thi 
of  it,  communicating  with  the  naeal  fossie.  Hia  n 
very  alow ;  and  he  suffered  much  from  pain  in  hii 
vertigo.  The  nose  was  obstructed,  so  that  he  vrai 
breathe  through  it. 

Fourteen  months  afterward,  a  soreness  waa  felt  o 
palate,  and  a  forei<;n  body  seemed  to  close  up   the   ft 


BBElXB-rni   IN  W.V&AI,  FOSSS. 


567 


*sum»  It  is  Uiree  and  one-quorter  inches  long,  and  ibreo 
'inches  in  cireiiml'erfnce. 

The  eoLulitlon  of  the  pstient,  wlien  he  entered  tLc  Hus]>i1jl1, 
vrn»  as  fLrlUiwe  ;  There  wiia  u  fis^iirc  in  die  palfitc;  llit;  eye- 
flnll  was  guiie ;  liie  eyelid«,  apparently  iiTiinJured,  n^mained 
ipen;  there  was  an  opening  at  ihi-  buck  [inrt  of  the  socketp 
com  in  41  ni  minting  vrith  the  noi^e  and  moutli ;  the  up|ier  eilge  oJ'  the 
aoeket  wms  irregidu-r,  where  the  Lune  hud  hecii  destroyed,  and 
the  hriiin  expOHed.  lie  ruuld  not  speak  intellii^eitlly  without 
pressing  bis  finger  into  die  socket*  and  clofling  the  lids,  so  hs  to 
prevent  the  [lEi^tiiige  uf  air  ihruiigh  fruiii  the  mouth.  Kven  llien, 
on  aiccounL  of  die  fr:4»iure  in  tlie  pjilnte,  Jt  was  nut  easy  to  iinder- 
etaral  him.  Swallowing  wue  difficult,  and  reriuircd  n  cerlnin 
position  of  ihc  head  to  effect  it*  The  first  indieaiiun  pE^nia]  tii 
be  to  obstruct  the  passtage  of  air  tliniugh  the  sucket.  To  cflijct 
diis  (the  pulient  being  etltenzed),  the  tnreal  cartilages  of  the 
eyehds  were  removed,  the  cut  edges  brought  together  by  su- 
tures^ and  r<)ll(hlii)n  applied.  His  ajieerh  wat*  lit  tmce  improved 
by  this  o|)eniti<m. 

The  ibilowing  week,  the  fiflsnre  in  the  jralale  wns  n]«nited 
upon.  It  lequireit  much  ilisseelinn  to  bring  its  eilges  in  r/>n- 
tact,  on  account  of  the  callous  imd  unyichling  condition  of  the 
soft  parts.  This  was,  however,  finally  ctfeotcd,  and  the  whole 
£ssure  cIoHeih 

The  fir;^t  operation  on  the  pulnte  failed,  from  the  patient^s 
having  peraiflted  in  diewing  tobact^o,  and  eating'  solid  food.  A 
repetition  of  it,  however,  with  better  liehnvior,  wns  auended 
with  success.  The  eyelids  nnileil.  with  the  exception  of  a  very 
small  a^)crture,  which,  for  a  long  time,  rcsLdtetl  all  alfenipts  tn 
close  It,  and  gave  issue  to  a  glairy  Huid.  supposed  to  come 
frijin  tho  remains  of  a  portion  of  the  lachrymal  gliiiid-  The 
hole  was  finally  i^dnreil  lo  so  small  it  size  that  no  air  coulil  (lase 
tbrongli  it.  The  patient  left  the  Hospital  quite  well,  with  his 
-voice  almost  completely  restored. 

Dr.  Henry  G.  Clark  has  kindly  furnished  me  with  the  notes 
of  the  following  c&ae,  which  I  saw  at  the  Hospital :  — 


$59 


GcysnoT  wouxDs. 


Case  CCCXXXW.—Gnn/ih'^lWottfxf  in  th^  Backtfh 
Jfeck*  Lo^'i  of  Bone  from  iSpiitat  I'rocesttcg.  &ttndim, 
n^eovnrt/. — "The  pwlient,  Cuptain  O.,    wm«   wuundc^l  it  tk 

batUc  of  Cliirkmimit^'n,  S^|it^  1^,  186v^,  by  n  ^Imi^-bull.  vbi 
cnter<^  the  neck  fit  the  nppor  part,  over  the  f^fHuci  poMio; 
forwnrtLa  to  the  ri<^ht  until  it  t'ounU  a  deep  lodgpemcut  oiukrtfa' 
right  car.  Oct.  14f  l?4t>3,  he  entered  the  ^liva^achuactta  Gevril 
HoBpitivI. 

'*Ho  wae  a  stout*  heftldiy  man,  hut  had  bcon  suffering  fU^ 
from  ewelling  nnd  iriflankmntiuD  nloEi;^  the  track  of  the  btdJ*  i^ 
tlywn  tho  ueck  iiudtii-  (he  allele  of  the  jww.  Thciv  woa  aEfn- 
Joii^  opcmn;j:  nml  n  ciciitrlx  behiml  the  i»r,  tho  fHijnt  at  nbia 
eeveml   un^ucccssfLi]  attcniptfj  hnd  hf<-n  mnilc  rti  oxtmct  ttc  U 

"  TiiG  |>aCifMiC  hein^  titiit^ri/.eiK  s^ful  the  tistuluut*  oitfiiui;^  c-- 
Urged,  Ihtf  truck  of  llio  \M  whb  pjtplurod  with  Iho  Hn-^cr  nai 
forceps;  nnd  several  em nU  picees  of  bone  from  tlic  f^piEtntUf^ 
oasse^,  mid  bits  of  elotli,  wem  r\^ui't\'ft\.  The  htisc  uf  the  o^as^ 
WW  discovered  to  bare  been  ;^hz(.h1  ;  but  the  baH  could  not  bt 
fbond.  An  incision  wa»  then  made  intfi  the  fistula,  hc1i>irtii* 
ati^dc  of  ific  jaw,  nnd  the  bfltl  fuiind  lyin;:^  two  inehe*  hdov,  la 
A  ftorL  of  pouch,  diret'tK'  over  and  upon  the  cm-otid  arftrr,  W 
CXtrJiotrd  by  the  f*>reej«i.  It  was  grooved  from  point  to  bw 
hv  ftttrition.  From  the  extent  and  h^rdnc^a  of  the  Awclfui:. 
tlie  b:ill  uuuhl  not  he  felt  enternfllly. 

"The  wound  wns  tboroucj;hly  cleanEed;  and  the  patient  Irft 
the  Hospital  on  Oct,  lDth»  rapidly  eonvaleaeing,  and  aftcrv>-ardi 
wholly  recovered." 


Cape  CCCXXXV.— ffu^*A*>^  }VoundofJVecJs.  Bnli  a- 
trticteU  three  months  a/ler,  at  Bane  of  A*ci%  in  Contact  tcitk 
iSpine,  —  At  the  battle  uf  Frederic ksbur^s  in  May,  18(13,  an 
offiecr  wne  etnick,  by  a  plungin;^  nhot,  on  the  left  elde  of  liic 
Jower  juw ;  driving  a  portion  of  the  bone,  with  three  or  fwir 
teelh,  doxvu  into  the  ncek,  from  which  t!»ey  were  femoved.  Pome 
wcekrt  aftcriv:u-ds.  by  !in  operation,  Thi?  bail  glanced  down  ibe 
neck,  and  disappeared  apparently  in  the  thorax.  Si>me  tbrtc 
months  later,  wliile  lie  was  [inrtidly  rei.Tjverinp:  from  the  effecis 
of  bia  severe  injury,  a  hard  Bubstance  wti«  felt,  just   above  the 


WOLMl    or    KECK. 


559 


[iiviHe,  mnlcing  its  wny  iipwiinl  JietweE'n  the  two  ln?n(ls  of  f!ie 

:;erno-maiit.oi(I   nxti^dL*,      Alter  moving  up  ior   IihIT  nn   indit  il 

roA  Eirreaied,  antl  remained  HULlionary  fur  une  or  two  ihoiiiIibt 

nil  October,  18ti3,  vih^n  I  iirst  siiw  Jiim.     During  liiir*  pericni, 

£nlfbrcd  from  o^FJiiinril  pAins  in  llic   left  aids  of  the   l'Ilcsc, 

[yA|>n(r]ir  anil  various  8ym|)tucia  inilicnlive  of  nervous  irriliiiitin. 

[l^e  wiiB  ocr'o.^iiino.ily  tfelzeJ  wkli  severe  pnin  in  the  ]e¥t  iirm.  with 

iimhiliiy  tci  r-MfiL'  iU  IjU'iing  »  while,  and  tljL'Ji  imj^^ing  ulf,  but 

lie  hniJ  at  nci  time  ihe  free  use  of  the  linkh.      On  examination, 

tlie  iiiiist:]ea  heing  relaxed,  in   tfie  di^pre^aion  htu^tween   tfie   two 

[iii'^iTtioTis  <if  (he  sr,erTio-tun^toiil   Enu^i-le.  n  hard  8nli?<tiuire  could 

be  fdt  deep  in  the  neck,  iyln'^  <in  the  b*x]iej4  of  die  veriehrse, 

and  reeiedin^  n  little  on  pressure. 

The  pnltfiit  wn«  etIienKed  with  grent  dif[i<:idt.y.  It  licin^  one 
of  those  en^ej«  in  wliirh  the  ether  euuues  great  Irritiition  tti'  the 
,]un^ ;  luid  it  vvaa  only  nl^er  a  Atru^^le  of  ten  or  lif^een  miniiiea, 
tliiLt  be  became  sufficiently  ijuiet,  fi-ont  hl«  eou^di,  Ui  idhnv  the 
Oj>eration  tti  prot-ee*!.  The  veina  of  the  neck  were,  iu  e<mse- 
qciencc,  imieli  distended  with  bluod. 

An  Incisiion  was  made,  juat  on  the  ontside  of  the  gre;it  ve.^- 
I,  two  or  three  Indies  Iji  leni^^lh,  dividiik;;  a  l;brge  vein  in  the 
time  of  till?  diH^C'etion,  by  wliioh  a  slii^lit  delay  wus  oeea- 
«)Gned.  chiefly  owing  tu  the  struggles  of  tlie  pntient  in  hrentliing, 
And  fnnn  fenr  of  ubaorptioik  of  lur  in  the  vinlent  nioveineniA 
of  retf[>iralion-  It  wa*i,  bnwevcr,  wjnn  lietl,  and  the  dissection 
continued  downwaida  and  to  the  outer  aide  of  tlie  large  \ew<'lf*. 
The  foreign  bixly  whs  now  exposed,  covered  by  n  thiek,  while 
euveh>[ie,  which  \v\iA  eiOier  the  ttae  mjrroundiiig  it,  iir  the  in- 
tamal  jn^TitUr  vein  lying  empty  and  Hattenetl  over  it.  A  hole 
waa  tbcrefore  earctully  wratcli&I  In  it<  when  a  qnnnliiy  of  white 
niilkv  Nobstunee  esejiped,  tLhoiving  that  the  ludl  had  been  eoii- 
iniiied  in  a  eynt  or  nac.  The  o|>cning  wan  then  enlarged,  iiiid 
the  bullet  pried  out  fnnn  it^  lodging-pJaee  by  the  aid  of  a 
furcejif4  nial  dheetor.  On  panning  the  tlnger  into  the  ftue,  it 
was  found  to  reach  the  ExKlies  of  die  tertcbne.  Tlie  bullet,  a 
conical  one,  xvaM  flatteneil  on  Uie  wde  where  it  hml  tmpin^d  on 
the  bone{  and  die  ct;p-cihaped  cii\ily  in  its  barte  wna  tilled  widi 
a  tliick  white  jia^te*  louking  somewhat  tike  mortar-      It  hud 


560 


GnSfinOT   WODND3. 


jippnrcntly  penetrntcJ  the  cheat  tu  a  certain  extent,  perhitris 
ploti;^4iin;;;  iilj  tlic  |)loLirLi,  tind  hud  tlicn  ^mdiialiv  worker!  ifs 
wiiy  Tipwardfl,  until  it  hod  readied  llic  epoi  when?  it  vrua  f>mi<l 
en-^ysted.  After  n  fow  Uavfl,  during'  whith  there  was  *omc 
ditliculty^of  J4Wid]i>wiiig,  reirbvery  tat.*k  place  without  other  un- 
toward svm|>riirnA. 

He  vieiied  van,  n  year  af^er^varde,  id  a  good    condidon  of 
healili. 


Case  CCCXXXVl— Wound  of  Chesi  from  I^isiol-fmlU. 

D^ftfh  ^ifjht  1/ears  /rfi^r.  Pi^ioi-bfiils  ei'^psuJcfl  wii/ttn  the 
C'h'^st  by  t/ie  I^leurti.  —  lo  a  fit  of  jcnlousy ,  iv  man  fhot  hi* 
mUtreitd,  corain;;  behind  her  while  she  waa  fitting  on  a  low 
bench,  fLud  tii'iii^  down  upon  the  chc^t.  He  then  plfured  a 
pietol  to  his  heart,  and  puMed  the  trjfj^'er.  In  the  act  of  di*- 
clkar^ni^  the  [Ui^iol,  the  luu^/le  heontne  u  Uctlc  elovatcd,  so  ihut 
the  hidlotd  ju«E  e$c:iped  the  heart  and  great  yeea^le  in  iheir  pa»- 
fia-^e  through  tlie  chest.  Buih  theee  patients  cnme  under  m? 
care  at  tlie  time. 

The  woman  lived  tliree  dnya,  oud  then  died  in  grent  n*^nv. 
On  a  posl-niortem  exdiuinalion,  it  was  tound  ll^at  tmc  of  ll;e 
bullets  lind  passed  tlirouffh  the  cnvity  of  the  che^t,  and  lodg:oil 
in  tho  body  of  a  dorsul  vertebra.  This  vertebra  1  now  b«%c. 
with  the  bftU  deeply  embedded  in  it,  A  second  bullet  struck 
the  firel  nb,  wae  cut  in  two  by  it ;  one  half  inivereing  the  lop 
of  the  rib,  the  other  trftverfiin;^  the  lun^,  being  fjund  loose  in 
the  canity  of  the  cheat-  The  heniorrhnj^e  produf?ed  by  thi.^ 
wound  filled  the  chest,  coniprot^t^ed  the  lnn«,  and  waa  the  iiu- 
mediate  ciiuse  uf  her  death.  The  third  bullet  entered  ijie  neck, 
and  ita  course  could  not  be  traced. 

The  man,  immediately  on  being  wounded^  had  p"cnt  craphr- 
Benin  cf  the  wnlla  of  the  chestT  followed  by  entire  Hutncds  oa 
percU8£ion  of  that  aide.  After  a  very  severe  illnese,  he  rccoTCwd 
Euffieienlly  to  be  brgught  Co  trial ;  and,  being  convicted-  wm 
jaenteacml  to  the   Stiite  Prison  for   life. 

I  saw  him  at  the  prison  abouc  four  yeare  after.  lie  then  hwl 
a  couBtiint,  dry  cuu^i.  On  niiscultation,  the  re^^pLmtion  vtaa 
found  rough  on  tho  left  siiJej  and  somewhat  bronchial.      There 


ll-OUND   OF   ABIJOMKX. 


561 


waa  no  rale.     Pemiaait^n  TtiveaM  notliin^  &l)Ti{jrm:il,     Ri8  hciiltU 
was  otherwise  ^[oikI- 

Hg  (liail  fliiddenly,  eight  years  titter  the  crime  was  camniitletl. 
On  oxarainnnoii ,  it  wjis  eupjHJsal  l>y  Dr.  \tirrin,  Sur^^tou  lo 
ibe  Prison,  that  aome  disenw^  of  the  heart  would  be  foiuid  tu 
expluin  hin  death.  No  ^uflieient  HIsphsp,  however,  cindd  be  de- 
tected. Tlip  vnlvtw  of  the  hen.rt  were  thii?keiied,  hut  imt  enough 
ti>  impeik'  clieir  Rc-tiiin.  In  tlir  upper  lohe  i»f  (he  laii  htng,  ii 
cii'iurix.  showiag  the  couriw  of  the  bnlirt,  was  diKtirutly  viftihle* 
The  bnllfi.  having  tmversu]  the  lun^a*  hnd  IcKlgBil  in  the  Mv  ot 
the  eliesl.  From  ihi.*  iilaoe^  'hey  had  bt'i'imie  ^rtdimlly  de- 
tifhed,  and  were  fniiud  sUfipended  from  the  Aider*  of  die  diest, 
like  cherries  limiting  from  a  tree,  having  earned  the  pleum 
beliire  tbem,  and  bein^  enveloped   in  thul  membrane. 


I 


Case  CCCXXXVII Gnn^hol  Wouttd  of  tfie  Abd<»men, 

JltHoiccil  htj  littMHfimtt  FiKhiUi.  Jierovenj.  —  At  tlie  ballle  of, 
Chan(?ellorsvil[e,  Mny,  18l^<l,  a  atrong  healthy  m;tu,  25  ycurs* 
ofuirc,  war^  Htruulc  on  the  riirht  of  ihe  abdotaeii  nenr  the  uiidaJi- 
C119  by  a  nnisket-sbot  fired  from  tin  eleration.  U  penetrated  tfie 
|)eritoneal  envity,  pjifi^ed  ihmn^h  The  pel  vis  ^  and  nnne  lait 
throutfh  the  middle  of  ihe  ritrbt  iiimn.  No  verv  seveiv  irt^ritiijihia 
oceiirred,  nnd  it  was  not  until  ntler  eeveraJ  dny»  that  fecal  matter 
appeared  at  (he  wooed  of  evil-  Pierea  of  bone  were  oecnsion- 
ajly  discharge  from  the  ennie  aperture.  A|\er  sevend  mimtlia, 
this  wound  heuleiK  and  dl^charge^t  of  pus  and  fece^  eame  !4way 
from  the  wound  of  entrance,  in  tfie  front  of  the  ihdoioen.  i 
HrHt  saw  the  [lalient  in  JannarVt  18^4-  He  wns  in  good  fieahh 
and  8pint!i,  witli  the  exreplion  of  the  annoyaure  from  the  wound 
juHt  d&4ml>e«l,  and  a  Inmenef^s  in  the  right  lower  extremity, 
resulting  fmrn  it.  A  small  boii^'e,  ietmdiiced  into  the  wound, 
peneirnted  abtatt  eight  inehes  in  an  oUiqtie  dirtK^tion,  when  it 
eucountercfl  dejid  bone  in  the  neigh  ho  rlioiMl  of  the  pelvis.  Alter 
one  ur  tw<i  explorations  with  die  houpe,  a  lon^  pair  of  iil3<]fhlly 
eur\e<I  fureeju^  opening  only  at  the  extremity,  and  made  of  two 
biTinehes  rolling  on  each  other,  was  careftilly  introduced,  tho 
edge  of  the  bone  seized,  and  »m,ill  fra^ment«  of  it  removed. 
From  a  fear  of  wounding  ibe  intestines,  however,  the  operation 

71 


AAS 


OtTHWIOT    WOUXDS. 


wiifl  not  persiHte<i  in>      A  jmiillice  was  applied  to  iherj 
the  hi[),  whirli  wnn  lliUft  made  to  open    agnin  ;    UTiA,  ^' 
UBiTuw  (!aJI<]Ufi   fi^^liitfi,  llie   lioiie  ciiuld    be    felt,  hv  ihr  jWrr/ 
somewhat  LtvonJ   the   rencU  of  the   Gn^er.      Purttmu  gf  W 
■were  nirnin  removtsi :   hut,  na  the  main   tVagtneni   •eeoicd  U 
nn^ilur  in  form,  and  was  in  the  immediate  neigKbcrKoud  if 
oipcuin,   in   which   |mrt  of  the   intedtiiie    the    »|tetiing 
exiaied,  no  further  nliem|it  van  niii(ie  ;    die  *msG  \mins 
one  in  which  great  caution  was  iieecsBarj. 

Early  In  March,  thp  wound  of  exit  was  diJjiied  po  di  to 
the  forefinger  to  penetniie  its  wh<jle  lenj^lh  thruug-h  ihe  fiitok* 
pflssjige;  but  the  dead  bone  could  tiui  be  reaclie<L  ThefoTTT|F, 
being  pnf^fled  in^  woidd  ocentiitmally  grasp  the  ed^  of  tiicton 
which  HeemiK)  to  he  nttitdicd  to  the  |>e]viiA,  iind  involved  rnik 
folda  uf  the  inie^liue,  frofii  whieh  ii  was  dangeruiiEj  vioJcnfti* 
remove  it^  It  waA  therefore  decided  to  leave  the  caMfvik 
.time  to  natiirOt  with  the  hope  ihnt  the  fni^rnieDt  imglii  Mf 
p4.'r  vine  paturaled. 

A  few  days  after  the  last  eiplorntion  with  the  forc^eps,  ■pP)t 
wns  introdiu^nt,  nnd  it  wtui  fmind  ihat  the  fragmciiii  of  httut  b^ 
wholly   disiijipeured.       Forty-eight  hours  later,   cm   visiting  ti* 
p&tient  in  rhe  morning,  he,  in  grent  delight,  held  up  &  |ii«** 
bone  which  he  hnd  pnssed  the  day  before  from  the  rectum,  »i^ 
out   pain    or  impediment  to   il»   paHMge*       The    frnpuicnl  ■' 
Bomicireular  in  form,  conijirising  a  portion  of  both  the  inutr  3"! 
outer  surfitcea  of  the  iliun^  nnd  mensured  about   two  inehe*  a 
length,   by  thrce-qunrtera   of  nu   inch   in   breadth,    lotjking  0^ 
unlike   n  portiun   of  the  first   rib.      The  diselmrge    frvib   Mt 
apertitres  at  once  diminished ;   and,  at  the  end  of  n   week,  H^ 
were  Ldmo^t  olo^etl.     lie  left  the  HuspitAl,  il:ircli  28t}i , Ving 
odvieed   t[>  nuuntaia    the   horizontal   posture,  and    a\oid   TOOch 
motion   until  the  wound  hud   become  perfectly    sound,  and  ^ 
danger  of  tetirin^r  throii-jh  the  adhesions  was  over. 

1  &!iw  ihi*  patient,  in  lJ^*ii5,  in  a  eomplete  gtato  of  hetllh. 
Hi*  wounda  were  henled,  and  no  funetional  disturbnnce  depen- 
dent upon  them  remained.  1  quOBiioned  him  purticulnrly  M  W 
colic,  or  other  syuiptoma  wliich  might  arise  from  a  ooDtnMUJ 
iDteatine,  but  could  diacuver  nothing. 


.SE  CCCXXXyilh  — Bullet pa^sutg  Ifirotr^h  the  Elboic- 
IT  joints  'ti'<^  lodging  in  the  iLiice-j'jiiU,     Recovery.  — A  yoiing 
tt  officer,  -1^  veara  of  age,  wfiile  fitoc»ping;  down,  ut  die  buttle   of 
ilieUm,  to  lie  hia  hnndkercliict"  around  the  tingh  of  the  miin 
icxt  to   liira,  wIki   wna   bleeding  tu  d(;atb,  hia  Ic^^  having   l>ccn 
[enrricd  nwny  br  a  oantioii-bBll.  received  a  ahijt.  which  passed 
liapionrtlly  throHp^h  his  clb(>w-jvint»  nnd  entered  and  lodged  in 
lia  kncc-jointn      The  clhnw,  at  the  time,  wna   bent;   and,  from 
lie  iiofliiion  he  wus  in,  kid  flni  against  the  knee-joint.     A^'rcal 
)Out  of  blood  at  once  took  place  from  the  inner  wound  in  the 
nrm,  indicatinj;  that  flr>me  large  vcsael  had  been  cut  off'.     He 
checked  the  hemorrhage  with   a  leather  strap,   buckled   tii^ht 
iftround   bid   arm.      Of  forty  in   hia  company,  ail  but  ten  were 
illed  or  wounded.     He  limped  otf,  on  his  injured  leg,  to  the 
[nearest  ambulance  atation,  where  the  wound  in  bift  knee-joint  waB 
[examined  by  a  jjui'gcon.     The  prohc  penetrated  tlie  joint  freely  ; 
|;but  the  ball  could  not  be  detected^     From  the  etrongly  bent 
'position  of  tbe   limb,  it  had  apparently  escaped   the   libia,   and 
Ipjijj^ed  in  bct>Tecii  the  eondyica  of  the  femur,  where  it  waa 
:urely  Jo<lg;ed  and  concealed.     His  arm  and  leg  had  water- 
Mrcepingfl  applied,  and  vrcre  put  in  aplinta;  and  be  was  imme- 
diately placed  in  the  ear^,  and  tran^[iorleil  to   Hoaton,  where   he 
arrived  in  the  course  of  a  week,  wttli  many  other  ^»ldiers.  aotnc  of 
whom  had  receiveil  equally  (»crioua  wounds,  aiid  to  whom  tlie 
danger  of  transportation,  except  under  existing  rircumfltanees, 
would  ha\c  been  considered  nlmoi^t  n  fatal  movement. 
H      When  I  flaw  him.  be  wan  lo  an  extremely  feeble  condition. 
Belonging  to  n  fresh  bod^'  of  troops,  he  had  been  marchetl,  some 
days  before  the  final  battle,  and  fought  fi^r  one  or  two  daya 
before,  subjected  to  great  Heat;  his  principal  nouriahment  being 
gifcn  corn,  which  produced  an  almost  eonaLant  diarrlicea.      It  is 
probable  lliat  to  thia  condition  he  owed  his  safety.      In  addition 
to  the  above  wounds,  he  wiia  eufFcring  from  a  contusion  of  his 
aide. 

The  knee-joint,  I  fonnd,  wa«  free  from  pain  and  in  flam  at  a  lion, 
but  the  wound  on  its  outside  elightly  auppuratcd.  It  was  dressed 
with  a  ham  ajilint,  and  kept  in  a  atate  of  cntli-c  rest.  On  examin- 
ing the  elbow-joint,  I  found  it  quite  If>o«,  both  condyles  broken 


J 


5fi4 


(lUNflnoT  wooivns. 


nfT.  rlie  joint  wnvilleii,  with  an  effusion  or  the  inside,  a  hul 
brilr*  IigIqiv  tUi?  jcjint  i.in  tlie  iiuUiile,  inid  ulictvo  it  on  che^K 
bIiIe.  The  elbiivr  w^lh  mnde  iitiEikovikble  ivith  splina:  ^M 
ahvr  a.  iiiiyk-rnte  ;inii^unt  of  inflHrnmntinn.  whirh  nt  no  timi 
&rm>uiitec1  to  any  ihin^  tlirefltenm<r,  liolh  tlie  knee-joint  an4  Um 
dhiMv-jiiint  tVv]  \H^rf&:t]y  ivi?l] ;  8m  tiint,  at  tlie  end  of  two  luikttt^ 
he  wii»  nble  to  g'o  out  of  ilcxira.  He  linrilly  roooverctl  fill  th 
rai>Tiiins  of  the  elbow-joint.  Now,  at  iht  end  of  (our  vonrs,  hi 
vrnWf  ivithout  the  l(?ii?«c  ^ii^ri  of  Inmcncj^H,  the  l>iill  dlilj  remainiof 
in  the  knee.  Tlie  power  of  entire  flexion  of  the  leg  unlv  iia 
willing- 


I 


Case  GCCXXXIX. — Ptn£ol-hti!i  pajtfiny  through  £,*. 
Recovery.  —  Siiine  years  since,  a  man  wa»  broiijjhi  uilo 
Hosfutal,  who  hi«i  re<ieive(l,  from  a  jiistul  in  carcles*  hand^. 
a  shot,  wliii;h  [in^^wtl  directly  through  the  right  si^le  itf  ilie  rlie^ 
and  lodge<1  under  the  integuments  of  tlie  b;ic-k.  When  I  ^M 
saw  him,  he  was  breftlhin^  with  <Jr11icidly,  In  a  deadlv  fnint  am 
ibrion,  his  head  liavifiir  fallori  on  hm  che^^t;  atitt  he  whj  enilti 
up  frcply  frothy  blond.  He  wa*  very  inudi  Jepresscd  in 
desired  his  wife  to  lje  sent  for»  nnd  Meeioi'd  to  feel  that  hU 
Aolution  w\w>  iLC-ar  at  hand.  I  eiidivnored  tu  enmurarfc  hi 
mueh  as  possible  ;  and,  after  having  administered  etiinulnn 
bring  np  the  L"iruida:ion,  remrH(.>d  the  bullb^t  fri-inii  hi«  b^c^k, 
st<>pped  the  action  of  the  chi^sL  by  broiul  strips  of  ndhesivc 
ter  cjirrie*!  Itvo-I.hird*  around  the  bi>dy.  He  eventually  rG<N>t 
after  an  attack  cif  plcuritis  and  pricunionilia. 

The  history  of  thi^  man  was  a  L-uriouH  one.  He  btul  b<-e 
California  on  a  gold-hunting  expedition ;  and,  \^-hil<^  then*.  hg4 
imagined  that  he  coidd  turn  the  waters  of  a  smnll  stream 
riv<»r  hy  nieiiMi*  of  an  Tndill-^^d^be^  tui)e,  and  ihus  expose 
^cJden  j*iind  hent^tlu  For  diis  piiqmae,  he  liuil  returned  to 
Dustonf  and  had  cammed  to  be  nmnufaclured  nueh  a  tube,  i 
hundred  feet  long,  luid  six  or  eight  feet  in  diameter,  T\m  htA 
been  nicely  packed  on  board  a  vcs:*e] :  and  he  was  on  ihc  rvini 
of  sailing  on  hl:^  return,  when  tJie  ca[itain  of  the. ship,  jdavi 
with  a  pistolr  atrddcntalfy  Bhot  hini.  as  aboYc  related. 


i 


WOUND    IN    THE    (3KOIN. 


565 


Case  CCCXL.  —  AntpHtfittnn  of  Thi»?i  fof  Oinishot 
Wound,  jtTodneitig  F^rucfnrc  find  Dititortian  of  Thitjh,  und 
Anahffh}iiA  of  Knee-joint-  Appearance  of  Bont  rrinoved,  — 
May  3-4,  l^iifi,  a  vminfr  mnn,  20  yenrs  of  n.ge,  ontcrecl  the 
Huripitul  to  hftve  his  le^  nmpEiidteil  Tor  gunshot  wound  uf 
the  thigh,  receiv«i  thri;tj  yenr*  Ijtrtore,  wliirh  h.iil  hrokeii  the 
ilii'gh,  ami  loft  ii  m  a  state  uf  neornsis.  The  hall  slnick  him  in 
the  hiLtrk  pjirt  f>f  the  thigh,  ra.ther  hpli>w  the  niitlilie*  from  whirh 
j)ln<;ti  ;i  nuiiil>er  of  piet'es  of"  duad  Imue  were  eTtnirled  at  the 
time.  During  thi^  confiiiemcnt,  the  knee-joint  hecamc  unchv'- 
losed,  Almiit  iL  year  before,  he  hail  an  wtUt^k  of  ervKijuOiW  in 
the  leg:  and  six  munths  after,  while  jumping  from  a  step,  he 
Btruck  his  knee,  anJ  hnd  not  l>een  ahle  to  uac  the  limb  sinc«  ; 
a  dusliiict  anap  Ij^lrig  heard  in  it  at  the  time,  Tiiere  were  m>me 
ai^^iiH  of  n  tuherouloud  de{)OH^  in  Im  lanu^g.  Hte  hi\  ]e<r  was 
shorteneil  nbi»ut  five  inchea;  knee  arichyloW  ;  the  niiddk-  pnr- 
tiim  (jf  lemur  whs  thickene*],  aa  if  large  qnaatities  of  bone  were 
thrown  out  tliere.  On  the  inner  aide  <if  thigh  was  a  eimtrix 
iiijirkiut;  the  jxiint  of  entrunee  of  llie  ball;  on  the  outer,  one 
Hhowing  the  point  of  egrefla^  and  a  ^inn^,  with  dead  bone,  eould 
be  felt  at  thi^  point. 

On  the  2Jltb  of  May,  the  thigh  was  amputated  by  Bmall,  oval, 
anterior  and  poaterior  flaps  of  skin  ;  the  muscles  being  divided 
at  the  bfisjp  of  those  by  a  cireular  cut.  This  patient  reeovercd  »\t 
as  to  he  able  to  leave  the  Hospital  in  about  four  weekti.  The 
following  were  the  ii[i[ieaniu(*e>i  '»f  ihe  limb  removed  :  — 

The  knee  vrnn  benl,  and  die  inner  condyle  anchyloftod  to  the 
tibin,  and  the  patella  To  the  femur.  The  femur,  where  it  had 
hien  broken  by  rhe  ball,  wim  overi^hot  about  three  ini^hent.  In 
the  up|ier  pnrt  of  the  lower  fragment,  whieh  wns  behind,  was  ik 
circiilar  a|»erture  the  niKo  nf  a  inri>ket-ball,  Masses  of  lead 
were  here  everywhere  emheddt^I  in  ihe  bone. 


C\SF.  CCCXrj.  —  Ciitfc  of  Guvi'hni  Wfjund  in  fh^  Groin; 

(Ac  Bttti  lodtfinif  on  the  Capgule  of  flit"  IHp-jotnt^  and  under 
ihe  Great  VkfiMett.  Extrar-Uon  tJiree  iceeLn  aflttrwarih.  Re- 
copfrt/.  —  Oiptain  il.  M.,  23  years  of  age,  at  the  battle  of 
Geltyfiburg,  on  the  second  clay,  was  stationed  with  his  regiment 


511(1 


HlTJiHllOT    WULNIJS- 


iu  tlic  Sci'ontI  Division,  Swimil  Corps,  nn  the  cre?tt  of  tbe 
oecujiied  by  ihp  left  centre  of  the  nrniv.  Oiiriog  tfie  mo 
of  the  thirfl  dnj,  the  enemy  had  ranasetl  his  artiUerv  oppiuitc 
thlfl  front ;  and,  hI  one  oVlorlc,  opened  upon  it  frctm  145  pjOB  io 
position,  for  the  purpose  of  clearing  tlie  way  for  tho  advanw  <A 
hU  infantry-  Our  bnttene?*  replieil,  and  a  must  terrifio  cannon- 
ade wna  Itept  up  fnr  nearly  two  hours,  after  which  the  Eisaftiil&fl 
mniie ;  nnd,  ihe  hend  of  the  enemy^s  column  havinn;  i>i?netrfw! 
and  ohiained  n  lotlgfrnent*  ^'ithin  uiir  liiLe;:f  on  the  ri^ht  of  ^hf 
regimeutf  the  latter  was  onlcrc^l  to  change  front  obliquelv  ia 
the  rii^lit  tinil  rexir,  in  ordpr  in  meet  it,  mnl  rhock  tta  fiiftlwr 
advnnee.  In  this  movement,  nnd  nl  short  range,  thia  offijH 
received  aLuIIci  in  hia  groin«  nl  oncedmbling  him.  He  wu^l 
ried  to  the  reiir,  where  his  wotind  wujt  cxainined  by  a  ffur^toir 
Tc  was  pnil^>eil,  and  a  finger  introduceii;  but  no  tracM  cF  ifae 
iwdl  could  be  found.  Tie  arrived  in  Boston  ahum  a  woek  afto-- 
wards,  in  a  state  of  grent  suffering.  The  witunj  Wfts  ft 
below  Ponpnrt's  ]in:;iment,  the  fluclllng  not  excesftit-e,  bul 
motions  of  the  jnint  e3ilreHiely  jwunfid. 

He  wnH  placed  in  a  po^ltJEm  where  the  limh  eotild  har«j 
most  perfect  re?^t,  mid  :i{>pli  cat  tons  need  to  reduce  intlamoir 
tion ;  but.  aller  two  weeks,  symptoms  of  acute  iTiflammat^ 
of  the  hip-joint  crtming  on«  nnd  the  pain  becoming  aIiiio«t'^| 
cniciating,  I  cut  down  nnd  reniovi."!!  (he  hall,  which  had  takes 
BornL^what  an  irregular  L-<iiirse,  lyin^  directly  uj^on  the  capsule 
of  the  hi[>-jiii[it,  which  had  not,  however,  appjircntlv  becti  pene- 
trated- The  patient  wna  then  put  u|ion  a  fi"nciurv*bed, 
posed  of  a  triple  inrlined  plane  pkced  on  a  eocom!  pi 
Bimllur  to  the  one  nued  in  a  niKe  of  fnit^ture  above,  bo  tliat 
whole  body  could  he  moved  wilhoTit  disturbing  the  joint. 
thifl  posithiTi  he  remained  for  many  we<'ks,  lieiao;  Dnnhlo  to  allov 
any  one  even  to  tmich  the  bed  without  experiencini 
sutTering,  and  requiring  the  nse  of  ether  when  lits  clothed 
clinnged. 

At  the  end  of  one  or  two  Tnonthe,  the  indiimitintion  ha* 
subsided,  I  broke  up  the  adhei^iona  to  the  joint,   while  ho  vu 
under  the  influCQco  i>f  ether.      He  did  well,  and  got  on  ■ 
bul,  from  an  accidental  fall,  not  being  aufficiently  careful  ii 


after 

i 


] 


wou!n>  m  THE  onoiir. 

^^  Case    CCCXL, — Amputation    of    Thigh    for    Ortnahot 
^^iVvift/fl,  prffr/ttcittg  Fract^rf  and  Dhtorfion   of  Thitfh,  and 
^^Anchj/fuftiH  of  /iJiec-Joinl .     A.pj3f:ai'Uncc  oj  liattc  Temoved*  — 
■^JJay  24,   ]8(rti«  a  juitii^  mau,  20  years  of  age,  entered  the 
^Hospital   lo    hiive    hia    leg    ftiiipiitateii    A>r   gunsliul   wound    oi' 
j^the  thigh,   rcctived   three   vcara   before,  wliirh   hinl   broken   the 
-  lliigh,  aiid  l(*1\  it  m  n  j^tate  of  necrotfia.      The  ball  atruck  him  in 
_^  the  buck  prut  of  the  thigh,  riither  below  ihe  luiihUc.  from  which 
place  a  number  of  pieces  of  dead  bone  were  extracted   at  the 
time.      During   the  confinement,  tlie  knee-joint  bcciimo  nnchy- 
loscd.     About  A  year  before,  be  had  an  attack  of  ery^ipelaa  in 
the  leg;   mid  aix   tiiuntha  after,  while  jumping  from   a  &te}>,  he 
struck  hi*  knee,  and  hnd  not  been  able  to  uec  the  limb  ajncc; 
^   ft  difltinet  snap  being  heard  in  it  at  the  time.     There  were  some 
"    Bl;;;'n»  of  a  tuberculous  dejjoait   in  hi*  bings,      Hia   Idt   {c<^  W!\s 
"    ahorteneJ  iibout  five  inches;  Wiice  anchvlosed;  the  middle  por- 
tion of  femur  was  thickened,  tm  if  Urge  quantities  of  bone  wero 
thrown   tiut  there.      On  the  inner  siile  of  ihjgh  was   a   cicnliix 
marking  the  iK)int  of  entrance  of  the  bdi;   on  the  outer,  one 
showing  the  point,  of  e^'i^i^r^i  ;iud  a  z^inuct,  with  dead  bone,  could 
be  felt  at  this  point. 

On  tiir  2{)tb  (if  MiLv,  the  llngli  wufi  ampiitati^d  by  smalU  ovaJ* 
anterior  and  [KJHterlor  ttaps  of  pkin  ;  tiie  nm^cles  being  divided 
at  the  bnB€  of  these  by  a  circular  cut.  This  patient  recovered  8i> 
a9  lo  be  able  tu  If^uve  the  lIo^[iitJi]  in  abciuL  fuur  neck^t  The 
followhi^r  were  the  nppOJiniuces  of  the  limb  rcmovctl ;  — 

The  knee  waa  bent,  and  the  laner  condyle  anchyloaed  to  tho 
tibia,  and  the  patella  lo  the  feamr.  The  femur,  where  it  had 
been  broken  by  ihe  ball,  was  overshot  nbout  three  inches.  In 
the  upper  part  of  (he  Lower  fragment,  wiiicli  naa  behind,  wus  a 
Circular  aperture  the  aize  of  a  muskct-balL  Mii^ece  of  lead 
were  here  cvcrvwhero  embedded  io  the  bone. 


Case  CCCXLL  —  Ctt/te  of  Giinnhot  Womtd  in  the  Groin; 
the  Sufi  IfnUjinrf  on  the  Cnpaidr  of  th^  Uip-joiiU^  and  under 
ihe  Great  Veaeein.  Entrnctian  thret  icecLa  nflerwdrdf^  Hc- 
covcrtf. — Ciiptain  II,  M,,  23  ye^ire  of  age,  at  the  bnlilc  of 
Oettyaburg,  on  the  second  da/,  was  stationed  with  hia  regiment 


566 


orxewoT  wounds- 


I 


1 


in  tlic  Pocond  Diviejon,  Second  Corps,  oo  the  crest  #»F  the 
ocfU|>ied  by  the  left  centre  of  Che  t\vmy~  During  llie  mo 
of  tlio  third  dny,  the  enemy  had  rnnaaed  his  ftrtillcrr 
tliifl  front ;  (inJ,  at  one  o'clock,  opened  upon  it  from  115  gwn*  ffl 
position,  for  the  purpose  i>r  doarini;  the  way  for  the  od^'uic^  "f 
hia  infantry-  Our  Liittories  roplieJ,  and  a  most  terrLlic  c&nnaft^ 
rule  wns  kept  up  for  nearly  two  hours,  after  which  tbc  n9«uill 
mrwlc  ;  and,  the  liead  of  the  eocmy'*  column  havinj^  pcni?!rn 
anJ  ohtmned  a  lod^^Pinent,  within  onr  Hnes  on  the  ri^ht  of 
re-^imeni,  tlie  latter  waa  ordered  to  chim^  front  ohliqtiely  to 
tlie  rl^ht  nnd  rem",  in  orJer  to  meet  it.  an<l  rheok  its  fur 
advance.  In  this  tnovemert,  and  at  eliort  range,  this  a 
received  a  bnlbt  Jn  his  groin,  at  once  diaabling  him.  lie  waa 
ricd  to  the  rear,  whei-e  his  wound  was  examined  bv  n  ftu 
It  waa  probed,  and  a  fiajxer  introduced;  but  no  Irnce*  of 
hiill  could  be  futind^  Tie  arrivet)  in  Boston  about  a  week  nfttr- 
warda,  in  a  «lnte  of  grent  BLifTenn^-  The  ivound  w^e  a  \ 
below  Pouparl*fi  lirfnmcnt,  Che  awelling  not  exc^eeiv^,  bul 
motiona  of  the  ji^int  extremely  painful. 

He  was  placed  in  a  poBition  where  the  Hmb  coulfj   hate  the 
most  jx>rfect    rest,   nnd    iippllcations   u*ed   to   reduce    inHiim 
tion  1   but,  iifter  two   weeks,   eymptoma   of  at?ute   inf!aiiiRjAl4 
of  the  hip-j<ttDt  cominn;  on,  and  the  piin  becoming-  nlino^t 
enidatin^,  I  cut  down  and  i-einoved  the  ball,  ivhicb    had  ta' 
BOmewhal  an  irregulnr  cour?e,  lying;  directly  upon    th^  ca 
of  the  hip-joint,  wliidi  had  not,  however,  apparentlv  been 
Iraletl.      The  patient  waa  then  put  upon   a  fraetiiro-be<l, 
posed   of  a    triple  indineJ  plnne  placed  on   a  second   pU 
similar  to  the  one  used  In  n  case  of  fmeiure  above,  eo   that 
whole  body  could  be  moved  without  disturbing  the  joint. 
this  position  he  remained  for  many  weeka,  belnfj;  tinablc-  to  all 
any  one   even    to  touch  ihe   bed  witliouc  experiencing 
iuifering,  and  re*|uiring  the  use  of  ether  when  hie  clothes 
changed. 

At  the  end  of  one  or  two  months,  the  inflammntion  havi: 
Bubsided,  I  broke  up  the  adhesiona  to  the  joint,  while  he  w» 
nnder  the  influence  of  ether.     He  didwpll,  nmJ  got  on  crutch 
hilt,  from  an  ^cidental  fall,  not  being  aitfliciently  eAreful  in 


WOUND    OF    THiGa, 


r>6T 


use  of   his   orutchea,   the  joint  wiu  wrenoh&d,  and   the   iiL^nm- 
mniinn  reprodnced. 

He  Eiltimntely  recovered  with  &  com^iletelj  strQight  limb,  but 
Blif1^nG(1  bip-Joint,  hEring  imwilLiiig  to  j^iibmiL  to  the  con^ncmenl 
and  uni:e[lainty  ufFeretl  Uy  uiiolbur  operLition  to  locsen  it. 


Cask  CCCXLIL — Gunshot  Wotmfl.  Ffacfure  in  Higkt 
Femur,  til  Itn  Upper  Third.  Greirt  Siippuratwn.  Con- 
Jitipment  for  ncarhj  a  ^jtar.  Greiil  DUlortian.  Operation 
Jor  Ncctitsis.  Suhfi^fjiiGtU  Death  from  Exhmtniio'iX.  —  A 
dislingiiis»bcii  officer  of  iirtillery  was  shot  bellire  Peterahurg, 
JuTic  16,  1864,  by  a  Minir?  bullet,  whidi  poB^ed  thruuglj  bis 
left  thigli,  and  penetraicod  tlie  riglit,  ueitr  tlie  fold  of  tbc  rmtes. 
He  was  (rnrried  lo  a  Hos[jitMl ;  arid,  ut  the  end  of  four  weoJc*, 
the  bullet  wa^  extracieil.  He  euffereil  luuch  frtuu  his  wuumU, 
and  frriin  beil-^urea,  which  formed  on  liis  hack.  At  the  end  of 
four  weeks,  he  was  taken  to  his  home  in  M}dno,  !u  au  exhfuL-^tod 
state,  where  he  began  almrtly  to  improve.  Four  weeks  afier 
thi^,  while  eadeiivoriog  to  turn  in  hiH  bed.  be  beard  a  hmd  snup  \ 
and  [[ninediiitc'ly  bis  rjvht  foot  bcaiiiie  i[iverted,  and  bk  thjgb 
shortened  two  or  three  inches.  In  thij*  condiliou  he  remiiiiit-d 
until  May,  18ii5,  nearly  ten  months  and  a  balf  after  the  receipt 
of  the  injury,  when  he  was  brought  to  Boston,  and  pbtced  in  a 
privnle  n>oin  at  the  HospiCrtI,  under  my  care.  He  wna  then 
very  feeble,  with  a  great  discbarge  from  the  wound  in  tlie  outer 
aud  lipjier  part  of  riglit  thigh,  and  apparently  failing.  The  foot 
was  fitrungly  everted,  the  limb  bbortened,  the  knee-joiut  partial- 
ly auchylose(],  and  he  eouLd  mjt  he  moved  in  bed  without  the 
^rentest  diflicnity,  Hk  waa  kept  idi^'e  only  by  means  of  fomt  of 
the  moet  nourishing  character,  and  large  ijuantitiee  of  atltnu^ 
lants. 

A  consultntiou  being  bebl  on  bid  case,  the  question  was  pro- 
puited  whether  to  amputate  the  limb  near  the  bip-joint,  or  to 
make  an  nttempt  ki  remove  the  dead  bone;  and  It  was  decided 
to  attempt  the  latter.  On  the  7tb  of  May,  a  free  incision  waj4 
made  on  the  outaide  of  the  tliigh  ;  and  a  large  sequestrum, 
locked  in  between  the  upper  and  Jowcr  fragmcLtd,  was  success-* 
fully  removed.      On  removing  the  sequestrum,  it  was  found  that 


568  GUNSHOT  wotrHDS. 

the  npp^  and  lower  fragments  touched  each  other,  but  were 
united  only  for  a  space  of  about  a  quarter  of  an  inch  in  cir^ 
cnmfereace.  It  wu  therefore  decided  to  attempt  to  remedy  ^ 
great  deformity  and  ehortenmg  which  existed.  This  w&s  done 
hj  slightly  twisting  the  foot,  and  the  adhesioas  eaaily  gave  way. 
The  foot  was  then  brought  up  into  a  proper  position,  and,  by 
exteneioD,  the  shortening  reduced  to  one  inch.  The  limb  waA 
next  carefully  secured  by  splints  and  bandages,  and  the  patient 
transported  to  his  bed.  He  passed  a  comfortable  night,  and  for 
a  time  seemed  to  Improve.  Two  weeks  afWward,  however,  be 
had  some  hemorrhage  from  the  wound.  He  graduallj  failed, 
being  worn  out  with  the  combined  effects  of  suppuration,  bed- 
sores, and  the  bleedings  which  occurred,  —  whi<^  laat,  tmder 
other  circumstances,  would  have  been  of  no  cons<kquenoe,  —  tnd 
died  May  2Sth. 

Autopgy.  —  The  upper  fragment,  about  five  inches  in  lei^th, 
was  turned  outwards  and  downwards ;  and,  at  about  two  ■"^  a 
half  indies  from  its  apex,  there  was  a  rou^,  irre^ulv  anr&cei 
the  seat  of  its  attachment  to  the  lower  fragment  before  the  op- 
eration- Its  contour  was  quite  irregular,  and  showed  signs  ef 
previous  disease,  as  also  the  marks  of  pressure  made  by  the 
pointed  end  of  the  lower  fragment.  The  latter  was  very  irregiH 
lar  in  aspect,  having  cavities  left  by  the  removal  of  the  seques- 
trum* The  interior  of  the  bone  was  completely  disintegrated 
for  some  four  or  five  iuchcs,  a  sanious  discharge  oozing  from  it- 
The  angle  made  by  the  two  fragments  was  very  strongly  moHced. 
The  adjacent  part  of  the  thigh  was  completely  riddled  with  bur- 
rows, one  of  which  extended  as  high  up  as  the  ci^st  of  the 
ilium  1 


CHAPTER  XIII. 


MISCELLANEOUS  CASES. 


PEyETRATlXG    WOUNDS  OP  IHE   GHEBT  AND  ABDOMEN. 


!nESE   are  rare   In   c\v'\}  practice,  but  I  h^ve  met  witli  wveral 

mgeroiis   woiinilji    Lm[»lii']iLing   tlic   ciLvitieH   of   the   ijlie::4t   and 

lomeiii  —  more    e^pi^cinll/    ihe   former,  —  which,    cnntrary 

■  ihe  uj*ijrtl]y  receivfi!  oplniun,  have  recuvered  under  jiuliciouH 

ire  nnd   iimnngemenL      Since   tlie  war,   imporlsint  discussions 

IVQ  h<!en  held  on  ihia  suhjecL;  and  in  co^^es,  for  insttTince,  where 

ills  hiitl  pas?cil  i!irtii[^r]i  the  ehesXy  followed  liy  rLH:<ivery,  ihe 

lijtgQosis  U\ts  Leen  ([Jie.*tioiied.     1  wiw  ^dntl  to  find,  however, 

ml  innny  tli^tlngiii^hei]  surgeons  hnd  been  hrouvht  to  the  same 

inHusioiw,  in  the  greiit  fidd  of  imjuiry  winch  wus  ofTereil  to 

lein   by  the  war,  thnt   I   hjul   a^lrenxly  arrived  ut  by  the  smnll 

:|ienence  in  these   woontls  presented   by  L'ivil   pnielice. 

Tlie  eiperienee  of  ihe  late  wnr  also  shows,  conlrnry  to  the 

ipulnr  opSnimi,  the  ranty  of  woiinda  by  llie  snbrc  arnl  the  bnyo- 

ict.      Out  of  87,822   waunJs  tlint  were  clnswified,   tliere  were 

LOli  8itl>re  woutuIh  ni^d  l^*!  Liiyonet  woimdit :   11  died  of  the 

former,  nml  Ct  of  the  bitter,  making  17  in  ulL 

ftiilhrie,  one  of  the  most  (listingiiisbed  of  English  tiiiliury 
flurgeons,  teatlfiea  lo  the  great  rnrity  of  this  lieacnption  of 
wounds- 

In  illustmlitm  of  the  nhovc  remarks,  I  woidd  quote  from  C'tr- 
culiir  No.  6  die  following  n?snlts  of  gunshot  woumls  in  the 
c!ie&t;  and  although  it  may  be  eaid  that  theae  wounds  arc 
diEK'ix'iil  fmni  womnls  m:nle  witli  it  [Munted  weapon,  yet  the 
diuiirej-  would  he  in  favnr  of  the   former  r  — 


*-  or  7,0G$  guaahot  vrounda  of  the  th«9t  whteh  hnvo  been  examined, 
nnd  truiiscribed  from  tit)  reports  belongiag  fo  the  pHriod  prior  to  July, 

72 


i 


I  and  sufTering. 


570  HIBOVLUmOUS  OAAsa. 

1864,  there  were  S^OS  that  either  penetrated  the  tltonde  ctTitjor 
irere  BccompHuied  bj  lesions  of  (bo  thondo  vin^nt  Tlie  renltt  bn 
been  Bscertained  in  1,372  of  these,  md  were  fatal  in  930,  or  73  per 
cent  Tho  4,759  tIeAb-woirnda  pref>eDled  a  rerj  wdkU  ratio  of  mnlil' 
itj.  It  waa  obeerredf  however,  that  Ibej  wera  commonly  long  in  bcd- 
tng,  in  consequence,  no  doubt,  of  tho  mobllitj  of  the  tbcmCTc  panMts. 
"  Of  2,707  goDBhot  wonnda  of  the  abdomen,  reported  fivm  the  ht- 
ginning  of  the  war  to  Jntj  1,  1864,  there  were  2,164  flcvb  woon^ 
and  54S  cues  in  which  the  pentonenl  cavitj  wan  penetrated,  or  ibe 
abdominal  viscera  ipjnred.  Among  tbe  flesh-woandn,  ]14  fttal  oici 
are  reported,  which  were,  in  most  inatancea,  caaoa  of  alougfaing,  fh» 
iDJuricB  of  the  abdominal  parietea  bj  ahella.  Of  Ihe  £43  penetratMf 
wounds,  the  reealts  have  been  ascertiuned  in  414,  and  W9T9  fiual  ia 
308,  or  74  per  cent  The  number  itf  lecoreriee  ia  unexpectedly  laz|S, 
but  indndet  only  caaes  in  which  the  reporta  showed*  bejcmd  qaalia^ 
that  the  abdominal  cavity  had  been  involved," 

The  following  cases,  which  happened  to  be  in  tbo  Hospital 
under  the  core  of  mj  colleague^  Dr*  H.  G.  Clark^  and  mp^, 
m  June,  1859,  (the  notea  of  whidi  I  made  inimediatelv  aAo 
wards^)  are  cited  in  coDfirmadon  of  what  I  have  now  said : 

Case  CCCXLHr.  —  St<df  m  Abdomen.  Secovery.  —  Tht 
first  case  vraa  that  of  a  young  woman,  about  25  yetm  of  tee, 
under  the  care  of  Dr.  H.  G.  Clark,  who,  about  a  month  be- 
fore, received  a  stab  on  the  upper  and  left  side  of  the  abdo- 
men from  a  drunken  soldier.  The  knife  cut  through  all  her 
clothes;  made  an  inciaion  from  three  to  four  inches  iu  length 
in  the  upper  part  of  the  abdomen,  through  the  ekin,  fat,  and 
musclea  ;  and  apparently  penetrated  the  abdominal  cavity.  The 
wound  was  brought  together  by  stitches,  and  the  patient  aeat 
to  the  Hospital,  where  ahc  arrived  in  a  etate  of  great  eshaustiop 


A  few  days  after  her  entrance,  the  wound  was  attacked  with 
erysipelas  i  and  aljc  underwent  a  very  critical  inflammation  of 
the  abdominal  parietea.  The  peritoneum,  however,  seemed  to 
escape  ;  and  she  recovered  well. 

Case  CCCXLIV,  —  Stab  in  ChesL  Recoveiy Xhc  sec- 
ond case  was  a  sailor,  about  %b  years  of  age,  also  under  Dr- 


PENETRATING   WOUNDS  OT  CHEST   AND  ABDOMES*      571 

iClnrk'a  care.     Abuiit  twu  wt^lts  before,  m  a   ilrmilteu  frsiy,  lit? 

Ireceivcil  a  atalj  from  a  iar^e  kLiife  iti  the  cheat  Wvvceii  i\u'.  t<!xLli 
acventh  rib  of  tlic  right  aide,  oldo  a  aecood  slab  in  the 
upper  jmrt  of  the  cibdomcn.  He  w^ia  at  the  time  aulfcriti^  iiDd^r 
na  attack  of  ;iii  ^MlmjulLC  Dnture.  Tbu  wouad  in  the  chest 
pccetl'ated  through  ihe  rjb*,  cutting  off  the  inferior  intt^rcoatiiL 
ftrtcrv,  which   bled  furioiislv,   and,   whca   he   entered   the  lloa- 

'pitnU  could  only  be  sfuppcd  by  ibruating  a   bit  of  sponge  intu 

;the  wound  between  the  ribs.  Tliis  elfecLiially  aluuiichc-d  the 
bleeding*  The  wound  lu  the  TLbdomen  gnve  no  ayniptoniSi  At 
the  end  of  three  daye,  a  poiUticei  being  rip^died  oA'er  the  ^pon^e. 
It  £»i>ftci]ed  and  came  away  nithont  hciuoirbage.  The  patient 
durin;^'  th!d  time  waa  very  anthmatict  and  the  action  of  the  lung 
on  that  side  eecincil  nearly  eu.*|>eiidcd.  He  expecLonited  fively 
a  muco-purulent  matter,  but  attributed  his  aymptoma  p^lllcip^dly 
to  previous  diaawe,  and  recovered  without  further  bad  *yrap- 
toma. 

Case  CCCXLV,  ^Suth  in  JVecfc  atid  Abdotnen.  Recov- 
try,  —  The  thiid  auso  waa  that  of  a  youn^  man,  19  year*  of 
nge,  who.  the  day  after  leaving  the  llou&e  uf  Correction,  engaged 
in  a  brawl,  and  received  a  &tiib  in  the  icf^  aide  of  ihe  neck  and 
upper  part  of  tlie  abdomen*  The  omentum  escaped  from  the 
abdominal  wound,  but.  bcin^j  return<'d  by  the  phyt^ician  Grat 
cidled*  \\\^  wound  wa^  PCAved  up :  and  tiiid,  aa  well  od  the  wound 
in  the  neck,  which  had  cut  ihrnugh  the  moi^toid  muscle  without 
injury  to  any  important  wlery  or  nerve,  was  elused  with  aillieBjve 
plutfter. 

The  [laticnt  wju  placed  on  bid  back,  kept  on  oatmeal  gruel. 
And  no  medicines  uded.  He  liad  no  tendernc^a  of  the  abdomeui 
no  fever,  anj,  at  the  end  of  a  week.  a[>[»eared  perfL^tly  rccov* 
ercd.  1  kept  him  very  quiet,  from  fear  leaD  adhehious  formed 
between  the  omentum  mid  abdoiuinal  pariclea  might  be  torn 
away,  and  r»enoua  uymptoma  induced  by  too  early  and  too  active 
movcmeatd. 

CvsB  CCCXLVL— ^m6  U  C&e»t.  R'^cot'^i^.—The 
f^mrth  cftac  wn^  an  Italian,  20  years  of  age,  stabbed  ui  tlje  chest 


S7%  HlSOELLAirSOUB  OA8E5. 

\^  ft  dmDken  man.  The  wound  wu  Wge^  and  appeared  qdto 
deep  :  it  wu  eituated  juat  on  the  edge  of  the  felee  ribe.  Eito 
from  fr^t  or  bleeding,  the  pmtient,  when  first  lirougfat  into  Ai 
HoapitiUf  had  the  aspect  of  having  received  a  mortal  wwmL 
Bot  on  the  following  daj,  no  symptoms  in  the  Innga  hafbg 
appeared,  I  was  convinced  that  the  knife  had  posted  betwcs 
the  int^umente  and  ribsr  and  that  the  viscera  of  the  cheit  asd 
abdomen  bad  escaped  injiuy.  I  did  not*  however^  make  asf 
examination,  in  this  or  in  the  other  case,  with  a  probet-^ 
a  practice  which  I  conaider  unnecessaij,  intermeddling,  and,! 
may  almost  say,  criminal ;'  as  k  might  in  some  instsncei  ooK- 
[dete  the  passage  of  the  wound  into  a  large  cavity  which  etha^ 
wise  might  have  esc^ed,  or  the  screwing  of  the  probe  icnsi 
in  the  chest  or  abdominal  cavity  might  of  itself  be  prodoctht 
of  serious  consequencee. 

This  last  padent  also  did  well. 

HIP   Ain>  SPIVAIi  DESEAfisa^ 

The  present  Improved  method  of  treadng  hip  and  spinal  &- 
eases  may  be  adduced  as  one  of  the  greatest  triumi^s  of  dw 
modem  school  of  pathology.  Hip-disease^  as  every-  one  knom, 
was  formerly  treated  almost  exclusively  as  a  local  inflammation ; 
and  the  patient  waa  confined  to  hia  bed,  tormented  in  turn  hj 
the  severe  pain  caused  by  every  motion  of  his  diseased  joist, 
and  by  an  appalling  routine  of  leeches,  cups,  blisters,  setom. 
and  issues.  Dr.  Phyeick,  of  Philadelphia,  demonstrated  the 
great  importance  of  rest ;  which  he  eecured  by  iQeana  of  the 
"carved  splint/*  accurately  fitted  to  the  hip,  and  confined  bj 
bandages.  The  carved  splint  ia,  however,  an  expensive  ap- 
pliance; requiring  to  be  made  expreaaly  for  the  case  in  whir^ 
it  is  to  be  employed.  Tiie  full  benefit,  therefore,  of  this 
treatment  vrna  only  realized  afler  the  iutroduction  of  spliaU 
of  gutta  percha,  at  the  llo&pitul,  aonic  twelve  or  fifteen  years 
ago.  The  real  thus  secured  by  the  ijmnobility  of  tbe  npparalu^ 
aif(>rds  inuucdiiUe  relief  from  pain,  and,  with  the  aid  of  bauketA 
which  I  hnve  hnU  ni:i<Ic  for  the  puqiose,  admits,  even  id  bad 
cases,  of  the  patient's  being  readily  carried  into  the  open  air. 


573 


or  even  tvanaported  grent  distauces,  llje  recent  invenlioo  of 
the  lEuiifcycd  iii3truiueiU&  of  Dra*  Davie  and  Sajre^  whiirh,  in 
uijiny  cnaci^,  admit  of  a  niotlernte  Jc^tcc  of  locomotion,  liaa 
given  ft  new  impetus  lo  the  treatment  of  this  dipeaae ;  avoiding, 
in  even  a,  greiiter  degree  thun  lieforc,  the  injurigu^  confinement 
in  Led  to  which  the  palietit  waa  formerly  condt-amed.  In  those 
cEuea  where  no  splint  can  be  borne,  great  relief  h  experienced 
either  hy  llie  appiioition  uf  a  ainiplc  weight  attached  to  the  foot, 
or  the  ejctendion  a|ijrarutU9  of  Delimit,  tu  separate  and  prevent; 
friction  of  the  indamcd  Hurfacca.  The  constitutional  treatment 
must,  of  course,  be  directed  ta  the  pte5er%'ation  of  the  stren^'lh 
during  the  cour»c  of  a  long  mid  tedious  di^ea^e ;  and  it  Is  hy 
the  mecbiiuicid  apphaficee  jast  mentioned  tljjit  we  aire  enabled  lo 
Avail  ourseJvea  of  the  ineetinmble  benefits  of  fresh  air  and  gen- 
tle exercUe*  so  eaaeatial  to  the  tuainteoance  of  health  both  of 
body  and  mind. 

Carie»  of  the  «]>ine  naturally  falla  into  the  same  category  as 
hip-diseascp  Mechanical  support  fchouIJ  be  given  to  tlie  bitck, 
in  order  to  prevent  the  breaking-down  uf  the  inflamed  vcrtebi'ce 
from  tlie  weight  of  the  upper  part  of  the  body ;  the  patient  ii 
thus  enabled  lo  move  about,  nnd  preserve  a  fair  degree  of 
heidlli  during  a  hmg  nnd  trying  disease. 

Muny  sei'ofaCoua  iinfeetioiis  of  the  kuee,  and  other  large  Jninte, 
are  to  he  treated  according  lo  the  bame  principle  ;  auAtuinin^r  the 
ayateni  by  Invij^'oratiiig  remedies,  Jind  sfcuring'  iimnobility  of  the 
affected  joint  by  proper  Ukechnnieal  appbaueea* 

It  ia  dtill  a  question  how  far  we  can  enfcly  venture  in  at- 
tempting lo  destroy  the  jiJliL'sinns,  and  eonsefjuent  Smuiubility, 
caused  by  disease  of  tltc  liip  and  other  krge  joints.  Some  ei- 
periuicnts  have  been  tried,  whh  a  view  to  deciding  this  point; 
but  tlie  rule  of  practice  ia,  a*  yet,  by  no  ujcaus  teltled, 

1  liavc,  however,  seen  In  tlie  practice  of  Dr-  It-  Brown,  of 
this  clty^  amZ  ll(^i^Ied  him  iu  the  ojienitioa  upon,  a  immber  of 
cases  of  children  aulfering  uuder  falj^e  anchylosis  uf  the  joint, 
l\us  t-cquel  of  hip-dirHeasc«  iu  which  the  adhesiunfi  have  been 
broken  tip   mi(!er  etlier  with  graLllyuig  results- 

The  diai^'DOsifi  of  incipient  bip-discnsc  ia  n  subject  of  mueh 
importance,  and  sometimes   a  nuater  of  consideiuMo  diffieulty. 


hii 


^      MISCEIOu^XEOUS    CASES. 


llipre  being  aucH  ft  variety  of  ^rmptomfl  conaect^d  willk  it. 
endly,  there  ia  n  pEiin  ip  the  kiiecjumt ;   fiiini<>time9,  tliotrk' 
mrelj,  in  tlic  \u[t  JlscIJ'.      In  oUuts,  lliere  ij*  u    L7uiu|ilclr  jic» 
nit)'  fiom  pniii,  antl  tlie  otiK  eyuipCom  i»  Jnuiene«a.      TUfcfi*] 
iu^  uiuIIkjcIt  i\>r  clearing  nyt  tliif  j>uiiili  I  Iiuve  seldom  htjn\ 

Tlic  (latlent   bdn;^  IniJ   upon  tlic   bau'k,    auid  |li€   llmU  fq 

rekxcil,  ilie  eouiiU   liuib  if^  ^rtt  «eizej,   Aud   fredv  beoi  9^] 

m 

it  neftrl^-  or  quite  touches  tlie  abOooicn.  The  ffune  iiiu««t{ 
being  aitcaipteil  with  the  nthcr  Itnth,  it  will  be  finmd  thtiDtj 
flexion  bf  the  Vnnli  iet  nhnotsl  invaniibfy  iurre^ted  at  or  aai* 
right  angle  with  the  binly  ;  th^Ltrp|)  [  have  seen  one  or  tau  9- 
<;cplioii9  tvf  this  rnle.  IK  the  flexion  is  compleie^  iiihI  if,  *ii* 
to  it,  there  U  wt  )>ain  rrum  deqi  pre^^nrc  in  tlie  gruni,  tk 
cuLisc  of  ihc  lameness  miiv  bo  searched    for  clM^wbere. 

A  qneetioa,    wLii^h   hus    been    muth    (UdcuH^&ed,   m,  wfcj  f 
llie   diecnHKl   limb    apparentlv   lengthened    in    anniu    raw*,  ui 
shgrLeniiJ  in  ulhers,      S\j  I'wr  as  1    Itave   obseno<l,    the  folliin^ 
is  the  cAjilaiiation  i   When  the  disease  comes  un  itiaiMioitalr.  sid 
^viih  hut  httlc  pain,  ^u  that  the  pnticnt  \s  nblc  to  keen  nboal,  ik 
limb  is  earned  in  front  of  ihc  other  in  walking  ;    nntt   the  itelvE*, 
in  tliia  way,  gradually'  becornee  deprcaned*      l^'hen    tlu^  affct' 
tiuii  is  !U.'ntt\  an<l  attended  ivilli  miicb   sufltTing,  the  [Wilierilh'* 
ia  brtl  i>rj  the  si>iind  side,   drawing  np  the  af1ecCe<l  limb;  1^ 
being    llie  most  canifurtahle   pudiliou  m  ihiHt  hs  iti  some  filhtf 
iaflamnkatory  affeetions  of  the  lower  e.\Eremltie9, 

Hip-4lisea>*e  U  not   nnfi'er|nenlly  niiftiaken  in  ohiJdiV!!!  fnr  di'- 
loeiilion  of  the  }ii|>-joint;    and   1    have   hiid  ;i    iiiiiTibor    of  cn^i 
under  my  rare,  uf  pxitienC^  who  havt!  siiHered  an  A^^rmvation 
tliL'JT  difica>:c  rrL>ru  alienipts  having  Ijeen  inmk'   l»   refluoo   n 
pns^d  du'^hrejiliiFiL,  ihe  Mniptnias  uf  which  liad  i^oine  on  nut  loni 
after  the  reeeipt  of  a  fall.      The  dingnosis  i«  at  r>ncc  c1t?ar«d  bfl 
the  nse  <if'  fiher,  whieh  relaxeii  the  iirilaled  niusclcs,  imtj  k- 
niQvt's  the   di*lorli[»n. 

T  do  mil  ])nipose  to  adduce  eases  in  illustration  of  thi«  ve<7 
cninmoi]  alTection,  but  would    reilenite  what   bai*    alrerulj 
Raid  in  re-^'ard  to  keeping  the  joint  in  :l  *tnte  of  (K^rfuei    rest.  Ii* 
Hueli  upplianees  ns  will  allow  t!ie  patient  to  eiijoy  the   invigoi 
ing  intiucaee  of  the  open  air. 


J.LJ Lk^-L 


GANGRENE  OF  THE  ATPEKUIX    VEiailFORflna. 


575 


ArPE?n>ix  VERaiiFORMia, 

V6E  CCCXLVIf,  —  Gangrene  of  the  Apprndix  Vermi~ 
Ih^ybj'^uV  — 1851,  Jimc-  Tlie  piitient,  a,  geiideinfln  40  ywira  of 
:i<^r,  Imil  Jilk^jija  been  ^ulijt^rl:  lo  nliat  are  riillnl  bilii>ijR  I'um- 
^g  pljiiiiU,  Abuiit  Tour  yeiLC»  Lcfuro,  lie  wiva  ;;(>i[rLnei1  for  some 
^  weeka  to  ilie  house  by  a  sevei'e  attack  of  coltc,  ntteiided  witli 
j^^   conf'tijmtioii,  at  which  lime  I  tihscrveJ  a  »!ijall,  hiu'il  tnmor  — 

»te[wler  on  jireflj^iire  —  in  llie  right  Innibnr  region-  Two  ycnre 
Ifttcr,  111  Oetolicrr,  he  hiiJ  a  slvojuI  nUikck,  in  nhich  llm  jijiin  was 
axi^nicijLting,  sinil  rotjuiroij  the  con^^tnnt  inhdutiou  ut'  ether  and 
tiie  use  lit'  ruiinles  ti>  rdievc  hhii.  At  thin  liunj,  thpre  was  n 
diffuse  flvveiling  in  the  right  iliiui  ftiid  hnnbur  I'egion*,  rjiiife 
hnrd,  Bud  yery^  tender.  Uuder  tlie  ubc  of  leet^hes,  and  hy  in- 
ducing a  sli^lit  mercurial  action  on  the  F^y^Tem,  he  ^huvly  re- 
wtvered.  Fearing  some  cjr^nnie  aompliiint,  not  only  fmni  the 
BvrcUin^,  bul  from  his  grejil  fliiJiceiitibility  lo  cold  ond  disturbed 
digeatieii,  I  advised  him  to  rellnquif^h  Luftiner<?i  :  at  IcJist  scj  far 
HA  III  allow  him  to  hiive  hj^  rnind  [lerlet-tly  free  fr<i[n  any  cnre, 
and  tn  give  him  an  apiiorturity  of  itnyiui^  purticulitr  jilicnliun 
to  [ilrt  hcjdlh^  ThtM  he  did,  and  wns  qiiile  free  from  any  trouble 
until  tlj(?  firm)  jituck,  which  came  on  nfter  esjJOHiire  to  cohK  inid 
»onie  irreirnUrity  In  dlel.  Tlie  |i)U[i,  lor  n  diiy  or  Iwii.  iLtiiciimird 
merely  tn  a  feeling  of  unearsitietts,  bul  ^rrsLilmilly  becnme  exees- 
slve.  A  tumor  could  l>e  dlsMuguiHliwI  ut  tlii^  period  in  tlie 
riglit  iliuc  fus&a,  nhout  the  sikc  and  It-n-^fh  of  ihe  fiFrefinjrer:  it 
wn£  quite  bunl,  and  t^ouUl  l>e  j^lino;:it  seized  ihrough  the  Inte^u- 
menlfi.  iind  lifti^l  u]i.  The  [iiiiu  ami  Icndemesa  were  ao  ^reut 
as  to  require  the  civcrpowt^nnir  ii*c  of  0|>iaie*  adminislcretl  hy 
cnenin. 

On  the  ihirtl  Jay,  there  waft  a  slight  evaenntiou  from  the  bow- 
els, hy  nitatirt  of  Jtri  enema;  but  t[;e  patient  shorlly  after  fell 
iuLo  a  state  of  rolhijipc,  juul  died  H.'vpn(y-four  hoiir^  after  ibe 
violent  BeiKori:'.  For  the  last  twenty-four  houra,  there  was 
the  inu^l  dir^tresaiu^  hie<;oijgh> 

An  e^tJiUL illation,  nftcr  death,  revenled  exteasive  pertloueid 
inllummatlou,     Tliere  was  very  great   induration  of  the  omen- 


icKcnosre  or  sitrtiij. 


Aed  to  be  formed  by  au  elevation  of  boaCf  tthoai  an  inch 
I,  as  if  the  tumur  hud  been  forced  out  frijiii  witliiii  the  cavity 
he  cmruim,  i^Laliiufj  the  hone  before  it.  Bj  prcaamg  rirtnly 
jn  Ihc  upper  part  el"  the  tumor,  irregular  maaaes  of  bone  could 
distingitiflhecl ;  some  of  iKem  loose,  otfaers  forming  hridjfca 
dcr  which  thcr  tluid  coiitcutd  of  the  (umor  eouhl  he  forecfl  with 
gurgling  sound.  It  was  highly  resonant  on  percuasioni  Air 
^K  uld  be  rendilv  forccxl  into  it  frum  the  noetriJet  and  the  teneion 
^H  kUs  imparled  to  it  remained  for  a  long  time ;  owing,  probably, 
^H I  the  intcrpotiition  of  a  pieee  of  loose  tjesiie^  acting  like  n  ^-cllve. 
^H^iiriDg  violent  exercise  also,  the  tumor  generally  became  inflated. 
^^  The  diagnDsifl  was  a  collection  of  pua»  bcnenth  the  occipito- 
^^rODtalid  jnui<€lc,  cotomuiticaling  with  the  froctal  ainusc^ ;  but 
^Brhether  it  onginatcil  from  periostitis,  or  from  diaeaee  of  the 
^^iploe,  or  from  a  tumor  aming  within  the  eronium,  speared 
luubtful. 

OperattoUf  Nov*  SO^A.  — The  patient  woa  etherized,  and  an 

icision   made   in   the   median   line  Inr^e  enoui'h   to  lujmit  the 

igcr,      A  quantity  of  nir  cscnpod;   nnd  tlie  finger,  which  waa 

icd  into  ihti  wound,  detcelcd  the  fuet  that  the  bone  wna  cvcry- 

rhere  in  a  carious  state.     The  incision  waa  then  extended,  and 

'O^iseil  at  right  angles  hy  another,  so  a*  to  expose  a  large  {*ur- 

Lce   of  the  diecnscd   bone.      The   whole  external   table   of  the 

■ntal  bone  was  mut^h  thickened,  and  in  proecsa  of  exfoliation. 

probe  paflAed   reatlily  into  the  frontal -situs,  and  from  thence, 

rith  bomc  man Jkgei [lent,  into  the  left  nostril.     The  patient,  on 

"vering  from  the   ttfects   of  the   ether,   was   able  to  force  air 

:cly  throuj^h  the  wound.      Blood  cecaped   alao  into  the   nnsal 

kvitJca.      The  apparent  elevation  of  bone  around  the  tumor  was 

lot  owing  to  an  expansion  of  the  outer  table  of  the  skull,  as  at 

Iriiit  supposed,  but  to  inflammatory  action  la  the  soft  piirts ;  a 

dccc|}tioii  einiilar  lo  tlidt  which  ia  often  found  to  follow  blovva  on 

the  head,  ciiuaing  nn  ap^wamuec  frequently  imposeible  lo  diatin- 

|Pgui»h  from  n  depression  of  the  bone.      In  the  present  coee,  the 

illusion  was  perfect.      A  compi>?ss  wa.s  applied  betftttn  the  lipa 

of  the  wound,  which  was  left  open  lo  favor  the  separnlion  of  the 

lecroaed  bone.    The  patient  was  immediately  relieved  from  pain, 

id  the  following  night  slept  better  than  for  six  months  before. 

7S 


his 


uiecGiXAyEous  cas&s- 


i 


'Hic  fifth  dnj  after  the  operation,  it  woa  found  poeeible  !« 
some  Urge  plalea  of  bone,  which  ncfc  eufticicnily  iiiuiabit 
taken  awaj  without  violence.     In  the  course  of  anoilier 
the   pnlicDt  went   home,  oodrely  fi-ec  ironi    piiiii,   and  m 
health:   it,  waa  thought  unnecessary  to  dctiun    hiui  longer  io 
town,  na  the  exPoiintion  of  the  carioua  bone  would  prulwblj  it^ 
quire  n  long  thiie  for  its  completion. 

A  month  or  tix  weeks  Inter,  Lc  mnde  «  second  visit  to 
when,  after  conEideriible  manipulation,  aDotlicr  loug  oni 
piece  of  hone  waA  remoreil  frtim  near  the  cetiire  of  the  os 
The  anntoniical  appeamncc  of  this  frn^ment  Ic^  to  rh*?  aiwiw 
tiun  tliat  it  might  be  mnile  itp  cf  both  lahleu  of  ihe  skulh  Jt£ 
hod  eyuiptoms  followed  ite  removal,  and  the  ^^uppiirAttois  u^| 
wound  was  much  diminished  by  itn  His  health  apponr^d  to  er 
excellent. 


«bljlt: 


He  again  canie  to  Uoston,  on  account  of  a  purulent  coUkiIa 
under  the  integuments  of  the  torehend.  Thib  being  rclieTnl  tif 
an  incision,  luo^e  bone  vv\is  again  rcmoved- 

Since  the  obure  record  nRA  made,  I  was  consulted  by  himjA; 
account  of  a  renmrkablc  de[>cbit  in  the  cellular  tlseue  in  ^| 
of  tlie  upper  extremities.  There  wa»  a  ^frent  depreciation  fl 
health,   and  u  dispositiuu  to   cerebral  dislurbnnce. 

Guthrie,  in  hi«  v^luabk  work,  "  Commeni.tries  on  the  SuraciT 
of  ^Var."  reiers  to  u  tumor  of  thl»  deseriplion,  nnd  in  prtclHlr 
the  same  situation  as  the  one  Jibove  dewnbed,  &»  follovre:— ^ 

*'  After  a  wouud  of  the  frontnl  aiaua  has  healed,  ihe  air  bav  IM 
known  to  raiAO  up  tho  intogaaioate  of  the  foreliFai]   lui^  ng  vjuik 
crGpilalLQg  Bwcltiug,  wl)ea<vi>r  iLe  pulient  bJfjw  his   nose,  so  t! 
eompre^A  imd  bftnila^e  on  the  pjirt  were  required  fur  ita  relief' 
the^  cases  ato  very  rare." 


PJUV 

I 


Case  CCUXLIX,  —  Poisoning  by  ^iiric  A^citf. 
Autopsy.  — A  negrcflfl,  34  years  of  a^,  of  abniidonoi]  ci 
ter,  thinking  ihnt   f^hc  wna   three   months  pregnant,  look 
acid  at   IJ,  I'.M.,  on  the  i3d   of  March ,  \^b\.\^  for  the  nurpo^ 
destroying  her  child.     The  quantity  taken  into  her  nioutii  wis 
reported   to   be   Siij,  hut  mo?t  of  it  was  epit  out>      Alkali 
mueilaginoua  drinks  were  used  ;  but  the  burning  in   the 


POIlOWDfG  BT 


LTC  Aom, 


579 


ms  intense  througli  the  ni^ht,  witTi  re^t]eH?<ne«x  fint)  tieliriuin. 

^he   next  morning  »lie  was  brtm^lit  from  the  jail,  where  the 

wid  waa  taken,  to   the  Iloepitol.      Yellow  i^EJiin^  were  then  ob- 

[servcil  upon  the   cluthinir,  and  the  whole  loE^iJe  of  the  mouth 

and   fiiucee,   ao   ftti'   aa   could  be  ^ee^»   wita   of  u   di^p   yeilow 

color,  the  ton^^e   looking  ua  If  twvertHi  with  Tiidian  iiipal ;   the 

^BreBpinLtion  being  jjiiinful,  labored,  and  striduloua,  ami  speech 

^fftlmo^t  imiinj^Hible.      Kxtremiciea  cold,  countenance  of  a  leaden 

^'liue  ;   pidae  120,   and  very  small.      Fur  the  first   four  or   five 

ditya   after    her    admission,    bIiq   buffered   from   fioreuesA  of  the 

mouLh  und  throsit,  dyaphugta,  thirst,  and  eollvation,  with  acme 

vomiliri;;^:   she  also  eonipliLined  of  lendernejrifl  <if  die  alnloraen, 

but  nol   particularly^  over  the  Htoniach,  walklug  with  diilicultj, 

and  beut  much   forwoj^s  ;  bet  tins  was  perhupe   owing  to  ter 

hLiVmg  been   thrown  down  und  stamped  upon,  in  an  atTray,  on 

the  daj^  on  which  the  look  the  acid.     After  the  first  day  or 

twa,  she  WBtf  much  of  the  time  up,  and  about  the  wai^;    at 

ihe  end   of  a  week,  she  was   reported   quite   comfortable,   and 

b;iving    oouie    appctiLe  ^     und,   on    the    14Lh  of  March,   aa  she 

was  doing  well,  siie  was  removed  back  ti]  the  jail,  there  never 

^■luiving  been  auy  fever,  but  ratlier  a.  state  of  dcpreasion.      On 

the  morning  of  the  ll3tb,  she  was  attacked  with  cram^js  in  the 

stomuch,  Jind  excessive  pain  and  tendernes.-^,  which  were  piirtially 

I  relieved  by  opiates;  on  tJie  following  morning,  however,  she 
wai^  found  deud  in  her  cell,  with  a  great  quantity  of  blond  in 
tlie  bed  about  her,  wliich  she  bud  apparently  vomited. 
On  dissection,  there  was  observed  great  rigidity ;  upon  the 
middle  of  the  tonj^ue  a  W^'e,  yelhiwiah,  smooUj  pateh ;  some 
redness  of  cpifrloltis  ;  (eaophagiia  healthy  for  the  firtit  two  in- 
chra,  lait,  below  this,  it  was  found  exceedingly  soft,  of  a  greenish 
yellow  color  internally,  purple  exteiTiuJly,  and  full  of  con^* 
lated  blood.  The  etuEunch  was  in  a  Bimilar,  though  much  worse 
^ shite;  externally,  it  hud  the  same  purple  color,  and  waft  univer- 
satly  adherent  to  the  neighixiring  pnrta  by  recent  lymph,  except 
[It  the  left  extreniitVi  where  there  were  old  and  close  adhesions 
to  the  spleen  i  internally,  it  was  of  a  greenish  yellow  color,  em- 
phyacmaton,i,  and  so  perfectly  soUcned  and  friable  that  it  could 
not  be  jsepnrated  froEn  the  surrounding  parts  without  giving  way 


576  UIBGELLANEOUS   GASES. 

turn,  with  firm  adliesiona,  arising  apparently  from  the  previous 
attAck,  two  years  before.  Some  purulent  matter  eecnpei]  tVum 
the  cavity  of  the  pelvia.  The  appeadix  Termiformid  woa  tounJ 
gitngrenoua.  And  pcrforitted  at  both  ends  :  in  its  central  poni<iD 
waH  contained  a  maes  of  Indurated  fecea,  aa  large  na  a  prune- 
stone-  On  section  of  thia  aubatance,  no  nucleua  could  be  dis- 
covered. 

It  is  well  known,  that  amall  shot,  apple-Beeda,  and  taHqus 
other  foreign  substances,  lodging  in  the  appendix  vermiformi^i 
will  give  rise  to  the  a1>ove  symptoms ;  though,  in  post-mortem ei- 
nmiiiationsof  persons  dying  of  other  diseaees,  these  substances  an 
often  found  there,  not  having  caused  any  disturbance  during  liie- 

Case  CCCXLVIII.  — -^ecrosw  of  Bonet  of  Skull  gitin^ 
rUe  to  a  Tumor  containing  Air,  (See  Plate  V-)  — A  man 
from  New  Hampshire  applied  to  me  for  advice  on  the  26th  of  No- 
vember, 1S61.  Four  years  before^  he  had  received  a  severe  blow 
on  tlie  forehead,  from  n  heavy  branch  of  a  tree.  Great  swelling 
ensued,  which  confined  him  to  the  house  for  a  week  or  ten  day^> 
Tiic  swelling  ^adually  subsidc^l,  leaving  a  sensation  of  dull  pain 
in  the  part,  neeompnnied,  from  time  to  time,  by  soreness  umI 
tumefaction.  In  July ^  1861,  while  at  work  in  the  hny-field,  lie 
wad  Heized  uiih  sevei'e  Ijendache,  and  other  symptoms  indicative 
of  cei-ebriil  disturbance.  Soon  nfter  this  attack,  a  tumor  ajv 
peijrcd  ox'ci"  tlie  sent  of  the  original  injury,  covering  ncurly  the 
whole  fori'hcad-  After  .i  great  deal  of  suffering,  n  discharge  of 
puA  li>i>k  ]ilace  from  the  lefl  nostril,  and  afforded  him  tempomrv 
ivlicf.  Sub?*e(|uentl_v,  the  lumnr  became  tense  n^nin,  and  wns 
opened  with  a  huioet,  wliich  gsive  vent  to  a  small  quanlitv  oi 
purulent  mattor;  a  second  oiienition  rcsnhed,  as  he  snye,  in  the 
cseitpe  iif  Mood  oztJy.  His  ^ufterings  eoiitinueil  to  increase  until 
till'  date  of  liirf  vi.<it  to  rue.  At  this  time  they  were  wo  excessive, 
jiiid  llu'  (■o]j>tilutioniil  j^viiiptiuns  iif  such  a  character,  as  ti)  IcjuI 
Iniii  to  tlie  <*(in\ii'ti()ii  tljjit  hi^  ciise  was  altogether  liopi'Ie.^i^i, 

Tin;  whdie  fiiri'hojul  was  ocrujued  by  an  elastic  swcllinir,  ''I 
thi:  sixe  of  h;ilf  <jf  u  larj^^c  oran^'o,  [larlially  divided  in  the  ceiiiro 
\tv  a  veilit'al  dqire.'isiim-  <'!iiisrd  ii|i]>anMitly  liy  the  tendon  <»f  tlif 
uccijjilo-fruntalis   mujsclc-       Tlie   marginal    baae   of    the    rumor 


582  ifiBCELi.urEOus  cases. 

duemse  is  nio«t  freqaently  found  ia  penom  wlioee  oocnpation 
produces   m  great  Btnun  on  ihe  joials,  anch  aa   blaclciumthSf 
I'  fltone-cotterft ;  «lao  in  wa^ierwomen,  being  Gansed  by  twudng 

I  cIoCheB.     It  occon  in  the  uikle  as  well  as  in  the  wrist  jointa. 

I  ^nie  disease  yields  to  treatment  in  about  ten  or  fourteen  days, 

I  as  in  the  present  case ;  no  pain  or  crepitation  being  perceptible 

aft«r  a  fottnigbt. 


Case  OCCLII-  —  J^injki  Orepttaiiott,  of  Tendons,  —  A 
woman  emplojed  in  wringing  out  clothes  was  eozed  with  a 
i«Tere  p«n  in  the  back  put  of  the  arm,  near  the  wnst,  which 
became  swoUen.  J  saw  her  on  the  following  day.  A  swell- 
ing and  redness  then  extended  up  the  arm  toward  the  elbow-* 
joint,  very  paiuful  to  the  touch,  and  on  motion-  On  rotating 
and  flexing  the  hand  and  fore-arm,  the  fingers  being  on  the 
injured  part,  the  peculiar  sound  alluded  to  was  perc^ved.  It 
was  perfectly  dry  crefutus,  which  at  first  nught  be  mistaken 
for  that  of  a  fiw^ured  bone  by  one  who  for  the  first  time  ob- 
served it.     In  those  cases  where  the  accident  had  occurred  to 

I  the  long  head  of  the  Incepa,  it  had  been  mistaken  fi>r  a  fracture 

fi  of  Ae  neck  of  the  humerus. 

J  The  symptoms  lasted  about  fourteen  days,  and  yielded  to  rest 

m  and  antiphlogistic  remedies, 

I  This  affection  I  have  not  seen  described  in  any  of  the  Eng- 

lish surgical  worka:  it  has  been  treated  of  by  Velpeau  under 

.■  the  name  of  "Crepitation  Douleureuae  dea  Tendons,"  and  is  a 

I  disease  of  some  practical  interest. 

jl  Partial  Rupture  of  the  Tendos  of  the  Quadeiceps 

Extensor  Fehoris  Muscle, — The  complete  rupture  of  this 
muacle,  or  rather  of  its  tendon,  is  at  once  so  patent,  frotn  its 
eymptome,  that  there  is  no  mietoklng  the  nature  of  the  treatment 

'  to  be  pursued,  and  a  coae  of  It  hna  already  been  given  above. 

}  Purtinl  rupture,  however,  of  this  tendon  near  the  patella  is  of^en 

at  firaC  not  marked  by  any  Bymptoms  whatever,  or  else  by  signs 
so  obscure  as  to  make  it  very  difHcult  to  determine  the  true 
nature  of  the  accident.  Aa  instances  of  this  accident,  I  would 
uiention  the  following  cnscB  :  — 


PAHTIAL   RCTTDBE  OF  TENDON. 


58a 


I 


Case  CCCLIII-  —  A  gcntlemim  tibout  65  ycara  of  n^, 
[of  lurgc  and  powerful  f'rcmc,  npplicd  to  roc  un  the  2\)X\\  of 
Kovcmbcr,  l^Gl,  on  nccount  of  A  lamenese  of  the  right  knee, 
of  which  he  gavG  the  fullawin^;^  account.  Uelwcen  one  nnd  two 
yonra  before,  while  kneeling  on  the  ?nnd  hy  the  seashore,  he  felt 
a  ButlJcn  pibin  shoot  through  hja  knee.  No  symptoms  of  anj 
coneeqnetiee  followed  until  three  months  after,  when  he  liegon 
to  be  A  little  Inme.  There  wiis  fiorencsB  iibout  the  knee,  some 
ali|^ht  ilifHcijity  in  extending  the  le^,  and  in  goin*^  up  fin<l  down 
iBtairfi.  The  limb  wne  rubbed  in  the  ufiunl  wny  with  limmenla, 
Ac.,  but  without  marked  etfeei,  Ae  time  went  on,  neundgic 
pnina  tvere  felt  in  diHerent  partjj  of  the  limb,  both  in  the  thigh 
and  leg,  and  the  litnb  beenme  obvioualy  more  tinbby  and  emnller 
thnn  it^  fellow.  On  e^inmintn^  the  knee,  I  at  onee  di^eovered, 
just  iihovc  the  pittelk,  t\  di^tinet  depreasion  or  ti^^ure,  about  nn 
inch  long»  in  the  cxtcneor  tendon,  and  penetrating,  as  it  ap- 
peared, through  nbout  hnlf  ita  eubalnnce.  At  (his  puint,  thet^ 
was  a  little  rcflnei^a  of  the  skin,  and  a  puDinesa  not  to  be  dk^ 
tingui^hed  above  (he  other  knee.  The  mti^lca  both  of  the 
thigh  and  le^  were  quite  aotl,  and  measured  one  inch  leaa  in 
circumference  than  its  fellow.  I  advised  the  patient  to  wear  a 
leather  Inecd  stocking  CAtending  from  the  nnklc  to  tlie  hip,  and 
fitted  acciimtely  to  the  limbi  to  use  a  cnne  in  walking,  and  to 
fitand  OS  little  i\&  poj^^ible  ;  hIbo  to  employ  bnthing  and  IViotlon:^, 
In  enee  of  nn  iiggravation  of  tiie  symptoms,  I  nUo  otlvii^ed  Ikiin 
lo  do  what  he  now  altogether  refused,  — to  have  a  splint  up- 
plied,  and  to  keep  perfectly  at  rc&t.  I  was  ;;lad  to  find  after- 
Wfli^da,  that  my  diagnosis  waa  confirmed  by  Frofesaor  Willord 
Parker  of  New  York,  who  hod  previously  eifimined  the  eofle, 


Cape  CCCLIV. — .Several  years  sinec.  a  young  gentleman 
was  seen,  in  consnllrttion,  by  Dr.  J.  C  Wnrrcn  and  myself,  to- 
gether «rjth  the  phy^ieinn  of  the  patient,  on  account  of  un  neci- 
dent  to  the  knee,  which  had  uccnrrod  siT  months)  or  a  veaf 
Ix'fore.  In  making  some  violent  etfort,  n  slight  ernek  was  felt 
in  the  neighborhood  of  chc  Joint,  followc<l  by  some  lameness  and 
temlerness.  At  the  time,  nrxhing  eould  lie  didtinguialied  upon 
examination.     Vorioiis  iijctbods  of  treatment  were  tried  wilhuut 


5H 


AnSCELLAKEOrrS  CABBB- 


effect,  nn<l  tlie  patient,  becoming  ^frfwlually  liitner,  was  brouj 
to  Bofitim  for  advice.  A  very  careful  inspoction  of  ilie 
uLiout  i\k  knee  revedcd  n  «m;ill  li^aure,  wlacli  was  dUtiootlv 
felt  in  tlie  edge  of  the  tenrlon  nc;Lr  the  pnlfll^,  qiiiiu  slmrp,  and 
evideudy  showing  thut  tlie  tendmoiu  fit^re^  h^  bceu  rupturv"! 
at  tliDt  point.  The  pnlieni  wna  advised  to  try  perfect  t**i  tor 
the  ]irnl»,  to  have  n  hiim-ApliMt  applied,  eontinuiii^  the  Crcntiuent 
for  flt  least  lliroe  nioiitha.  ThU  wns  fuithfully  done  for  betvree^ 
three  and  fuur  months,  and  resulted  Id  n  perfect  cure.  ^M 

As   I   now  Btute  ihia  cnse   froin   reoollociion,  I    am  tinnbU  to 
give  with  Jiatinoitiesa  dl  the  incidents  in  it ;  but  the  t»ci  of 
rupture  and  the  result  of  ihe  creshtuicnt  are  undoubtccli 

nilJKOPHOBIA. 

Cash  CCCLV.  — Hydropkohh.  D^nth.  —  Tlie  tbllowm^ 
account  wnA  principally  written  from  data  fumishetl  by  Dr.  J- 
Stejims,  then  hoiiae-surgeon  to  the  Massachusetts  General  Hos- 
pital, who  tof>lc  much  irterest  in  investigating  the  fiitts  of  the 
caae.  The  patient  was  u  male  rliild,  hy  name  Patrick  Murphy, 
three  years  of  age,  living  in  BoHtun,  and  was  brought  itklo  t^^ 
Hogpital  on  June  2^,   1)^59.  ^^ 

Five  weeks  before,  he  was  bitten  by  a  dog  six  or  ei^ht  months 
oM.  The  animal  was  not  thought  to  be  rabid  by  the  bysiei 
ers;  altliougli,  on  the  eoine  day,  he  had  "snapped  ui 
slightly  bitten  **  a  man,  as  was  tliouglit,  from  play^lneea, 
litFle  boy  had  a  eniekcr  in  \\\a  hand,  which  the  dog  ^tlc!tnpli^  to 
fleiac,  tnking  into  his  mouth  with  it  the  whole  of  th<;  right  hnni 
nnd  inHicIing  a  wound  on  each  ^ide  of  tlie  wrist.  The  won 
on  liie  anttsrior  surf:icc,  was  frinn  hulf  to  two-thirUs  of  un  \i 
ill  length;  that  on  tlie  cj[tpo^itc  side  wna  likij  llie  iiturk  from 
simple  punciure.  Tlie  wounds  were  treated  hy  a  siir^on,  who 
cauterized  them  nut  long  nfter  the  injury,  ami  oi-dereU  a.  poultu3^| 
There  was  no  further  treatment  used.  They  were  verv  s<»re.  for 
a  time,  pnrticiiUrly  the  one  in  front;  but  the  ehiJd  continued  u 
well  as  usual  in  his  geneiiil  lienlth,  and  nothing  remarkable  oc- 
curred rill  a  week  before  his  admission  to  tlie  Hoi^pital. 

At  chijj  time,  the  mother'ti  ntteulion  was  drawn   to   tb 


nuts 

I 
.1 


HTTJEOPHOBIA, 


565 


^ 


by  wlittt  sbe  cnllerl  a  "  dulneas  ''  conaing  over  him,  fiilloweil  hy 
&  "  aiHinea^  ami  li^tles^nejia."  Four  days  Ijcfm'e  Wa  enLru.n(;e  to 
tliti  TLigpitLLl  wii^  tire  fir^t  onset  (jf  the  (iiiroxyaiiis,  whkli  wsvc 
dcACribci)  ua  haviii*^  beca  faults  fonniJable  :  they  were  eapcmuUy 
\iolciit  when  witter  wna  bruiight  ueiir  liiiii»  oo  that  the  nuitlier 
was  i>blige[l  to  give  uji  waabing^  the  cliiM.  He  manifesteU  a 
desire  t<i  tttke  fooil  nnil  drmk  from  hla  mother,  tliough,  on  atr 
tempting  til  swallow,  he  wa^  quite  unuble  to  eAtfCt  It.  For  this 
reuflon,  he  touk  eciircely  any  DOurUhjDcat  for  four  Jaya  bcfor? 
Le  was  brought  into  the  Hospital-  The  pieceJing  facts  were 
principally  obtmnett  from  the  parents  of  the  cliilj. 

On  hi3  entnince  uito  tlie  hou^e,  he  wria  in  a  liiglily  exciteJ 
GoDditioii,  torislng  lijs  ii^al,  linJ  tijrowlni^  about  bis  linibti  in 
every  dlreiitioii.  Hi?  spit  violently,  or  attempted  to  do  eo,  as 
if  bis  mouth  waa  full  of  fenthers  ;  occasionally  crying  out  or 
snapping  at  those  about  him*  saying  that  he  vvlahed  to  bite 
tbcm,  and  they  nniet  get  out  of  hid  way.  Ilia  eyea  were  very 
bright,  his  faee  pale,  and  there  waa  a  Hvidity  about  the  eyelids, 
and  generally  over  ihe  whole  surface,  with  a  quivcnng  of  the 
lipa  JLud  mUHck-a  of  ihc  fuce,  and  eonataoC  ti'enior  of  tlie  whole 
body.  On  tiikiiigp  a  doae  of  morphine,  he  was  quictcil,  and  the 
Tiurae  prevniled  on  him  to  swallow  some  niilk  from  a  mug. 
Afler  a  time,  he  drank  a  whole  mugful,  itEid  ate  a  duinll  piece 
cf  ciikc.  His  manner  of  taking  the  milk  was  not  as  If  he  hud 
any  aversion  to  itt  but  from  apparent  consclousneas  of  the 
cffbrr  necessary  to  swallow,  lie  elutchcd  violently  nt  the  mug, 
with  eyeballs  starting  out,  and  the  whole  frame  undergoing  the 
grealeai  agitation.  The  effort  of  avvdlowing  vvns  attended  with 
Q  sense  o?  suffocation*  and  the  corners  of  the  mouth  were 
fitnjngly  rctmcteJ.  He  exhibited  the  same  eymptomo  on  taking 
cake;  mid,  from  his  great  desire  for  both,  jippcared  to  be  suffer- 
ing niueh  from  hunger.  A  viscid  di*cljarge  Uwk  place  from  the 
mouth*  Tlie  urine  waa  paased  iii  great  abundance  through 
the  al^ernoon  and  evening. 

He  gradually  became  quite  calm,  through  tbe  great  attentions 

of  tile  nurse,  nbo   seemed  to  inspire  him  with  confidence,  und 

'ent  to  bed  with  him  in  her  arms,  in  apite  of  the  remonatrancea 

of  those  about  her.     He  talked  ineesaoiitly  and  incoherently, 

7* 


586  UleCEUUANEOUS  CASES. 

though  At  timee  he  could  be  understood.  He  eeemcd  to  Appre- 
ciate much  the  kiudncBB  of  the  DurBe,  find  told  her  he  should 
bite  her ;  but,  when  she  put  out  her  arm  to  hini,  he  kiMed  and 
stroked  it.  He  had  several  paroxysms  af^er  HIb  entruKc, 
with  intervals  of  comparative  quiet;  the  attacks  being  toAjd 
short  duratioUf  lasting  about  five  minutes  each.  He  becanie 
weaker  as  the  night  advanced,  and,  at  half  poet  3,  a.m.,  died  in 
one  of  the  convulsive  attacks. 

No  examination  of  the  body  could  be  obtained. 

Dr.  Steams,  at  my  request,  visited  ^e  haiise  at  which  ibe 
child  had  resided,  for  the  purpose  of  obtaining  eome  more  ftctt 
in  regard  to  the  case,  but  did  not  elicit  any  thing  of  importann 
beyond  the  preceding.  He  saw  the  wife  of  the  man  who  w 
bitten  on  the  same  dny  with  the  little  boy :  the  bite  n^as  said  to 
be  a  very  slight  one,  on  the  joint  of  one  finger,  and  no  blood 
came  from  it.  The  man  promised  to  be  at  the  Hospital  on  tbe 
following  day  for  me  to  examine  it,  but,  for  some  reason,  ^ 
not  appear.  The  dog  was  drowned,  and  Dr.  Stew^is  conU 
get  DO  further  history  of  it,  A  superstition  existed  with  them, 
—  of  which  they  informed  him,  —  that,  if  the  dog  could  imn 
been  killed  by  one  of  the  family,  the  patient  would  have  e»- 
caped ;  also,  that,  if  the  liver  of  the  dog  could  have  bsfn 
applied  to  the  wound,  the  effect  would  have  been  equnlEr 
eflictcnt,  which,  of  course,  naturally  implied  the  death  of  the 
dog. 

In  connection  with  this  case  of  hydrophobia,  I  would  remark, 
that,  about  fifteen  or  twenty  years  since,  I  proposed,  at  a  meet- 
ing of  a  society,  for  the  purpose  of  obtaining  information,  the 
question  wliether  any  case  of  hydrophobia  had  ever  occurred  m 
Boijton,  or  wliether  tlicre  was  any  tradition  of  one  in  the  New- 
England  States ;  but  no  answer  was  elicited  in  the  affimai- 
tive* 

The  first  case  reported  in  Boston  appears  to  be  that  of  Dr. 
Coiiie,  in  October,  1848,  which  was  followed,  shortly  afterwanl. 
by  that  of  Dr,  Curtis,  in  LowcU,  supposed  to  have  been  caused 
by  the  same  dog,  wliich  had  escaped  from  Boston,  and  made  li"; 
way  to  the  latter  city.  This  was  followed  by  other  cases  lu 
various  directions,   running  through  a  course   of  two   ur  thnK 


HYDROPHOBIA. 


587 


yeftrfl^  darmjj  which  time  I  saw,  in  Ronsultaiion  in  Brooklice,  a 
patient  of  Dr.  Wild,  and  ihe  co^e  of  a  child  brought  into  the 

^HoepJtn]  within  twclvo  hours  after  having  been  hiiten,  where 
the  parts  were  freely  oauleriaeJ  a.t  the  tinio,  and,  within  twenly- 

^four  hours  from  the  time  of  the  ixccideni,  cut  out  by  Dr.  Cabot. 

y  This  piitient  returned  hrjine  vvidnTi  t'jur  weeks,  ftpparenlly  per- 
fectly well;  butf  by  the  expimtiun  of  i;noth&r  week,  the  digcAse 
ap[>eanjd,  and  she  waa  returned  to  the  HoapitniT  with  nil  the 

I      Bympioms  siniilnr  to  those  detailed  iibove. 

^fe     All  the^  pniioEitA  died,  &ftor  three  or  four  dnys'  illness;  the 

"atlnck  corning  on  in  nn  average  of  about  Sve  weeks  from  the 

[^receipt  of  the  injury. 

^P  Ai^f  that  pedod,  the  contagion,  if  it  may  be  so  called,  or 
inoculation,  seemed  to  have  exhausted  itself;  and  but  few  cases 
were  recorded  until  1859,  whi?ii  rumors  began  to  be  heard  of 
its  re-jiHppearance,  I  have  constantly  had  persons  call  to  eonanlt 
me  with  very  severe  bites  from  dogs ;  but,  not  finding  from  them 
that   the   nnimnls   had  shown  any  signs   of  rabie*,  I  hare  not 

»  thought  it  wari'iinlablo  to  apply  so  severe  a  remedy  as  cauteriza- 
tion or  excision  to  an  accident  bo  common.  When  rabies  is 
actually  present  amon^:  the  canine  race,  I  should  feel  mj-aeif 
called  upon  to  make  a  thorough  nppliciition  of  the  nitrate  of 
silver  to  the  wound,  as  recooimeuded  by  Mr.  Youatt,  who  oon- 
siderod  this  remedy  as  almost  infallible,  if  applied  immediately ; 

I'  and  who.  from  his  linhllily  to  be  bitteni  alvvavs  carried  a  piece 
of  cansLJC  in  hi4  pocket,  and  had  many  Times  made  use  of  it  with 
effect  on  his  own  person;  or,  if  circumstaocea  required,  free 
excision  should  be  made  of  the  injured  part. 
The  following  remarks  of  Mr.  Yfmatt  are  of  so  much  value, 
that  I  have  extracted  them  at  soine  lennth  :  — 


^: 


Tlie  wound  sliould  he  thumuglily  waslied  and  ol^ianwd  a*  HOim  bj^ 
piK^aiblt:  a^W  thti  bite  la  inHii^ied  :  no  auckirg  of  tlie  part»,  an  n  ad- 
vised bj  many,  for  die  purpose  of  eitraotiug  the  jxiiaon,  aa  iho  proi- 
Ittnoe  of  ft  smnll  abrasiun  of  Ihc  llpi  or  interior  of  the  mouth  would, 
mo^t  osscirciUy,  aitbject  ibc  y»arls  to  inoculalion.      If  the  wounri  be 

Ira^j^J.  Ihe  eilge*  mny  be  tnkoii  off  with  a  pair  of  pharp  aciflaor* :  the 
wound  mu»Jt  tJi?n  hti  iUorou^Uiy  caulerizvil  with  nitrate  of  silver  (lunitr 
eaasiic),  being  sure  to  intnxlnce  the  cauwiic  into  tJiB  very  deptb-*  of  The 
[ : 


588 


mSCELZ^NZOUS    CASES. 


wounds  io  thut  U  will  reach  ever^  particle  of  pol<oo  lint  ere 
iDBmuHltfd  ilFPlf  into  Ibe  flesh.  If  (he  wound  ja  too  smill  id  mk 
the  stick  of  chubIic,  it  uia^  be  enlur^d  bj  tJie  kntfe  ^  lathif  fit. 
ever,  not  to  carry  llie  jioiEon  into  ihe  fre^L  cut,  which  c«n  Ix  »«£' 
wiping  the  knjfe  al  «uch  incision.  Should  ihe  iround  LeiE>^:t:| 
of  Ibe  \mhfit  a  InnJage  maj  be  placed  around  it  dun'ng  ibe  f^i 
of  (htpe  rcni^dicH,  the  more  effeclually  to  prevent  ihe  abMrpiii»J3| 
veiDfi-  Nitrate  of  silver  is  a  mo^t  powerful  neulmltzer  (I'inil 
poisoup,  and  the  affV-cled  ports  will  soon  come  away  wjili  iht  slnai  ?1 
droseingB  bving  rccestarj,  except  perhaps  olive  oil,  if  tkere  ^'1 
much  inflaminntion  of  Ihe  parity  If  the  above  plan  be  parnrt^ 
])alient  need  be  under  no  apprebenaion  aa  to  the  result^  bvi  biUj] 
miad  perTeclly  eaaj  on  the  poinL" 


A  questioD  haa  been  freqtiently  aaked,  whether  tbe«  ^ 
toma  might  not  be  of  a  tetanic  character,  froui  the  irritttke" 
the  wound.  There  haa  not  been  the  slightest  nppearai]ceolt>' 
tnus,  or  locked-jnw,  in  any  of  the  caaes  I  have  aeen;  lodn" 
lapae  of  lime  from  the  receipt  of  the  wound  hasbrtu^' 
long  to  be  attributed  to  such  a  cauae,  the  wounde  btk 
healed,  and,  for  the  most  part,  having  abown  little  oigitt  ^ 
irniation. 

When  writing  this,  I  hod  a  cnae  of  triamua,  or  locked-nv.t 
the  Hospital,  which,  nlthongh  not  severe,    affotxled  an  oppa- 
tuiiily  of  conipat^ing  this   rare  disease  with   hvdrophobia.    'i-- 
pationt  was   il   wi^mnn,  45   vcara   of  age,  in    quite  "tuxl  he^ht. 
upon  uhom  a  lurgo  pjiitik  feli,  producing  a  compound  fracture, 
and  dij^Jof'atinn  of   the   anktc-joint,      I   saw    her   nbout  hnir  ^ 
hour   after   flic  receipt  of  the  injury:    the   lower   c.-^tremiiv  '■■ 
the  tibia  pny\?<'(e<l  through   a  hirgc  wuund   at    the   Bnkle-j":::^ 
the  internal  tuallcolus  being  broken   off,  and   left   in   the  u-ounu- 
Thia  1  removed  with  a  knife,  r<o  as  to  allow  the   dtj^looateil  b(^^--- 
to  l>e  rost<»red  to  \U   proper  pbiec,  uitli  the    iiopt-,  in   the  iir>: 
view  of  the  ea;^",  of  saving  the  limb.      On  further  oxanjinnti^m, 
h<)\vevcr,  wbeii   cho   rcr^toratiiui   iif  tJie   bone  nilowe*!  •.►f  a  uv^t^ 
full   invci^tigatii-n  of  tlie  juinC,  I   found   the  injury   of  the  lil-i^ 
to  be  cnmjfiicated  witli  a  ctjiuniinnted  fracture  of  the  ti'jula   souk' 
piceoa  of  which  lay  loo,-^c  in  the   jifint.      Anolhi_'r  fraolmo  of  tl  t 
tihuhi  nUo  exiatcilf  abtJuC   h:tlf-way  up  the   limb.       Aii)Liuiau<-j[^ 


HTDHOPHOBIA. 


fjgO 


of  the  leg  was,  therefore,  reacrled  to  by  tlie  double  llnp,  just 
obove  iho  upper  frin^tiire,  in  wliut  rippenred  lo  be  sound  j>nrt#- 

Althtnifrh  every  thing  Beemcd  to  be  favomble  for  union  by 
tlie  first  intenfton,  jet  tbe  u'inmd  pnrtiidly  siippnrntwi.  nnd  tooV 
on  SI  sloughy  n[>penriin<*e  ;  the  viinl  powers  of  rhe  tissuea  having 
pi'ohiibly  been  injured  by  tlie  blow^  Tillhou^h  t\ns^  iil  the  tinie, 
wxa  not  oppflrent.  The  pntient^  hoi,vever,  complained  of  little 
or  no  p^in,  but  seemed  to  be  qnirc  cnniforlTible  nni]  in  gnod 
spirits^  thongh  witb  little  npiM-tiJe  :  sbe  lind  no  levpr,  and  no 
other  s^mplom.q  of  const!  till  ion  nt  [rriFaltoii. 

On  June  30th,  when  I  visits]  lit'f  ill  tbe  morning,  shi?  tohl 
me  that  Uec  jnwa  were  fltifif,  nnd  fihe  euiild  only  open  them 
nbout  n  qnaner  of  nn  inch,  bv  tnking  hold  of  ihem  with  her 
hnnds.  She  said  tlint  *he  ha^l  felt  some  soreness  in  her  jaws  for 
nbout  four  days,  huL  Ijnd  not  thuuirbt  it  cf  eii(!^cicnt  iinpoil- 
anee  to  mention.  I  euspecied  the  nature  of  tbe  di^ea^e,  and 
roijuested  Dr.  Stearns  to  keep  a  close  watdi  upon  her,  nnd 
inform  me  if  any  thing  unit^unl  OL"c*uri'cd  :  I  also  enwmraged 
her  to  take  a  more  Fitimulatlug  diet.  She  herMilf  Virus  uot 
advised  of  our  suspicions. 

[n  the  afternoon,  ahe  was^  j^uddenly  taken  wilh  uligbt  tetanic 
ini!*,  greut  difficulty  of  breaihin^,  and  coldness  of  the  ex- 
tremities' stimnlants  were  administered,  hot  npplicntion^  ^nd 
olher  external  remedies  used  ;  and,  when  T  saw  lier  abuut  ll, 
l\M,,  she  was  iii  a  very  comfor(at>le  cundition.  Her  jnws^  at 
this  dine,  had  to  be  piied  upen  to  ijitmduce  any  thing.  I 
ordered  a  drachm  of  tlie  sululiou  of  Lhc  sulphate  of  morphia 
to  be  jidministereil  every  three  or  four  hourf>,  and  ns  tiiueh  brandy 
to  be  given  as  **he  was  disptisetl  to  rake. 

She  pa^swl  a  very  <iuiet  night  under  the  treatniefit  dlit^eied, 
and,  on  tlie  following  day,  prononni^ed  herself  inueb  relievi^l : 
the  stump  was  su|>punLting  fri.'cly,  and  gave  her  no  pahi- 

The  mental  condition  of  this  patient  and  of  the  one  with  hy* 
drophobin,  ii  will  be  pereeival,  were  strikingly  diJTerenL  The 
ler  was  juTfet/lly  calm  tind  coliectwtt  the  pulse  not  imich 
!ted,  being  ralber  below  than  abme  tlie  natural  standard: 
the  latter  scuu-deliiioue,  agitated)  anj  violent;  the  pulse  very 
rapid.  To  a  person  who  has  seen  the  two  diseaficf;,  a  nii^^tnkc  in 
the  dl^ignoSLH  id  nut  easy. 


S90 


1119CEI.I.ATrEOCa  OASES. 


EXTRACTION    OF   KEEDLBS. 


Th, 


.11< 


'liicli    hf 


LteO 


n<!eiiiea  wiiicii  nti\c  penef 
parte  of  the  hmly  ts  nut  un  uniiiijioiluDt  part  of  t^ursGTV.  A* 
a  rule,  it  is  better  never  to  nltempt  ah  opertLCioD  unices  the 
neoiUe  can  lie  illstinctly  fph.  Even  t]i<n,  after  the  Aret  irkdaiafl 
if  [t  JH  not  immei]iMttly  eipusttl,  the  traL-Ks  of  it  are  apt  lO^i. 
limt.  and  tlie  aejiix^j  tedious.  Where  the  openition  fails  to  i^^ 
close  lit  by  tbc  ap^jlJcnllon  of  a  poullicc  bringiug  rhe  wo^| 
into  n  ^uppiiniling  etale*  the  cjiscoloreil  i^ee^lle,  in  ihe  f^nrw 
of  a  few  (]:iv^.  often  nutkeK  its  a,p[FennLiice ;  arul  X  i!o  not  ^ 
iDemLcr,  in  mv  own  pniclice,  anj  instojice  of  injtirv  ta  ^| 
patient  from  dduy  ULider  tlic  uhuve  ci re uiu^ Cancel,  %vherf*BS  gmf 
liu.rm  tu;iv  be  di^ne  by  an  unu^vailiti^jr  ^carcli  ainun^  delimte  and 
ftcnaitlve  teiturea;  fbr  iikMance,  the  palm  of  the  Laud,  the  ^^U 
of  the  foot,  I  propose  to  give  a  few  cases  of  (he  results  of 
needles  penetruling  the  koee-Joiut,  a  number  i>f  v^'^liicli  lutv 
come  under  my  obaervatiun  «  theae  bemgt  on  tlic  wliole,  thfl 
most  enilKirnissing  of  nnj  of  this  class  of  cases  that  w«  hfti 
deal  wilL^  and  the  kntfe-joiut  bein^*^  more  ex^xised  than  am 
the  jonits  to  tljis  kind  of  injury.  It  will  lie  observeil,  tliai 
three  out  of  tlie  four  cjises  given  below,  the  needle  broke, 
in  the  joint,  after  having  been  fixed  in  the  bone. 


Case  CCCLVT,  — -*Vee<^/f  iivnctraling  ihn  TTrtee-jotnl^ 
Ilemauted  Ji£€d  hHwttii  Coitdiflcjt,  —  Feb-  l,t,  1K54,  &  ehiH 
of  scrofulous  inibitf  five  or  six  years  old.  whih*  kneclinj  on 
the  iloor,  Imd  n  needle  larger  than  the  onlinarv  darnij»^*needU 
penetrate,  imd  break  off  in  the  knee-joiilt.  Being  called  to^| 
tills  child,  hi  conaultiitlon.  I  fifund  thiit  a  small  aperture  cottIT 
be  dUlinguishcd  below  and  to  the  inside  of  the  [mtclln.  The  Itg 
was  flexed  on  the  thigh,  and  Bxcd  in  that  [lomtion  so  tliai  it  could 
not  be  cxlendedn  The  needle  seemed  to  have  pencimCe<l  b^ 
tween  the  condyles  of  the  femur,  lo  have  become  IiAec]  there, 
and  to  be  broken  off  in  the  joint,  as  nothing  could  be  felt  of 
it  externally.  I  advised  tliat  a  dissection  ehoidd  be  mnde  aa 
as  the  capsule,  but  to  abstain  from  goin^  iurtlier  unlesR 
needle  could  then  be  detected. 


BXTRACTTOW  Or  WTlKDIiEB, 


5S1 


This  wj^s  (lone,  but  nothing  found-  The  question  ihen  arose, 
whether  the  limh  sHonld  l)e  left  in  The  }>osilkin  in  wJilcli  it  was 
fixed-  1  ndvif^ed  Pirung  flexion  iind  exieiieinn  lo  be  made,  bo 
that,  ID  case  the  body  were  lodged  m  the  way  eupposed,  it 
might  eilher  Jje  dislodged,  or  else  plout^b  up  for  itself  ii  cavity 
in  the  cariilagc  of  the  bend  of  ihc  Tihia.  By  these  meanuresi 
the  TDOtiona  of  the  limb  »erc  restored.  The  cbiM  wum  tept 
perfeeily  qiiiel  for  n  few  weekn,  tinril  all  itiflnniiTiutiJry  eymptoma 
hiid  eiib^ided ;  .il^er  which,  he  wnlked  alutit  without  ineon- 
venience. 

This  pjLlient  died  uf  phthisiH  Home  jeara  after  tht^  Occident ; 
and.  on  exiiiiiination  of  ihe  knee-juiiit,  the  following  whs  the 
appennint-e :  Tlie  needle,  nn  had  heeii  RUppused,  was  finnly 
lodged  between  the  condyles  of  the  femur.  It  wau  eomewhiiE 
corrirflcd ;  niit].  fmrn  the  motions  of  the  joint,  it  hml  worn  and 
nrainUined  for  it»e]f  ii  passage,  no  as  not  to  interfere  with  flex- 
ion or  extension.      Tbe  joint  itself  vras  otherwise  healthy. 

Case  CCCLVII.  —  A^^eille  jiefitlratintf  KuPt'-jolyU.  Fnn- 
goits  Growth ^rom  Wound.  Hecotjfrrjf. — A  child  six  years 
old  ran  a  needle  into  the  knee-joint,  In  llie  Hiiinmer  of  18r>.3. 
It  was  imunKiijitely  withdmwn;  and  tbe  child,  not  suffering 
any  pain,  was  allowed  to  use  the  limb.  A  few  diiye  nfter, 
severe  inflammaTion  came  on  in  tbe  wound,  and  n  fungus  shot 
out.  At  [his  [jeriotl,  1  was  called  to  see  the  patient.  Tbe 
joint  wufl  found  to  be  in  a  \ery  tender  and  iiiHained  eonditiun. 
On  flexion,  a  quantity  of  pa»  ran  from  tbe  wound,  wbiob  was 
Hurrtiundeil  by  n  fnngua  of  the  size  of  a  fivr-cert  piece.  Entire 
refit,  with  a  tiplint.  wan  enjoined^  and  the  fungus  wor  touebed 
with  caitt^tic;  criui^ing  a.t  eneh  fipplication  an  inerense  of  in- 
flammatory trouble.  Afler  four  or  five  weeka  of  treatment, 
the  case  finally  fenninJiIcd  ravi>rably.  Tlie  needle  liad  entered 
just  on  ihe  inner  Hide  nf  the  ligament  of  the  patella. 


Cask  CCCLVIII,  —  .Vee^Z/e  broken  of  tn  Joint.  Fixrd 
in  Jione^  Rtmmnd  by  OjR'.nrtion. — Tliiw  instance  was  ob- 
served in  a  cbilU  of  five  years.  Kneeling  down  on  the  floor  in 
front  of  a  bureau^  to  get  sometlnng  fponi  underaeatb  it,  a  needle. 


592 


HiSCEXLANEOUa    CAflEfl. 


which  had  been  engaged  in  the  carpet,  ran  into  die  jusltl 
broke  off-  When  aeen  by  mc  with  her  physician.  Dr.  Mk 
limb  was  painful  on  motion,  eomewhat  swollen,  and  ^^-^ 
unable  to  walk.  By  making  strong  fiexion,  a  hard  9a]ffLD 
could  be  felt  below  the  patella,  on  the  inside  of  the  joint,  gi^z: 
to  the  touch  the  sensation  of  aome  larj^e  bodj  like  a  nul- 

The  patient  being  etherized,  a  disdection  waa  made  dnx' 
the  akin  and  fat,  until  what  appeared  to  be  the  capBuk  ai^ 
joint  was  reached.  Within  this,  the  foreign  Bubettoce  t 
felt,  firmly  embedded.  The  naila  of  the  two  forefiogtrtw' 
pressed  agaiost  it  on  each  side,  causing  it  to  pntject  thmg^i 
capsule,  when  it  was  seized  by  the  forcepa.  It  was  no«1ov 
quite  JifHcult  to  extract ;  and  this  wna  only  done  after  a  Tond 
of  efforts,  and  by  working  it  laterally,  thua  disengaging  ii  tr 
the  bone.  A  aplint  was  directed,  with  applications  of  <i 
water,  and  care  in  diet ;  her  physician  promiaing  to  gire  infon 
tion  if  any  symptoms  requiring  attention  should  present  dx 
selves. 

The  patient  did  well. 


■ 


Case  CCCLIX.  —  ^terf^e  broJcen   off  in    Knce-joiiUi 
fixed  in  Bone,      Extraction.     In  January,  1867,  I  yvt9<t 

in  the  evcnin*^  to  see  a  young  lady,  15  years  of  age,  who.  iJ 
himrs  bcfine,  while  kneolmj;  on  the  carpet  \vitii  a  child  in 
annj<,  felt  ij^omotliing  penetrate  her  knee.  She  imiiiedU 
examined,  and  withdrew  through  her  clothes  two-thiixU  ^ 
coininuii-sized  nccille.  She  was  able  to  walk  up  stairs,  lin> 
Bonienhat  lame.  When  I  ?aw  her,  with  her  phvsiciun. 
detected  a  smull  puncture,  atiiTounded  by  an  ecchviuo^U  In 
anil  on  the  inner  side  of  the  |iatelia.  On  Ji  careful  cxaiiiina 
willi  tlic  fin^jor,  a  liai'd  snbstanee  could  be  detected  like  the 
tion  of  a  needle,  whirh  varied  its  position  acconlin"  to 
motions  iA'  the  joint.  It  i:onld  not,  however,  be  made  nr 
nont.  Tiie  prohability  wii?^,  that  it  hjid  penetrated  the  boiic. 
ha<l  hrokeji  oti'  in,^j[lu  the  joiiit.  I  determined  Uy  cut  duw 
far  iis  tiic  i^a^isiilo,  :in<l  explore.  This  was  done  bv  u  \crv  i 
fill  dir^seeliiiu,  oecasion;*!  |)au''erf  beini;  made  to  allow  the  b 
ing  to  cease.      TJie  capsule,  covci'td  by  a   sli-'ht   celluliir  1; 


nfjuRiES  OF  tht;  os  coccraiB^ 


693 


dnff  nrrived  at»  the  euJjstance,  whJcli  coulii  ensilv  be  felt  with 
the  limb  extended  befijre  the  incision,  now  ahnoat  c^Nuplclely 
(liflfippcnrcd*  The  limb  wna  tiicn  forcibly  bent,  whcLi  the  needle 
at  once  iraa  felt  predajnj^  again:^t  the  cnpAule*  and  apparently 
fiscd  in  ihc  under  part  t>t'  the  patella.  The  wound  bciiiir  bcld 
widely  open,  ttnd  every  thin^  kept  sleady,  w'llb  the  hunillc  of 
the  knife  en  one  aide,  and  the  nJiil  of  the  tbnmb  on  the  other, 
the  Dccdlc  wns  innde  to  prciject  through  the  ciipsulc,  and  could 
be  seen  through  the  areolar  tiaaiie  over  il.  A  touch  or  two  of 
the  knife  vow  expnseil  it;  andi  being  seijsed  with  the  forccpsi 
with  a  iittlc  force  it  was  disengaged  from  the  bone.  It  vrna 
about  half  an  iueh  long,  nnd  had  already  Ijeeomc  blackened. 

The  wouud  was  nt  once  cloacJ  by  a  suture  nnd  adhesive 
plnatcr,  nnd  the  IJmb  confined  in  a  atnught  positton,  in  a  aplint, 
with  an  injunctioji  not  to  Hex  it  for  a  week.  1  haw  her  on  the 
foJIiJwiug  day  ;  and  she  was  quite  free  from  any  pain,  swelling, 
oe  aensibility  of  the  joint,  and  hua  aincc  done  well. 


INJURIES   OF  THE   08  COCCTGIS, 

htiTC  met  with  quite  a  number  of  instances  of  thia  kind, 
where  the  lower  part  of  the  oj  ci.'ceygis  baa  been  injured  ;  all  of 
them  oceurnn«r  to  females  from  aUpping  while  descending  the 
stnircaac,  or  dlepping  suddenly  out  of  dciuv9  on  a  etcp  covered 
with  ice,  nnd  receiving  various  coneuagions  in  aliding  from  one 
etair  to  another.  The  ecvere  and  l(>na:-coi]linued  fiymploms 
ariaiug  from  thia  injury  ore  not  ensily  explained-  Scarcely  an 
inatJinec  can  be  Paid  to  have  resulted  in  perlect  recovery  ;  and 
many  of  tliem  have  caused  severe  local  eymptoma  for  some 
months  and  even  years  afterwards.  The  ^ymptome  do  not  acem 
to  he  easily  ONphuucd,  either  by  supposing  ihcm  to  be  cauaed 
by  a  concussion  of  the  spinal  marrow,  or  by  n  local  Icaion  of 
the  nerves  of  tbia  pari:  although  the  region  la  very  fully  auj>- 
piicd  by  nervous  filaments.  They  seem  to  reaenible  more  closely 
thoac  nciLte  pnina  which  attend  periosteal  inBamniiition .  The 
eHbet  of  tbi^  iiijui-y  I  propose  to  illustrate  by  a  number  of 
cases. 


upper  and  lower  extremitiGB. 

The  conetitutional  aymptoms  very  grAdually  si 
pain  ond  inability  to  sit  upon  the  part  Justed  nu 
ftnd  the  BeneitivcnesB  of  it  continued  for  teD  yea 
dent.  At  the  lime,  on  eiammation,  no  fh 
detected  ;  but,  on  account  of  the  sensitireneas 
touch,  the  iDTcetigation  was  necessarily  supen 

Case  CCCLXI,  — /n/ury  of  the  Ooccyx.  - 
for  some  jcare,  had  been  in  delicate  health, 
was  desceudiug  the  stairs,  and  went  irom  tLe  tOE 
Btriking  auccessively  the  lower  part  of  the  bacl 
She  was  taken  up  in  an  almost  iusensiMe  com 
first  shock  of  the  accident  subsided,  the  most  viol 
nervous  ajinptoms  supervened,  attended  vvith 
the  coccyx-  The  head  was  in  a  state  of  great 
confusion,  the  hearing  and  eyesight  exquisiteli 
arms  and  legs  spasmodically  contracted. 

Being  out  of  town,  this  lady  was  attended  by ' 
tiuguished  physicians,  who  came  to  her  Jrom  a 
coccyx  being  examined,  a  distinct  displacement 
was  distinguished,  and  by  proper  manipulations 
this  condition  she  remained  two  or  three  mon 
be  removed  to  the  city,  and  requiring  constant 
remedies  to  relieve  pain  and  sustain  life.  SI 
brought  to  Boston,  and  came  under  my  car«. 

When  nhp  fin*t  nrrivfil.  T  mmlp  nn  PTnmmnttnn 


DJJUIUrS   OF  TOE   OS   CX>00TOI5. 


595 


Buggcet,  was  unable  to  bcur  jiay  prcaaurc  it^wn  the  injured 
pnrt.  Air-cuehiona,  with  nperturtis  in  them,  hud  been  tried, 
but  without  effect ;  tJic  mere  tigUtcuing  of  the  skin  arornid  pro- 
ducing^ aufTcring  not  to  be  eupportcd.  The  pfiljout  was  now  able 
to  wnlk  about  tlie  room  a  littlo  with  support,  and  niter  a  timo 
was  takon  down  etaira  in  the  arms  of  nttondante,  put  into  the 
carriage,  an<J  driver  out,  auppoi'ted  in  the  horiEontal  position. 
Shu  did  not  recover  from  tlie  icnmcdintc  clfecta  Df  tbc  uceideut 
for  one  or  two  ycara,  (lud  now,  at  the  end  of  eight  yoara,  id  not 
ftbl©  to  ascend  stairs  without  sufferins. 


I 


Case  CCCLXIl-  —  Lijitry  of  tho  Goccyx^ — An  unmar- 
ried femnle,  dii  ycflrs  of  age,  waa  brought  into  the  MaasfLohu- 
sctts  Generul  HoEpital  in  the  spring  of  1^5>(,  having  fallen 
while  goin;;  down  the  eeliiir-atitirs,  striking  violently  on  the 
coccyi,  iind  injuring  one  of  tlie  riba.  She  cornpluiiied  very 
little  of  the  latter  injury,  although  one  of  them  aecraod  to  bo 
fnetured,  but  made  the  most  violent  exclamntioni*  in  i-egard  to 
the  suffering  in  the  lower  part  of  the  njxcrum.  There  was  an 
innbility  to  move  the  lower  extremities,  but  no  want  of  acnat- 
bilily  Id  them.  No  fracture  or  dispiaeement  of  the  coccygeal 
bonea  could  be  detected.  Leeches,  tomeotations,  the  internal 
adniinidtration  of  opEuuii  were  reaortcd  to.  The  only  relief, 
however,  which  ahe  obtained,  waa  from  the  local  application  of 
laudanum,  or  poultices  aprinkled  ever  with  ten  gmina  of  opium, 
)l  was  two  or  three  weeks  before  she  began  lo  obtain  decided 
relief,  and  about  six  before  she  wob  able  to  lenve  the  HoHpital, 


Case  CCCLXIIL  —  Fractur-c  of  the  Cocctfx.  —  Whde 
making  a  vLait  at  the  Hoapitol  with  Dt.  Cnbot,  in  February, 
19^!:^  he  pufnlpd  out  to  me  a  padent  he  hod  just  suoccss- 
fuliy  treated  for  veaico- vaginal  fistuk.  I  observed  tliat  she 
aat  leaning  forward  in  a  very  awkward  position,  Dr.  Cabot 
eaid  that  the  pofilion  waa  not  owing  to  hor  ptcaent  difficulty, 
but  to  an  injury  alio  bad  received  aome  years  before  in  goin^ 
down  the  ceUar-stMira,  when  ahe  alipped  upon  something  left  in 

I  the  way.     The  consequence  wna  a  fall,  in  which  ahe  struck 
uu  the  lower  part  of  the  back-     The  coccyx  was  fractured  and 


596 


KlfiCElXAXEOCS    CASES. 


dU[iliir^l,  itnil  remain^  su,  um  vrnji  veri6od  br  flu 
Tumle  b^  hiinseir,     At  tb<?  time,   alie  u*tti*  cvnfiiKd  Jtct^ 
wi^rlcH,   vvifli   v^ry   seiere  (^ymjittimv^   and   IwhI  ncvrr  frwi^ 
«ulti:r  lu  tlii^  pfirt  ui)  la  iJiut  Lime. 

Case  CCCLXrV.  —  ^rjv^ff-^  Tr>jurtew  t>/ ilu  C««f 
In  Miircht  1859,  I  was  va\W\\  lo  a  niftrried  JaJy  wtmU  ■ 
tliD  day  bc-fore  tin  iho  u^,  striking  licr  l>ack.      Pari  trf  ttc  i 
wn*!  m'civcil  ii[w>n  tlie  rocryx.     The  injury  |>rwlo<t<l  ctnwi^' 
Up  lnnion<T)iHj  nml,  fur  Honi<.'  daj-St  nltiujst   inaiiiliiv  to  W"! 
buck  or  niiiku  amy  liiitral  iikOtioLi8. 

TliiH  pnticnt  iwi(?47  b(?fi>rc  hiid  d  MmUnr  injuri' :  oscc.  v^^i 
ctilli],  fixjiii   i]i«  (?nVct   of  wliidi   nlio    never   rc'Ot»\ot«d;  tt^'^ 
«c.H'nncl  lime  III H ml  tilievn  yenm  nfrur,  wlicii   «lic  wtu  ondv' 
C0TC  ibr  Uio  asmc  injury,  at  wliidi  time  &he  wma  confined  IB  hi' 
}hh]  for  It  nuuiber  of  JiLjAf  requiiiuj^  llic  pei^iatent  uppJiAW^ 

Case  CCCI^XV.  —  />y>m;  «/ (Ar    Off    CfHJejyi*.  — »« 

1850,  a  young  lady,  19  years  of  ugp,  was  btoiinbt  to  tw« 
nn  injury  uf  llie  coccyx.  Three  y»^i<ra  before,  M'hilc  sliJing* 
the  \cQ.  filic  ftli,  and  rec^ivod  a  severe  blow  oo  the  lower  fi* 
of  rho  a|>inid  column.  The  |>!iiu  nnd  icmlernesA  eonfitKHl  btfi* 
two  or  llircc  Java,  and  slie  wai^  luuihlG  iirierwftrda  to  U'ftr  li* 
leafit  pressure  on  the  pan,  wliUe  iliere  waa  a  constant  fitt* 
of  nnpji^iness  in  it. 

About  a  j'ear  before,  a  swelling  commenced  there,  and  ^lo*h 
increased  till  it  became  of  the  size  of  sl  wnJnut,  hut  niili  to 
inflniumntory  appearanws  about  it.  This  wns  puncliircd  m 
Api'il,  18h5J*,  by  hor  pliysii-inn;  and,  bs  lie  stated,  ai.  cuT^r  mat- 
ter diBcbiu'iri^!  from  it.  After  [hat,  a  scnma  ffiiici  conliniicJ  10 
flow  ;  llie  opening;  remninin;:^  fistulotia,  v/jtb  an  inffanicd  elevaiiia 
of  nearly  hjdf  fin  ineh  aboxx  the  surrounding  tissues.  The  fe 
clinrge  eanso^l  oonbiJcrabJe  irritation  between  the  natea  and  in 
the  vicinity. 

Having  exj^mined  the  disease  iritb  n  probe,  and  not  discover- 
ing nny  eitrioua  bone,  1  adv  i&cd  tJiat  llio  patient  ^IkiuK]  be  cliitr- 
ized  on  the  foUo^ving  diiy,  and  llie  tumor  freely  iiiciaed,     Thib 


rEACTUEE   OF  BASK   OF  SKULL,  597 

being  done,  and  the  cavity  fully  exposed  by  a  free  incision,  a 
finger  wna  introduced^  and  the  end  of  the  coccyx  felt,  but  not 
denuded.  The  interior  of  the  cavity,  being  now  exposed  to  the 
light,  presented  that  white,  ailvery,  epithetinl  aspect  observed 
in  the  aacs  of  some  encysted  tumors.  The  whole  of  this  eac 
was  carefully  dissected  out,  and  the  cavity  stuffed  with  scraped 
lint. 

On  the  second  day  after  the  operation,  a  poultice  was  applied, 
which  freed  the  wound  from  the  adherent  lint.  The  wound  was 
afterwards  dressed  simply,  and  the  patient  allowed  to  get  up 
and  move  about.     She  recovered  entirely. 

Dr,  SimpHon,  of  Edinburgh,  has  described  thie  afTection  in 
his  u£ual  clear  manner;  and,  in  eome  obstinate  cases,  after 
having  tried  all  remedies  in  vain,  proposed,  and  practised  with 
success,  the  girdling  of  the  coccyx  by  subcutaneous  section, 
just  above  the  diseased  part,  so  as  to  cut  off  all  nervous  com- 
munication with  ]t< 


FRACrrURB    OF    BASE    OF    8KULL. 

Case  CCCLXYh  —  Fractnre  of  the  Base  of  the  SktdL 
liecover^^  —  A  man  was  brought  into  the  Hospital,  June  2, 
1866,  in  an  apparently  dying  state,  who,  two  dnys  before,  hod 
fallen  from  an  attic  window,  out  of  which  he  was  leaning  on 
account,  as  he  afterwards  said,  of  an  asthmatic  affection.  He 
lost  his  balance,  and  fell  twenty  or  thirty  feet,  striking  on  his 
head.  When  I  saw  him,  he  was  lying  on  his  back  In  a  par- 
tially comatose  state,  and,  when  roused,  answered  reluctantly  by 
signs-  His  right  eye  was  ecchymosed,  pupil  fully  dilated,  and 
not  at  all  stimulated  by  the  light.  He  had  had  a  bloody  dis- 
charge from  both  ears ;  the  marks  of  it  on  the  right  side  still 
remaining.  His  pulse  was  120,  soil,  regular,  and  moderately 
full. 

An  examination  of  the  cranium  being  made,  no  fracture  could 
be  detected.  There  was  very  great  tenderness  at  the  upper  part 
of  the  spine,  where  it  joined  the  head.  Contusions  were  found 
over  various  parts  of  the  body. 

The  patient  remained  in  a  very  low  condition  for  about  foui^ 


598 


mSCELI^NXOUS    CA9ES> 


tccn  d&yi,  and  with  M  the  symptoms  of  &««tiire  oT  ik 
ihe  ekiilL  He  waa  then  aitucked  with  a  severe  lEkitfami.' 
none  of  tlie  reTncdics  used  Bccmo<I  to  hnvc  tiny  dlectap^l 
u'hile  it  rcduceJ  \us  strcnglh,  ficomed  to  itnprote  ba 
gcnce.  Under  it,  in  tho  ctjurse  of  ten  cJava,  the  ccnbnl 
toms  dien[>|icnrcU ;  nml  lie  bctr^Ti  to  recover  the  BonlAfl 
tho  ri;j;lit  eye  so  oa  to  di^tingiiUh  Jiglit  from  clArkn»,0A^| 
tJiuee  cuiild  aee  large  objocts  before  him.  After  ammg«*l 
very  lowest  slate  of  muscular  debility,  J»e  began  to  leWntit' 
wa.4  finnllr  eent  to  one  uf  the  public  tnftituIioii«  ;  thcvjn^ 
caused  by  hU  orin^inal  injury  beln^  i^  o  ^''eAi  loe^iaim  itM 
alter  about  four  weeks  of  treatment. 

Tliit?  eitsc  ie  related  ns  one  in  which,  from  t}ie  wnv  the  t<^ 
occurred,  nnd  the  eub-^eftuent  eymptoing,  dcnih  vra»  ibongfe* 
bo  inevitable  by  aW  the  sur^oons  who  saw  hito.  The  afdnei 
Byiniiloma  were  apparently  relieved  by  tho  fiupcrvcntioD  of  ^ 
rhcea. 


Case  QQQLXyiL^Jicstt^ciMicnofa  Tnunff  Loil^nfl'] 
Lon<f  iSnbm^rf*if*nn  — There  hna  been  con^iiclcmlile  diffemmcif 
opinion  expressed  aa  to  the  length  of  time  reqiiireil  for  dfl^, 
to  take  plnee  by  drowning.     Two  or  throe  mtniitew'  Mibmciw 
is  generally  conaideicd  siiffieient  to  deetroy  life.      Cases, 
CTcr,  have  been  adduced,  of  peraonfl  who  have  been  sia, 
or  even  thirty  inmutca  under  water,  nnd  yet  have  been 
The  foUowiiig  case  occurred  tit  the  drendful  accMciii  at  XorwalU 
Conn.,  where,  from  the  tmio  of  cars  nmuiuf;-  off  the  bridce  inffl 
the  ehannci  of  the  river,  fixjin  forty  to  fifty  persons   lost  tbrii 
tive«.     In  this  eaee,  nearly  twenty  minutea  eliipj<ie<|   before  ii- 
tempts  at  rcMJ^citation  were  coninicnecd :  nnd,  ut  rhe  V4?rv  l»«- 
eat  computation,  ten  julnutes  niut^l  hiive  parsed  before  the  naticm 
wiia  taken  from  the  water;  i.e.,  time  enough  for  ik  bomt  i^  uai 
oiit  into  the  middle  of  the  slream,  nn  aperture  to  be  em  with  w 
a\e  in  the  side  of  the  car,  her  ruoilier  to  be   remove^!,  who  hJiJ 
lier  hciid  above  water,  and  etill  kept  hold  of  the  youn"-  lady,  wlw 
was  fixed  in   the   ^eats  beneath   the  water.      Aitcr  beinc*  tukeo 
frojn  the  ear^  die  wn8  tr!ins]iorIed  to  tlie  shore   in  a  hoiti    nnd 
thence  an  eighth  of  a  imle  to  the  shed  where  1  iirAt  saw  lier. 


RESrsClTATlOJJ    AFTER    DEOWNIXO. 


599 


I 


At  this  time,  iJI  the  plivsicnl  EppGnrnnceB  of  denth  were 
present.  The  body  was  cold,  the  njouth  and  nose  covered  with 
froth,  the  face  Bwollen  nnd  liviJ,  ilie  pulae  could  not  he  felt,  and 
respiration  had  entirely  ceased.  Af^cr  cleurinrr  nway  the  froth 
fntm  tlie  mouih  and  nostrils.  1  h»d  the  body  invei-ied^  so  ns  to 
drnin  the  water  as  much  ab  po^^sible  from  the  nii'-pnssagea.  The 
motionB  of  respiration  were  then  imitated  by  raising  and  depress- 
ing the  ribs.  At  the  same  lime,  the  finn;£!r  was  passed  down  the 
throat,  am\  The  epi^dottia  lifted,  to  onfthJe  the  nir  to  enter  the 
coviry  of  the  chest.  By  following  up  thia  process,  hided  by 
frictions  over  the  whole  hodv,  T  finally  rliacoverrd  pomc  nelion  in 
the  muscles  of  tliD  throat ;  and,  on  peraeverance,  n  slight  gasp 
at  length  showed  that  life  woa  not  extiiict.  Kcfpimtioti  and 
restoration  of  the  pulse  were  not  established  lill  after  long  per- 
Biafpnne  in  flie  process  described-  Meanwhile,  hy  sending  to  the 
village,  a  blanket  was  obtained,  in  wliieh  she  wns  wrapped,  and 
her  wet  clothes  removed-  Having  procnrod  s(jme  brandy,  her 
mnuth  vias  stimulrtted  with  it;  and  subsequently  n  little  was 
poured  dnwn  tl»e  tfiniat,  when  I  thought  the  power  of  ewalluw- 
ing  was  restored.  Consrant  and  long-eontiuued  action  waa  re- 
quired^  before  the  circulation  and  respiration  were  regularly 
performed.  In  about  rwo  hours,  or  m  soon  as  I  thought  it 
safe,  she  was  wrapped  up,  and  conveyed  to  (lie  hoiiee  of  the 
hospitable  people  in  the  vicinity,  who  did  eo  much  on  that  dny 
to  succor  the  wounded.  She  shortly  after  became  delirious,  in 
which  condition  she  remained  for  a  part  of  the  dny.  For  a 
week  ehe  was  seriously  ill ;  but  I  saw  her  about  a.  month  after- 
wnrda  completely  recovered,  and  entirely  unconscious  of  the 
e\enCs  whldi  Imd  transpired  during  that  dreudful  day. 

Out  of  fifty  person*  drowned,  ehe  was  the  only  one  reeovered- 
Tlie  shed  in  which  I  waa,  was  filled  ivith  bodies  taken  from  the 
water;  flnd»  as  they  were  brought  in.  1  instructed  and  encour- 
aged the  bystanders  to  go  through  the  same  manoeuvres  that  I 
was  practising  in  the  present  case.  Partly  from  want  of 
persistence  iti  them,  but  more  probably  from  the  attempts  com- 
ing loo  late,  nothing  was  effected.  There  were  many  dlstiu- 
gni&hed  physicians  in  the  traiiii  some  of  whom  were  destroyed 
either  by  drowning,  or  from  concn^sion  received  by  the  falling 


600 


Misccn,Axi:ocs  CA^es. 


carp;  and  t}io«e  wbo  e«capei1  wcro  cn^n^f!  in  the  tenvEfV 
wnik,  at  a  UiMancc,  doing  cdicient  work  iuii«>D£;  the  nimaiaL' 
eotlin^  rr:ic[urc<l  boneSi  Miwmg   up    n'ounU^f   ami  giiitt;  i^ 


l:li 


Ci9E  COCLXVTTI— /Wura^/ort  of  the  CcUultrT^ 
—  Thia  diacaeo  is  a  very  common  one  ia  tlic  Fr^oth  liuifh^l 
«»{]  n  \t'ry  filial  one;  more  than  two-thirds  of  rho««*» 
auackcd  \vith  it  dj^m^.  By  examinnciond  Rftev  doih.  f^ 
lowisli  or  <jrooni*ili  soro-albuminous  fluid  is  fuund  rfniol  * 
llio  rt-HiilEtr  iihi'iiibniu(^.  Tlic  rc^molc  cnuec  is  uuixrUili.  h^ 
b^en  frequently  itttnbuled  to  the  imperfect  filling  of  ibiM 
\vitli  :ilr  01  Lii^ili. 

tn  thi«  ciMiniry  aluI  in  En^lnocl  tho  affection  ia  a  ¥0710 
one,  aad  I  hnvc  floea  but  few  cases  of  it.  My  fricDd.  Tn^ 
Bor  D.  H-  ^ti-irer,  —  wlioiie  exjHiTii^nce  on  the  euhjcct  i*  «*i 
to  t)];U  of  na  one  in  New  Kn^dnnd,  nnd  whwec  viUuabfei^ 
r  tnko  this  op[jortuiiity  of  eayin^,  1  huve  availed  n»j:«U«J* 
many  cnsus  ru-lulcd  in  tlna  ;vork,  —  infot-ms  me  that  he  itf^^ 
seldom  met  witli  it  in  his  pracUee.  The  foliowhig  it  a> 
Btflin'W  :  — 

In  Kc'hnuiryT  1847,  I  was  requested  to  see  a  dnhl  bis  »* 
old,  nnd  i-ecoived  the  folJowlr^  history  of  it ;   When  a  week* 
it  vviifi  nct:iiionta.lly  diaoovered  llmt  tlie  cdliilar  tiicniLraiie  of  ^ 
thiglks  and  Ici^a  WAS  as  hfLrd  as  marble,  and  thnt  this  hud  iti^ 
nlly  extended  up  on  the  bi>dy  ]    tlie  pnrt  nt  which    the   harriitf 
IcrniiortCed  beins;  eo  peHectly  distinct  that  it   couM    be  lunrl^ 
by  a  3ine  drawn   in-onnd  the   body.      I  directed    frictions  to  I* 
made  over  the  indur:tlcd  part  wilh  wnrni  sweet  oil  ;    and,  io  tl* 
event  of  lliid   fu]Jin<^t   the   use,   to  a  limited   extent,    and  ^ 
proper  preciiurioHS*  of  merourml  oioiment. 

Under  this  treatment,  the  hardness  be^Q  graduallv  to  be  <IU- 
pel  led  ;  Jtod,  at  the  end  of  eix  weeks,  it  had  fjiiiie  diciappwired 
from  every  part,  with  ihc  exception  of  ft  few  luuip^  in  l\^^^  pop. 
liteol  £pace. 


Case  CCCLXIX, — Ivoi'ij  Penholder^  four   incAcs   ioiWi 
removudji'om  Bludd^i'^  —  In  February,  1844,  1  vi-a^  regnesitiJ 


/^ 


TBT 


601 


ij  a.  phydr^liin  to  see  n  htty  14  yeara  old,  who,  two  days  before, 
whily  eagti^d  in  pjuiising  an  ivury  pen'hauJIe  ititi>  liis  urtllira, 
liJid  it  tilip  fri>ui  hib  gHL^p,  and  rarrled  liaok  into  the  blndder. 
ACter  tlie  accidentf  his  water  dribbled  uwuy  fr[>[ii  hnn,  and  wna 
OccuaioDally  lin^^ed  w!tli   bluod. 

Wialiing  Ui  Lijnopjd  thf.  ?-M-.t  ul'  ita  introduction,  lie  had  made 
&a  incision  into  the  periniPum  with  a  penVnife,  for  tlie  purpose 
of  cxtrntlLjig  ki  tliiriking  he  felt  It  at  that  point. 

0^1  examination  liy  the  rectunii  the  foreign  body  cotdd  be 
distin^tiishfd  lying  across  the  bkdder,  one  end  of  it  just 
en.i^agt'd  in  the  neck  of  tliat  organ,  fram  which  it  hnd  been 
prevented  from  entering  entirely  by  the  irritation  eao^etl  by  it 
producing  a  contractii^n  of  the  cavity  to  half  itH  natural  dize. 

(Jooj>er's  forceps,  for  extracting  aniall  calculi,  were  now  in- 
troduced into  tfie  urutlira ;  and,  on  reaching  the  foreign  body, 
opened  and  manipulated,  with  the  expectation  [>f  engaging  it  in 
it^  gnhspi  Afler  dome  inc^ffectual  mnnosuvres,  thb  waa  Unally 
elFe^^ted;  nml  the  jiefdmlder,  whose  farlber  exireniity  wjih  lifted 
up  in  the  hhuMer,  wuh  sei^^eJ  at  an  ohtuae  angle.  By  a  little 
Iruction,  and  aidoil  by  the  finger  in  the  reelnm,  it  made  a  spring- 
like motion  on  the  forceps,  and  came  into  a  etraigbt  line  with 
It,  ami  was  i\i[i^  withdrawn. 

Alt  the  isyinplcma  were  at  once  relieved. 

Dr.  Paul  F.  Eve,  in  his  collection  of  "  Rcmiirltiiblc  Cases  in 
fiurgei-y,"  has  given  a  number  of  instance*  in  whii;h  foreign 
bodies  have  been  removed  from  tJie  bladder  Ln  this  vray. 


WRY  NSOE. 

Case  CCCLXX,  —  Divhion  nf  ike  Sterao-tmutoid  Mun- 
ch for  Wrtf  Neck,  — I  waa  requested,  in  1841,  to  *ee  a  boy 
16  yearti  old,  afTeetetl  with  wry  neck,  and  received  the  following 
history  of  hia  ca^e  :  — ■ 
B  ^Vhen  four  years  of  age,  hp  fell  from  the  top  of  a  slain^ase 
to  ihe  bollom-      N^o  wound  wiia  to  be  discovered  on  any  prirt  of 

I  the  [xjdy  :  he  complained,  [lowever,  of  a  pain  in  the  le[\;  side 
of  the  neck-  Shortly  after  the  accident,  it  was  found  that  the 
fiead  inclined  to  the  left,  iind  that  the  musclea  of  that  aide  were 


602  MiaCELLANEOUS   GASSfi. 

in  an  unnatural  etnte  of  tenBiOD.  This  diatortion  gradnally 
creaeed,  untU  it  attained  the  appearance  which  it  presented 
the  time  I  saw  him,  twelve  years  afler  the  aoeident.  At  i 
period}  he  was  eufTering  from  frequent  attacks  of  headache,  ■ 
from  an  almost  conaiant  and  severe  pain  id  the  leit  eide  of  i 
neok.  lie  was  rather  short  for  his  age,  and  the  distortion  an] 
much  to  diminish  his  natural  height. 

On  viewing  him  in  front,  the  following  were  the  appeanuK 
obeer^ed :  let.  The  head  was  di-awn  down  to  the  left  stA 
the  ear  usually  resting  on  the  lefl  shoulder,  although  he  had  t 
power  of  raising  it  a  little  &om  that  position  ;  2d,  This  incliD 
tion  was  accompanied  by  a  rotation  of  the  head,  00  that  the  h 
■  regarded  the  right  shoulder. 

■    I  Observed  from  behind,  there  was  a  deep  sulcus  on  the  left  ai 

'    I  of  the  neck,  with  a  corresponding  projection  on  the  right  &A 

J    -  made  by  the  transverse  processes  of  the  cervical  vertebne.    . 

,    I    ,  curve  had  taken  place  both  in  the  cervical  and  in  the  lumbarpo 

'    \  tione  of  the  spinal  column.     The  leti  shoulder  was  higher  tLi 

,     ;  the  right.     The  left  side  of  the  chest  waa  projected,  and  tbei 

i    i  was  a  considerable  depression  of  the  ribs  on  the  opposite  ad 

On  examination  of  the  vertebne,  proceeding  upward,  the  spii 
ous  processes  of  the  cervical  portion  could  be  diatiniruisheduiii 
the  third  vertebra  was  arrived  at:  here  the  line  of  the  coluro 
was  lost,  being  concealed  under  a  lar^  mass  of  muscle;  wil 
great  ci\ro,  the  spinous  process  of  the  second  cervical  vertehi 
was  discovered,  having  performed  a  rotation  of  nearly  ll 
quarter  of  a  circle  on  its  axis.  The  stern 0-1  nastoid  muscle  < 
the  left  side,  on  being  examined,  was  found  to  he  very  strong] 
retracted,  as  well  aa  the  deep-seated  muscles  of  the  neck'  tt 
sc^lent  particularly  could  be  made  out  in  an  unnatural  stale  * 
rigidity.  The  former,  however,  appeared  to  be  the  cbii 
obstacle  to  the  endeavors  for  bringing  the  head  to  an  upri^^ 
positron. 

la  addition  ro  tlicse  changes,  the  face  had  undcrt^one  a  n 
markahle  altcrJition,  worthy  of  notice.  The  whole  left  ^ide  <. 
the  face  was  luorc  or  less  atropliJeil,  and  each  of  its  conjponen 
parts  was  much  smaller  than  tho^c  of  the  other  side  ;  the  K'l 
eye  was  much  smaller  than  the  right,  which  was  raised   uii   aa 


WRT 


«0S 


on  a  level  liiglier  cIhiti  its  fellcw ;  and  tills  n|ipearance  wna  not 
owin^  to  the  inrlined  j^osidnn  of  tlie  IilmJ  alune,  an  was  iiiore 
ditftinutly  verifi<?d  when  ibe  ftice  was  brouglit  intT>  ita  natural 
poeltion  afler  the  operation. 

The  henTlh  of  the  putient  was  not  good;  and  in  udditJon  to 
the  imiitificaciun  of  being  aflli^^ted  with  so  Bevert  n  deftinnit^.  the 
pnin  at  tlte  eput  where  the  curvature  witn  moat  extreme  waa  at 
tiiHes  excessively  aevere.  He  elejit  usaally  «n  his  ri^Lt  eidc, 
Boniethnes  on  his  biick,  but  never  by  any  chance  on  Lhe  lefl 
Bide* 

It  bavmi,^  heen  aacei'tained^  so  far  aa  was  praeticuble,  tliat  the 
chief  ohsta.ele  tu  the  realorjition  of  ihe  head  existeJ  in  the  un- 
naiiiral  stale  of  the  ftlerno-tnastoid  iniiscle,  it  was  determined 
tu  divide  it  at  ita  sternal  insertion  ;  the  retraction,  according  to 
Gu^rin^  who  U  oonaidered  the  best  aiilhnriiy  on  tins  poiut  of 
Burgery,  generally  eiisling  in  tins  portion  of  llie  muscle. 

Tlie  operation  w&a  performed  as  follows  :  The  head  being 
*iipp<frletl,  and  i:arried  a  little  forward,  so  as  Ui  project-  the 
'inaade  outward  from  the  «ubjiiL*ent  parts,  tlje  patient  was 
direcled  to  raiike  strong  efforts  to  exaggerate  the  exirttlnir  rota- 
tion, so  HS  to  produce  iia  great  a  tension  of  the  mtiscle  as  poe- 
Bihle.  A  puncture  waa  now  made  with  a  lancet  through  the 
«kin,  about  six  lines  above  the  ehtvielc,  between  the  sLernid  and 
clavicular  portions  of  the  muscle.  The  narrow^  blunt-heailed 
knife  of  Bouvier  was  next  iiitrishieed,  its  flat  *ide  lowarde 
the  muscular  fibre,  curried  behind  tlie  sternal  head,  its  cilge 
towards  the  muscle,  and  the  section  completed  by  a  slight 
sawing  motion.  The  effects  of  this  operarii>n  were  at  once 
manifested  by  a  distinct  crackling  sound,  by  a  separation  of  the 
divided  parts,  and  by  the  partial  re8tJ>niliori  of  tiie  head  to  its 
natunil  position,  also  by  the  [Xissibility  of  rotation  in  every 
di^tection.  The  wound  on  the  neck  was  covered  wilb  a  piece  of 
court-plaslei-.  a  cap  pliiced  on  the  heud,  to  the  bat*k  of  which, 
op[ios]te  tlie  right  mastoid  process,  a  strap  was  attached,  >md, 
being  drawn  tigfit,  was  secured  over  the  breast  of  the  same 
oide. 
B  On  the  fullownig  day,  he  was  quite  comfortable  :  he  had  slept 
Hwell,  lying  on  his  lefl  side,  which  he  had  been  nokble  to  do 


tlie  hend  secured  by  a  bapdage  carried   under 

attached  to  the  upper  part  of  the  board. 

In  the  course  of  a  fortnight,  a  very  great  itr 
perceptible:  the  head,  however^  had  not  yet  reg. 
position,  but  waa  still  incHned  to  the  left.      The 
had  united ;  a  firm  and  almost  cartilaginoua  e 
apparent  at  the  point  of  union.     The  clavicular 
muscle  had  becotne  much  more  prominent  fiiuce 
its   sternal  attachment,  and  felt  rouud  and   con 
an    obvious  obstacle   to   the   adjustment    of  the 
therefore  thought  advisable  that  the  division  of  t 
muscle   should   be  effected;   and,   in   order    to    * 
advantage  from  it,  the  operation  was  perfornied  i 
manner  :  — 

The  head  being  supported  and  ^e  muscle  euffit 
the  body  of  the  stemo-mastoid,  just  above  its  div 
nal  and  clavicular  heads,  could  be  readily  eeizei 
thumb  and  forefinger,  and  completely  isolated  f 
sealed  parts*  An  appropnate  knife  was  now  can 
muscle,  until  it  could  be  felt  by  the  finger  unde 
the  opposite  side;  and,  the  patient  being  directet 
muscle  in  strong  contraction,  the  section  was  com 
difiicuUy* 

The  second  operation  was  not  followed  by  any 
the  wound  being  quite  healed  at  the  end  of  fortj 
and,  by  persisting  in  the  treatment  before  directed 
very  shortly  restored  to  its  normal  position.      Xim 


intT   fflSCK, 


carrying  the  head  in  an  opjiosile  direction.  The  face  stiJl 
lenU  tha  altcmti(»n  nlrcady  pointed  out;  viz.,  an  alrophy  of 
^yje  whole  lii  the  nliccUd  ^klc.  The  eye  of  ihc  Left  siJc  ia  Riuch 
i^i^ee  prominent,  the  lid  more  closed,  and  tho  level  of  it  lower 
^ghao  its  fdlcw  :  the  ivhole  onacoua,  rcJlulnr,  nnd  miLt^culnr  system 
l^pattakc  in  this  Qktcratmni  or  WEUit  of  Uevolopmcnt, 
1^  From  bdiiml,  the  following  chungee  are  visible:  The  dorsal 
^  and  lumbar  cunuturci^  of  the  epinal  column  have  dianppeiircd, 
ami  the  fchoulders  have  regained  their  nutural  elevation.  The 
depresflion  of  the  ribti  on  one  eide,  nod  ihc  projection  on  the 
Bother,  are  fnst  di,^ appear Ln^^  The  right  half  of  the  munclca  of 
Hfthe  neck  etill  remain  ^Tcntly  developed  above  tliat  of  the  other 
^nidc,  nnd  a  alii^ht  curve  atill  cxiels  in  the  cervical  Tcrtcbnc- 
.  The  health  of  the  patient  hrta  ^atly  improved  ;  and  hid  nppoar^ 
fc  anco  is  en  eomplctelv  altered  eincc  the  operation,  that,  his  former 
p  trienda  scarecly  recognize  him. 

Cask  CCCLXXI.  —  DivUio-n  ofths  Stern o-nmafo id  Mhs^ 
th  for  Wrtf  Keck- — The  tbllowinv  ciiae  was  operated  upon 
by  IJr.  John  C,  Warren,  in  the  hrst  part  of  June,  1>J41  ;  — 

The  patient  was  a  little  girl,  nine  years  of  age.  When  about 
four  weeks  old,  the  pai-enta  observed  that  the  niuric^lea  on  the 
left  eidc  of  the  nci'k  were  in  an  extraordinary  stale  <ii"  icnBiun : 
it  waa  not,  however,  until  the  ago  of  four  ycnra,  that  the  hea<l 
in  to  he  distorted;  ami  IVoni  that  perioil  the  distortion  bus 
iually  increaeeU,  ho  that  the  contraction  become  so  great  as 
to  bring  the  mastoid  procGBs  ncnrly  in  contact  with  the  left 
shoulder,  accompanied  by  a  atnmg  rotation  of  the  Itead  to  tbo 
right.  Tiiid  distortion  evidently  hud  a  y;rt'iit  effect  on  the  health 
of  the  child,  who  was  pale,  emftcijvled,  and  of  n  feeble  consti- 
tution. A  double  Inecml  curvature  of  the  epine  esiatcd.  thou<^b 
not  BO  markdl  u^  in  the  preceding  ease. 

Under  tbedo  eireiimstaneea,  Dr.  Warren  determiucd  to  divide 
the  elemo-eleido-mnstoid  muscle  of  the  left  side,  whidi  wna 
fbujid  to  be  (^tron^ly  retraeledt  and  was  evidt^ritly  the  chief 
obstacle  to  the  return  of  the  head  to  the  upright  position. 

The  operation  was  performed  in  the  following  manner:  The 
bend  being  supported  so  as  to  give  aufKeient  projeclion  and  ten- 


to  make  strong  an<l  constant  eflbrts  to  rotate  t\ 
also  placed  on  flb  inclined  plane  for  three  or  fi 
the  head  secured  by  a  bandage  carried  unde 
attached  to  the  upper  part  of  the   board. 

In  the  course  of  a  fortnight,  a  very  great  ii 
perceptible :  the  head,  however,  had  not  jet  r«j 
position,  but  was  still  inclined  to  the  left.      The 
had  united;  a  firm  and  almost  cartilaginoua 
apparent  at  the  point  of  union.     The   claviciUaj 
muscle  had  become  much  more  prominent  since 
its  sternal  attachment^  and  felt  round    and  cot 
an   obvious  obstacle  to  the  adjustment    of  the 
therefore  thought  advisable  that  the  division  of 
muscle  should  be  effected;  and,  iu  order    to 
advantage  from  it,  the  operation  was  performed 
manner :  — 

The  head  being  supported  and  the  muscle  sufi 
the  body  of  the  etemo^maatoid,  just  above  ita  di' 
nal  and  clavicular  heads,  could  be  readily  seize 
thumb  and  forefinger,  and  completelj  isolated 
seated  parts.  An  appropriate  knife  was  novr  caj 
muscle,  until  it  could  be  felt  by  the  finger  und 
the  opposite  side ;  and,  the  patient  being  direct* 
muscle  in  strong  contraction,  the  section  was  coi: 
difficulty. 

The  second  operation  was  not  followed  by  anj 
the  wound  being  quite  healed  at  the  end   of  fort 


WRY    NECK, 


605 


hy  carrymg  the  head  in  an  opposite  direction-  The  fitce  etiH 
prescnta  the  ulterfttion  nlrenJy  pointed  out ;  viz.,  an  atrophy  of 
ihe  whole  of  the  iiffccted  *^idc.  The  eye  of  the  left  side  Le  much 
le^B  prominent,  the  lid  more  cloaod,  and  the  level  ".if  it  lower 
thn.li  its  fellow  :  the  whole  osscoub,  cellulur^  and  mu^culnr  eyatem 
pnrta](G  in  thia  nlicratlon;,  or  wiint  of  dcveZopmont. 

From  behind,  the  following  changee  are  vieihle:  The  doraal 
and  lumbnr  curv:iturej?  of  the  s[>mal  coluoin  have  Jisiippenretl, 
and  the  diouldera  have  re^ineJ  their  natural  elevHtion.  The 
depreEfiion  of  the  ribe  on  one  side,  and  tho  proJectiLiD  on  the 
other^  are  fast  diaappcariag.  The  ritrhl  half  of  the  muddea  of 
the  net:k  still  reiiioio  ^roiitly  Jeveluped  above  thsit  of  the  utljer 
gidfit  ^nd  n  ftli^'ht  curve  atill  exists  in  the  cervical  vcrtebrie. 
The  health  of  the  patient  has  ^reailj  improved ;  and  hia  appear^ 
once  h  uo  completely  altered  since  the  opemtlon,  that  hi&  former 
frienda  scarcely  recogniae  him. 


Case  CCCLXXI.  —  i>i"iv"jjfjji  of  the  St^rno-mastoid  Mu^t- 
ch  frr  TFi-y  Neck. — The  followinrr  ease  waa  operated  upon 
by  Dr,  John  C.  Warren,  in  the  first  pnrt  of  June,  iJ^il  :  — 

The  patient  wiia  a  little  prl,  nbe  yeara  of  a^re-  When  fibi>iit 
four  weeks  old,  the  parenta  obaen'ed  that  the  nmselea  un  llie 
left  side  of  the  neek  were  in  an  extraordinary  state  of  tension  : 
it  wafi  aot,  however,  until  the  age  of  four  years,  that  the  head 
began  to  be  dij^torted :  and  from  that  period  the  distortion  has 
gradually  increaseJ,  so  that  the  contraction  became  so  great  iia 
to  bring  the  mastoid  process  nearly  in  contact  with  the  loft 
shoulder,  accompanied  by  a  atronjj;  rotation  of  the  head  lo  the 
right.  Thia  distoition  evidently  had  a  ^reat  effect  on  the  health 
of  the  child,  who  wiu  pale,  emaciated,  and  of  a  feeble  consii- 
tuiion.  A  double  lateral  curvature  of  the  spine  exited,  though 
not  ^o  marked  as  in  the  preceding  eiwe. 

Under  these  clroumstances.  Dr.  Warren  dciennined  to  divide 
the  fltcrno-eleitlo-mastoid  niu^ele  of  tho  loft  side,  which  was 
found  to  be  strongly  retracted,  and  was  evidently  the  cliicf 
obstacle  to  tlie  return  of  the  bend  Xi>  the  upright  poaition. 

The  ciM^ralion  was  performed  in  the  following  manner:  T)te 
head  being  supported  fio  jis  to  give  sufficient  projection  and  ten- 


u 


again  entcrea  ai  ine  same  onDoe,  carneU  m  front  o 
mastoid,  and  this  head  of  the  muscle  divided  in  a  f 
Der. 

The  result  of  the  operation  was  an  imniediate  altf 
head  to  a  more  upright  position.  The  wound  he 
days.  The  subsequent  trealnienl  waa  the  same  ; 
tailed  in  the  preceding  cnee. 

The  following  Is  the  substance  of  a  letter  r^cei^ 
father  two  months  nfter  the  operation  :  He  stated  t 
perfect  command  of  her  head,  and  a  power  of  rol 
directions.  Her  head  was  so  nearly  straig-ht  thai 
would  not  notice  any  deformity.  "From  the  dh 
neck  slopes  to  the  right,  which  is  apparent  -wh 
behind  her-  The  short  curve  at  the  upper  part  of  t 
scarcely  be  perceived.  The  cavity  on  the  ooe  side,  t 
largement  on  the  other,  have  returned  to  almost 
shape.  Her  schoolmates  are  astonished  when  th 
with  her  bead  up,  and  Bay  how  toll  she  has  groTra. 
you  will  probably  remember,  was  appareatly  very  i 
now  a  very  long  neck  for  a  child  of  her  age.  She  o 
inclined  plane  four  horn's  each  day/* 

Remarks. — In  reviewing  these  cases,  we  shaJI  fi 
lowing  circumstances  worthy  of  netice  :  In  the  first 
anatomical  changes  produced  by  the  contraction  of 
are  very  interesting,  as  bearing  on  many  cases  of 
besides  that  now  under  consideration.  The  \eh  haJf  < 
as  has  been  already  stated,  had   become  more  or   leas 


tramiinicated  t 

T^ioes  a  rotntion  on  its  axis,  so  as  to  brinp;  Jt  into  the   huri- 
ontftl  <iii-ection  ;   the  ej-ea,  as  H.  truorin  rcmiirka,  being  pluccU 
n   relation  to  each  otlier,  as    it  were,   on    a   staircnee,  from 
^vhencc  eon  did  enable  trouMe  in  vision   ia  produced  an   tbc   firat 
Jjudtmont  of  the  head,      Tiic  alteration  in  tlic  apinal  eoluma  ia 
interesting*      In  ordor  to  abvtJite  the  inclinati[)n  of  the 
kd  to  the  left,  whieb   brinfra   it  without  the  nxia  of  tbc  body, 
inclination  takes  place  of  the  ecrvic?ul  on  the  doreul  region, 
>f  the  dorsiil  on  the  Jumbar,  and  of  the  Inrabar  on  iho  eacral, 
'he  deprceaion  cf  the  ribs  on  the  one  aide,  and  their  projec- 
tion on  the  other,  nutiirally  follow  from  iUs  pcr^JsCcnce  of  the 
mrvaturc  In  the  ^spinal  eolumii. 
There  are  few  opcrntions  that  have  been  more  benefited  by 
le   eBtabllehinent    of  the    principle    of  subcutaneous    ineUiona 
ban  that  for  wry  neck.      The  operation  prcviout:iy  emploved  by 
Ijstiaguiabed  fiurgeotie  eonsiaEed  in  tirst  itiakin*r  a  tran3ver9e  in- 
ihtoTi  ihrT-JUgh  tbc  ekin,  so  aa  lo  expose  the  fibre  of  the  stcmo- 
[tnaetoid :    the   muede   was    then    carefully   JiHflecled,   layer   b^" 
lyer,  until  the  whole  was  divided-     The  rceiilts  of  this  method 
retc  often  very  eevcre:  there  was  great  intlrtninmtiou,  and  eitp- 
mi-ation,   frequently  fuUowed    by   infiltration    of  pne    into  the 
[ftuterior   mcdiu&Iinum,  ^ometimed  eauHJng  ihe  dontli  of  llie  pa- 
ieati     Tbc  contraetJon,  aleo,  of  the  cicatrix  trom  so  severe  a 
^Ivonnd.  often  eounteracted  the  benefit  derived  from  the  division 
Lof  the  mUBcle. 

To  Mi  Gu^frioi  of  Fnriaf  wo  are  chiefly  indebted  for  the  ex- 
position of  the  pathology,  physiology,  nud  tlie  surgical  treat- 
nient  of  wry  ucck»  \[p  Gui^rin  has  endeavored  to  establiah 
the   following  propositions  :  — 

l8t.  That  what  has  been  calleil  the  etemo-cloirlo-mafltoid 
jiiusetc  constitutes,  in  fact,  two  diatinct  musclea,  —  the  stcrno- 
ntattoid  and  the  eJeido-mti^toid* 

2d,  The  stern o-miwtuid  and  the  cleido-maatoid  are  poBBesscd 
of  different  functions  :  tbc  lirst  is  a  Hi'xor  and  rotator  of  the 
hcnd,  the  otbcr  muscle  i^  oefcntially  a  muscle  of  ret^piration. 

3d,  In  wry  neek,  which  has  i\i\ia  far  been  attributed  to  the 
flhaptening  of  the  aterno-mftstoid,  the  aternal  muscle  ia  primi- 
tively alone  affected. 


i 


608 


MISCELLANEOUS   C^Afl&8. 


1 


MJ 


4lh,  That,  iti  the  trentraent  of  chronic  vrty  neck,  ovring  u 

the  aht>rCening  oi'  the  flterno-mAatuid,  the  section  of  ihc  Hin^ 
portiuu  nlone  eufKcee  to  deatroj  the  e^cntial  cauae  of  d» 
dcforraitj. 

The  praoticol  intercoce  to  be  drawn  from  them  appears  m  lifc 
fourth  proposition  ;  vis.,  diat  m  the  mnjorit_v  of  cases,  ihc  ^teni4- 
mrtatoid  is  priuiiirily  aiiectod,  imd  thia  done  requires  ao  opcrv 
tioD.     Where  the  jiffectioa  hoa  k^tcJ  for  a  length  of  time.  a£  in 
llic  tvro  i;naoi<  slated  nbovc,  the  clcido-mfLst<>id    almoj5t  di 
parbikea  in  the  dtf^caaed  action ;  and  jilthough,  by  ii  Jong 
ence  in  the   use  of  mechiinical   means,  thla    tnny  be  f  vmetj 
overcome,  yet  the  cure  i»  undoubtedly  much   fn^niiiitcd  hy 
division.      M.  Gljl'hq  hns  drawn  a  dislinetion,  vrortiiy  of  jioUk 
betwe&o  what  litr  calls  die  retraction  und  the  contt^actioM  of 
muecle.     Tlie  formefi  he  hoa  cndeavarod  to  show,  only  I^kei 
pUce  afler  a  loug  per^i^teccc  of  didcai^c,  und  con^i^^Fs  in  a  f  hroiM 
degeaeratiou  of  the  miidc'lo,  and  nlwuyt]  retjuirci^  f^ur^ie;^  inO^I 
ferencfi ;   whercoa  the  latter,  which  occurs  in  ncutc  vrrj  neck. 
is  a  simple  lemporary  ahorteniiig  of  the  inuecuhir  fibres,  &nch 
occurs   in   cominijii   mu^etilar  notion,    and   i:^    aJ%vn_vd   ome 
to  the  nae  of  locid  remodics,  more  porticnlnrJy  the  appliot 
of  the  tiirtOT'Cmctic  oiotmcnli 

The  fuUowing  ifl  the  most  approved  manner  of  perfurniiiig 
operfttion  :  The  head  of  the  jiaticot,  being  firmly  euppijru 
carried  H.  little  forward  oiid  strongly  routtf^,  30  oa  to  p 
tl)c  muadc  outward  tVuni  the  euhjaeent  piirte,  and  make  it 
tense  fts  possible  A  fold  of  dkiu  over  the  lquscIc  bein^ 
a  puncture  ia  made  with  a  lancet  from  four  to  six  lined  aboi« 
the  clavicle,  and  betwcfu  the  insertions  of  the  two  lienija  of  itie 
muscle.  The  narrow,  blunC-hendcd  knife  of  Bouvicr  ia  nov»'  in^ 
troduced,  and  carried  with  its  flat  side  between  tlie  muscle  and 
the  akin^  The  hold  on  the  gkin  may  nuvf  be  relaxed,  the 
of  the  knife  upphed  to  thi^  muscle,  nnU  the  division  cJTuc 
Tins  ia  usually  announced  by  it  crackling  aound,  itnd  bv 
pai'tinl  adjustment  of  the  head.  In^lcnd  ol'  posj^in^  the 
in  front  of  the  muscle,  it  may  be  (.virricd  bohind  it;  but  in 
case  it  ii:'  well  tiiat  the  knife  dhuulil  hitvc  a  dilTcrcct  ahape; 
the  former  a  concave,  and  in  the   latter   a  convex,  edg«   ia 


JU-4 


CroyOBSTTAL  FtT8H>N  OF  FINOER8. 


609 


ureJ.      If  It  hKouM  iiuAv  Ije  dt^tcrmincJ  to  divide  ttic  c1aviculn,r 

lead  (»r  the  muscle,  tlic  knire  may  be  Introduced  Into  llifr  snme 

lorifice  ill  the  akin,  Cj\rriei.l  h^ckwArd^  and  t^ic  divi^iod  uin^le  !ia 

the  jtrecc^llng  case;   the  acotion  of  tlie  muscle  from  without 

iitwunl   htin*;  here   alwu^H   to   be   jir^errcd,   aa  mure  aafe  uud 

;eH*>  of  cxeeuticm* 

\Vlien  the  projeelion  *j(  the  muscle  from  the  p^trta  beneath  i* 
[•ufficient  to  remove  them  fmni  tlio  diin^er  of  Jicing  puuctured, 
land  it  lias  been  deU-rmmed  t^  divide  the  hitAy  uH  tbc  muscle, 
|thc  mcthjd  iiia^  be  ndojited  which  wa?i  practised  lji  tlic  former 
of  the  two  ciiaes  which  have  been  relnlcd.  The  botlv  of  tlie 
muscle  jn.*t  before  its  division  Ijein;^  seized  between  the  finj^'crs, 
%o  lliEit  thcde  jtre  luado  to  meet  belilml  it  and  nscertnin  ihjtl  no 
abstflcle  intervenee,  n  narrow-bkdcd  knife  is  curried  benendi, 
UDiil  the  point  is  detected  under  the  skin  on  the  opposite  aide; 
luid  the  division  is  then  to  be  mndo  from  vrithin  L>ut^'brd. 

In  dividing  the  interiiul  head  of  the  muAcIe,  we  have  occasion- 

filly  henenlh   the   skin  the  nnterior   jugnW  vein,  aa    it    passes 

ifici'usa   the    neck    to    enter    the   subclavlnn.      This,   hDwever,  id 

liljr  avoiiieii    h_v    making   ihc   incision   aufBciently   near   the 

clavicle-       The   carotid  nnd   internal   jugular  are  protected  by 

die  etemo-hyoid  j^nd  tiei'no'tljyrold  musclea,  and  could  not   be 

reached  but  ljy  the  [mint  of  the  knife  carelci^sly  introduced,     In 

Hdividing  the  clcido-miLstoiil,  the   cxiemal  jugular,   which    lies 

between  the  bolder  of  the  ninsele  and  the  skin,  may  he  wounded  : 

tfaia  ia  avoided  by  raising  the  skin  and  passing.'  the  knife  with   '\Xs 

cutting  ei]*>;e  jterpendiculMrly  to  the  muscle;  the  vein  hein^  lelY 

between  die  back  of  the  inatruiiient  and  the  ekin.     In  dividing 

—^  llic  body  of  the  muscle,  ihc  external  jugular  is  the  prineipal 

^  Toaael  to  be  avoided,  and  with  auftieicnt  circ  can  be  easily  left 

on   the  outside  of  the   puncture   neccfisary  for   iDtroducing  the 

knife  employeil  In  tlie  operation- 


COSOENTTAL  FUSION  OP  PUJOERfl- 

Case  CCCLXXIL  —  Cot^tnilal  Fusion  of  the  Middle 
Fiiiff^rs  of  both  Hands.  Operation,  Cure. — I  am  led  to 
record  the  following  case,  from  tlie  difficulty  experienced,  when 

77 


ft  4 

'I 


filO 


snsccLL-umoua  ca^iba. 


it  wftJi  firat  brouj:lit  t"  my  noltcCi.  of  |>rociirin;!  auir  pnrte 
inFurrtiiitbn   on   tho  aiibjcct  from   the   our^jcnJ   wprlu  fewn> 
rL*fiTiT<l  tit  ns  im'lniritv.      I  wiia  rc'yiin?3tc<l%  in  OdobcTi  li'Hs 
BCD  n  <:Uiltl,  who  lui^  Ijcimi  l^trn  it  few  cjiivra  lictoro,  nirb  u  eO- 
mntc  union  uf  tltc  midJIc  and  nn^  iin^ers  (>f  cJtch  haml.  Ik 
4<)iiM  was  n  ^(jrv  Rnc  <jiic«  »mt  iiihcr\t't8C   perfect;  its  pmk 
rcinnriii^bJy  linnd^^oiito   nnd  vt'll-forincJ*       Tli<^y  were  exERW^ 
imxioLts  llint  ^>mc  opci^atioD  ^lioulc]  be  ditnc  tu  brin^  tbc  fi>|ff 
iiiti.»  n  ni^tcrul  comljijun.      On  a   cnrcfaJ    intf|teclii>D.  i  IM 
tlio  iiU\tv  of  thiii;;s  (18  fdllovvfl  ;  — 

The  0(iiLjL>mLil  iiiiifcr  of  cndk  1mm]    liAtl    but  a  euigl«  >u^ 

I»o6icion  tobroHk  up  intn  two.      K<i   liattire  «r   dcprc^it>l  O^ 
he  Uictiti^uj^lioil  iiimkiii;;  llic  Jjstmcfiim  lictwocii  ihc  Iwob^ 
ns  nviy  bo  ubsorvcU  in  wliat  ht  ciillixl    tt-cbbctl  fiti^rcr^.    7^ 
fin^'cr  wne  euscc[>lifilc  of  Hcxion  ami  csctcn^iuti  ;   but  no  i];'^ 
nnoo  r>r  ^epunLtc  joints   ouitUl   be   oh^ervo^l,    or    tfCtrATiiie  ^1 
Btruttui'ci  in  fnct,  tbera  whs  ii|n»iM-e[itly  but  <»nc  finger  in  (J* 
uf  twOi     1  tiLcrofoLC  ndn^cU  lluit  the  o)>t;rniiuu   aljould  \ft^ 
Iftvt-tl,  to  nfford  fiiitficicnt  lime  fiir  tlie  ik'VL'lojujicnt  of  i\t*:^ 
crctit  urgnna  ;   tlikt  tljc  coiijulncd  Itn^'oru   ^itutiltl   be   neizeiL  ii' 
mode  to  wurk  ialGmlly  ono  upan  tho  other,  ao   na  to  dou^ 
if  ]n»Sflib!cT  the  uniting  lucdiuni  bctwtcti  tbc  tvro. 

The  jjrccciling  pJiin  was  nUvptLHl ;  iitiU,  al  ibc  enil  of  «s 
montlis,  the  bony  etructtirc,  joints,  and  otbcr  textures,  wea 
autficiontly  devclofK^l  to  sbow  the  elements  of  two  Gn^era  iiiik 
niaaa,  nnd  WJUrant  the  ntlcmpt  nt  an  operntjon  %vith  n  rt^awn^ 
cbnncc  of  tepn ruling  tbtiUi,  without  cutting  iiit\>  ibu  Joiiil:'.  icJ 
producing  &titihc&a  or  ancUylo&La.  The  operation  wua  ibiis  pt-r- 
formed  s  — 

The  fbild  being  ctlicrized,  tho  ends  of  tbc  fingers,  where  d« 
bony  dtructure  j^ecnieJ  to  be  united,  wore  acpnrntcil  u^i  to  ihi^  fir*t 
joint,  by  ihc  t^Litting  plicra,  A  carofiil  dj^soclion  then  spiuiratrJ 
ihcfingcra,  forluiiatcly  without  entering  the  jointiii,  except  [lo^ 
eibly  the  laat  joint  of  one  finder  on  one  hnnd,  wJudi  ini<r]i;  have 
been  opcnol ;  but  thii^  wn^  doubtful,  nnd  not  at  all  indicncod  by 
the  anbsL?qiicnt  progvo^a  of  the  case-  Tiic  disi^cction  n-;is  nuTiH 
r;ithcr  further  towmd^  ihc  hand  than  the  uutural   diviaiou.  in 


arlv  down  tu  the  first  or  Icmifklc  ji>int,  in  < 
^ifor  It  ccitnin  nnioimt  <if  fldticoiuu  or  coiitpiiuiion,  whieli  iL  wrw 
fet#thou<{lit  nif  nrt  or  lubor-  wouM  l)o  iiblo  to  prevent-  It  wna  then 
n,.ntti'iu|>tej,  nt  flie  nnifle  Jind  a»lt*d  of  the  fin-^er,  to  brinjf  the 
^tflkin  ot^  iIk-  Imck  »nil  iiiilni  of  tho  h^Tid  tn  ccxitncC  by  meiirid  of 
fiulure^,  Tiiis  wns  ctt'octcdj  but  with  grcot  atrjiiit  of  thciiito^- 
JDts,  on  nccount  of  the  thickness  of  the  parts.  A  lon^  piece 
>f  ndhc^ivc  }>l£ister  waa  pisiced  between  tho  two  fin^oi"^,  ntid 
mdo  to  eserl  ns  grcut  n  [ircfl:*ure  ns  poadibic  on  tho  iin^le  of 
ic  wound.  Thiif  wiie  roplieeil  from  time  to  IJme«  the  uao  of  it 
'bciiijr  mniutuiiied  lhr(>ri;;hrjiit  the  vvhtile  trciitmcnt. 

It  will  be  imnef^es^nry  tu  ^\j  iiiLo  nil  the  n^iiiuLin:<  of  tlie  aub- 

jquciit  mnjMgcEiiont  of  the  ciuCi     It  piMvcit  pcilcjtlv  eucccss' 

Ful,  mid  left  llic  diild  with  two  wcll-fLinneJ  tin^r^,  jind  the 

sntirc  iwQ  of  the  joinia.     The  inula,  which  lind  been  dividL-d,  in 

Lho   00111*80  of  Olio   or   two    mouths  wcro   otivero<l   on   tlich'  cut 

[aiirriioca  by  tiew  skin  ntid  Hcah,  jxiviii^  them  quite  n  njiim'iil 

ftppcnmncc.     The   *Mr/itrit,  wfiirh  cJtteinlL'd   frnm   the   nrirlc  uf 

tlic  firk;rQra  upwnnk   on  cwh   sjdi-,  hjul   n   rcndency  to  t^ontmur, 

|«nd  eiirvu  tho  Bn^cr^  in^ninU;  nnd  thi^,  n^thov  thnn  the  di^po- 

^aition  of  the  fin^^or^  to  n^snUi  unite,   wns  the  pHnd[>]d  ptunt 

iwhidi  requiri'd  nttctttiun  tinvnitU  ihc  end  fit'  the  trctitmetir.     It 

\yirae  lhoii<;ht  u^de.'^s,  Jit  tl»o  curly  njre  of  tho  pnliont,  1o  ritlempt 

Any  iiicehanicnl  mL'rine  to   obvintv   thia   eorLlrnclioti,  whieh   wna 

Itonnteriictcil  by  iho  constunl  nltcnMnn  of  the  mother*  in  BonkinLf, 

«nd  fui'cibly   bending  tboni   otit.      Tho   resnJt  of  the  itporatioii 

wae,  in  pJnM  of  a.  very  grcftt  dcfbrmily,  tn  rcijtore  the  hntid  to 

n    useful  comlnion,  nnd  to  nn  rtppcnmnee  which   would  patiB 

wiflmul  reinni'k, 

I  hrtve  cfteii  operated  to  remove  Biipcrnmncrary  finger*  nnd 
froni  inftmLd«  and  invnriiihly  with  rrood  rctttihs.  Houie- 
■e  two  tiu^ei'j}  or  toes  nrc  pWcd  on  the  fitme  juinl,  eaeh  bnv- 
in*(  itfl  peetdinr  fncet  in  the  joint.  When  the  patient  iu  very 
youn^T'  »uid  the  additional  excresoenec  on  tlie  outside  of  tJio 
fin^'or  or  toe,  I  hnve  not  seen  any  intlommntion  of  the  joint 
euDiic  from  removing  it.  At  n  kter  period,  when  ibe  joint  la 
Rioro  fully  or^ani^ed,  it  nppenr«  be^-^t  to  eut  oH'  ibc  hend  of 
lb«  bouv  jufit  bhort  of  tlie  jumt,  whieh,  il'  neatiy  JonCf  ahovra 


^a 


HISCEtXAS&OUS    CA8EB. 


but  little  aflcrwardfi.     I  have  lately  opcraloii  on  tiie 
coeo:   A  little  girl,  eight  years  of  «i?Ci   bad   two  tcrmiBal 
on  ihc  ]a£t  joint   of  lh^  ibiLtiib,  with  two  nails  ;    t\\f  tw^Hm 
B[irin^i]g  from  one  joint.     By  difFectin^  up  the  ekin,  1  mW] 
tlic  outor  one,  with   pnrt  of  tlie   b^ee,  mtbout  ictcrr«nit*<^l 
the  joint;   aod  the  deformity  remoining  after  tbc  openttioa»i| 
very  sliglil. 

I   hnve   twice   eeeu   perftone  with    &   eioglc   enonaous  fn^,' 
Bppearing  ns  if  viewed  tlirotij^b  n  injigfnifying  glasf<-    The  *A] 
lowin-j  remarkable  exuberance  o{  growtli   and   dcfomiiiT  jf  di 
ioQi  U  the  only  one  of  the  kind  that  I  huve  met  niib :  — 


Case  CCChXXUl.  —  ^faf/or^7lat^on  ofJ^oot.—Xw 
fiboiit  30  yoiu'e  of  n^e,  nppli«il  to  me  for  an  injury  of  herhif 
which,  ahe  anid,  waa  n  remiirknbla  odg,  boin^  congenitjJlf' 
formctl ;   and  ihia  I  found  to  bo  thcooee.       The  foo4t  as  firial 
grnaX  toe,  on  the  inside,  wns  nutuml;    and,  on  tfic  outer  aqc^ 
were   two   natural   toes-     Springing  from    between   theic  «■ 
wh(it   nppeored   to   be  another   fteahy   foot,    terminated    br  tW 
rudiments  of  toes  buried  in  the  end  of  it.      On  a  cnrvful  MW- 
pulation,  ihe  oaaeovis  p^irt  of  it  wils  found    to   be    cct uj pcecii  *i 
two  lar3;e  bonCH,  apparently  the  metatureai ;    there  was  no  pn«a 
of  flexion  in  this  pnrt  of  the  foot.     On  the  dorenl  u&pect.  acdi 
the  junction  of  this  foot  with  the  other,  was   w-jiai  appcarel  » 
be  a  gniiglionie   swelling,  wliich  was   quite    tender,   anJ  Wd 
been  caused  by  n    strain.     This  yielded  to  trcAitnent  in  a  irect 
or  two,      Tiie  leD*^tb  of  the  foot  was  thirteen  inches. 

I  lately  measured  the  foot  of  a  man  six  feet  fijx  Inchea  hish, 
at  the  Hospital,  and  it  was  found  to  be  n  little  less  tlian  twdrt 
inches  in  Jengtb. 

Mr.  Annndale  has  recently  written  uu  interestinrr  book  on 
"Deformities  of  the  Fingers  and  Toes,''  in  whieL  are  caxa 
sometvbat  eimiUr  to  those  given  above. 


chapteh    xtv: 


AN-£ST1JETICS. 


:e  cliFin^  mndc  m  the  praciioo  of  ^iirgcrv  hy  ihe  dWoverv  of 

Ltlte   anitalhoric  power  of  crher  cnn   scnrcely  !x>  iip|irm!Hefl   hj 

I0A«  who  huve  come  on  the  Miiji:^  aince  the  introduction  qT  this 

igent.      It  wns  in   ihe  city  of  liostim,  n  little  more  tlinn  tAvcniy 

'ear*  sinec,  that  tlip  full  rnluo  of  this  discovery  wrt«  first  di?- 

tlPOD-itrnted   and   piibli«h<?<i ;    anJ   it   ]<»  truly   rcmarkatiJe,   that, 

Lt  the  preaenl  day,  artificial   anawtliesin  ia  best  attiiined  by  svil- 

Iphitric  clher,  tis&l  in  suUstanlially  the  same  numn^i'  0.4  whf^n  it 

^ivas  first  Tried  in  sur^ictd  ojierationft  at  tin?  Mus^acliusett*  Get»- 

rul  IW|»itnl.      Wiule  chloroform  la  nekao^vleil^r^J  to   be  ikn- 

pemua,  and  while  the  fjreign  medical  jnumalu  conmin  frer^iient 

notices  of  Uantb  from  ibc  use  of  this  po^oni  anient,  it  is  a  strikiDg 

ifiiet,  that,  out  of  iha  hundreds  of  l[kousuii<k  of  cusee  of  etheri- 

[ffaiiun,  the  fiwt  umlnu^iteil  ca*e  of  detith  from  its  nciioji  i»  yet  to 

be  recordwl,     Ii  la  not  pretended  by  this  staieinent  to  abjure  the 

nae  uf  chluroform,  which,  in  anme  cases^  ia  certainlv  preferable 

to  any  known  aitaesthetic ;  being  far  more  f?onccntrnted  in  fortn, 

morp  ngreeable*  and  more  ncrive  in  administration,  than  any  of 

the  ninny  snl)<4titufE^  which  have  been  pinpnsicd  for  it-     On   the 

baitlt-fitkl,  en]>eoitdly,  its  grearer  poriabiliiy  in  likely  nlnaya  to 

secure  (lie  preference  far  ft  over  «afor  bnt  more  bulky  aun^ 

the  ties. 

Tlie  flrst  and  perhaps  the  moat  important  application  of  ether 
is  in  prmliicinir  nnconscLmi.^ncas  of  piin  ;  and  it  is  for  lhi?4  boon 
that  ihi?  pailent  will  ever  be  cbicSy  lliantrul.  To  the  fliirjjeon, 
aIj»o,  the  Ti  on -in  diction  of  pn.in  is  often  a  mniter  of  the  greatest 
moment ;  for  he  eaii  now  undertake  a  long  anU  tediours  dJHM^ction, 
or  u  delieaCti  explorution   of  an  acutely  inflamed  cuvity,  undi^- 


614 

torbed  bf  tbe  InToluiitary  moreiDMit*  of  die  potittit.  llMpCH 
to  ftboUah  pain  has  also  nuiterulJy  enlarged  the  domaia  of  ope 
tive  siirgeiy,  not  only  by  ^mtwUliifty  ^^^  dreed  of  eoma 
operadom,  and  allowing  of  diur  miwe  frequeoit  pcrforiBM 
but  alao  bj  admitdng  iato  the  liat  of  juetifiiU>le  operatiaiM  m> 
whose  severi^  would  othorwite,  in  moet  oaooa,  IbrbHl  mta.  i 
thought  of  attempting.    , 

The  other  great  ^tplioation  of  edur  ia  mar^ery  depeade  v| 
ilB  pow^F  of  ralaxlDg  the  T<4imtU7  ainflolea  by  InAt^i^r^  «  ga 
<^  the  brain  aiiah>goiu  to  ooioa*  la  die  de^  toleep  of  ooo^ 
etherization,  the  manipuladon  and  fedoedoai  of  liaemeB  i 
difllooationt,  the  diagnosia  and  traatment  of  eaeli^^oett,  te  : 
duotion  of  atraagulated  hernia,  Ac.*  are  immrniiulj  fagjlrtift 
The  question  of  iu  OM  in  oertain  tpecial  departnenCa  of  m 
gesry  wiU  be  nodced  ebewbere. 

Thi«  it  not  the  plaoa  to  dwell  on  the  Ter^  inqwrlant  oMi 
ether  in  midwifery,  and  in  painfnl  or  oonTnlaiTo  medteal  diasM 
bnt  of  its  inostimable  valoe  in  the  alleviation  of  maSUmg  d« 
the  last  iDomente  of  life,  I  cannot  omit  thSa  peaiing  afftffm. 

Having  been  oonveraaiit  with  the  prindpal  fiieta  rehtag 
the  introduction  of  the  inhalation  of  ether  for  amttieal  **fiiHT*** 
from  the  bcgioning,  it  may  not  be  considered  inappropriate 
give,  in  this  place,  n  alight  sketch  of  ita  early  hlstoiy,  mi 
especially  aa,  aince  the  introduction  of  chloroform^  and 
almost  complete  adoption  abroad,  the  oH^d  of  etherijotti 
seems  in  danger  of  beiug  lost  sight  of.  The  ikcta,  eo  fn  u 
am  acquiiinted  with  them,  are  briefly  as  follows  :  — 

In  the  autumn  of  1846,  Dr.  W.  T.  G-  Morton,  &  dentist 
Boston,  a  person  of  great  ingenuity,  padence,  uid  pertiiwcj 
of  purpose,  called  on  me  several  times  to  show  eome  of  I 
inventions.  At  that  time,  I  introduced  him  to  Dr.  Jt^  I 
Warren.  Shortly  nfter  this,  in  October,  I  learned  from  D 
Warren,  that  Dr.  Morton  had  visited  him,  and  informed  bi 
that  he  was  in  possession  of,  or  had  discovered,  n  means  of  pr 
ven(in<r  pain,  which  lie  had  proved  in  dental  opemtionSf  ii 
wished  Dr.  Wnrren  to  give  him  an  opportunity  of  tryin<r  it 
a  surgical  operation.  After  some  questions  on  the  subject, 
regard  to  its  action,  arfd  the  safety  of  it.  Dr.  Warren  promisi 


AN-^EflTHETIOfl. 


615 


thtit  he  would  dn  sn.  On  the  Titcsilfiv  fullowin^,  Oct*  13tli, 
nfler  tlie  aur^'iciil  mit  nt  the  HoyfjitJi],  n  patii^nt  was  brauj^ht 
iTitiJ  the  umphitlicntre  fbr  0|>emtioni  Thia  being  the  first  op- 
Hurtunily  wliicli  \md  occurred  eiiica  Dr,  AVurrcii'a  proiniso  to 
Dhp  Morton,  Dr,  AVurrcn  said  to  usi  "I  now  remember  thnt  I 
hare  ntiLdc  n  promise  to  Dt^.  Marton  to  give  hliu  an  oppurtunity 
to  try  A  new  remedy  fiir  preventing  psiin  in  euigioal  opernliona," 
nnd  ti^k\id  tlic  piiticnt  if  be  elioutd  like  to  ]ihvq  tbc  opoi^tion 
done  witEuiut  soiToringp  He  nnturally  nnswered  in  the  nfliniiR- 
tivo,  Tho  operation  wna  thereloro  deferred  until  Friday,  Oct- 
I6lh»  wlien  tbe  ether  vrns  fidmini&tere<l  by  Dr.  ilorlon  with  bia 
nppuratua,  and  tho  operation  jjerformc*!  by  Dr.  Wnvren.  It 
conaiatetl  in  the  i-oraovfll  of  a  vnsculnr  tumor  of  tho  neck,  which 
occupied  five  minute^,  Durlcig  a  purl  of  Lhc  time,  the  putietit 
ebowcd  some  tnnrka  af  seiuibility ;  but  fsubs-cqueiilly  nun]  ihnt  he 
bnd  no  pain,  uhhou^b  he  was  awiire  lhn.t  tbe  operation  was  prL>- 
cccding.  On  the  following  day,  »  womun  requiring  the  removnl 
of  rn  adipoac  tumor  from  tlic  nrm  wns  rendci'ed  inecortiblc  by 
Other,  given  by  Dr.  Mtnlun  ;  nnd  Dr,  Wsirrcn  reqiieatL^d  Dr. 
Haywniil,  who  was  proBont,  to  porform  tlio  operation.  This 
wjia  Eucc^eefful ;  the  ether  bein^  continued  thruuph  the  whole 
nperjition,  wliiuh  was  n  ^liurt  one,  and  the  palient  being  entirely 
in&cn^iblo. 

A  few  days  nftcrwnrda,  Dr,  ^A'arren  informed  mo  that  fie  li»d 
learned  from  Dr,  Charles  T,  Jaekson  that  he  had  suggtiattd 
the  lite  *jf  eilier  to  Dw  Morton* 

The  aucoe^B  of  this  proecas  in  the  prevention  of  pain  was  now 
fpiitc  establiahed.  ltd  u?e^  liortever,  wne  siiapendcd  for  a  time, 
for  rcneons  which  Dr.  Wiuren  lisis  already  given  in  Wis  tirat 
paper  oa  ether;  and  the  expenmcnta  were  not  ogaJn  resumed 
until  Nov.  7th,  when  Dr-  >Iorton  declared  hi.'^  wilhngnesa  to 
state  the  nature  of  the  agent  employed.  Two  imporUiit  opera- 
tions were  now  dune  ^iiceessrully  nt  the  Mas.'iaehuaetis  General 
IIo7^[>ilal  under  its  uj^eney :  one,  an  anipulxttion  of  the  thigli, 
by  Dr-  Ilaywaitl;  the  other,  n  very  dtt^c^ult  and  bloody  opera- 
tion, — -reinoTul  of  a  portion  oT  the  upper  juw  in  a  woman  ^  —  hy 
Dr,  Wnii^en.  On  the  enme  day,  I  operated  on  nn  infant  f^ir 
liure-lip  \  but,  a^  we  had  tliuei  far  hud  little  experience  in  the  use 


616  ANESTHETICS. 

of  ether^  it  wns  not  thought  prudent  to  employ  it  with  f^  jnet: 
a  child.  With  ti  more  full  cxperteace*  however,  1  havt  ^i 
given  it,  in  thid  opcnitlon,  at  the  earliest  ^g^^  of  lif^^  '^^ 
between  eix  and  eight  houra  after  birth. 

On  Nuv.   12tli»  I   performed   the   firat   successful  optn&c 
under  ether  wliich  was  done  in  private  practice,  on  a  ncz 
woman,  for  a  tumor  of  the  itrm.      The   ether  wms  ftdminkiaa 
for  three  minutes,  when  the  patient  became  unconscious.  Tk^ 
enition  then  proceeded,  the  inlialacion    beiagf  conliaued.  Tk 
patient  was  bo  entirely  tranqnilf  that   Dr.  «T.   C.  Warren,!^ 
wns  standing  by  her  side,  was  not  aware  ihat  the  operaiion  H 
commenced  until  it  was  nearly  completed.      Nov.  £lft,  1^ 
another  operation  in  private  practice,  at  ivliich  many  of  the  pifr 
fcssion  were  preacnti  —  the  retnoval   of  a.    formidable  tumoia 
the  thigh,  wluch  is  thus  described  by  Dr.  J,  C.  Warren:  — 

I  '^The  patient  lying  upon  a  bed^  the  vapor   was  admialsUftd  ^ 

j  Dr,  Morton,  in   tha   presence   of  Drs.    C.    T.    Jackson,   Kejwl^ 

[    !  J.  V-  C.  Smiib,  Flagg,  Gould,  Shurlleff,  Lawreoce,  Pursona,  Brigs- 

(  nod  otliers.      After   he  liad  breathed  the   vapor  for  three   miaaip- 

',    j  hla  head  fi:!I,  aud  ho  ceased  to  respire  it ;  but,  presently  awaking,  ^ 

•    J  inhuiatioQ  wn^   renewed   until   he   again  appeared   iniieasible'    Tbr 

I    ■  operation  wjis  limn  oonimGnead.     At  the  first  stroke   of  the  koiff.tf 

!  dafipcil  Ilia  liand  on  the  wouml ;   but  1  tminedlHteTv  s<?ized  ami  heM  '-'i 

diintig  the  rctnmnJer  of  iht'  opcralionj  ihougU  not  wEthoui  >nine  Ji^- 
cuUy^  ill  c'tJiis<.'c|m!iiL'i!  of  JiL^  3(ru^n[k'a.     The  opcmtiun  wixs  iximpW- 
in  two  or  llnuG  tiuuiHe:^,  iieuJ  lliu  p^uienl  remaiucil  if  iiieUv  ou  \m  biif^. 
wiiU  hi-t  ej'ua  fh)9cil.     On  exainiuaiion,  (he  pupiJs  wurc   foumi  to  w 
ililati?d  ;   ilic  pul^-c  whs  not  inxtermlly  iifFcrltit.      Afrer  hv  [mtl  Ui^ 
nbout  Hvo    tniijiiica,  1  ichim'iI  biin  hy  (lii^  in<|uiry,  '  How  do   vuu  an 
lo-Uiiy?'  ill  vvhii'h  lie  ropli^^U,  *  Vury  well.  I  iliank  yon/     1  iheii  iistcl 
what  he  Imd  boon  iloin;^-    Jli:  ^aid  he  Iiclicvcd  he  had  hceu  dronmic?: 
he  iJroamcd  rlint  hi:  wjn  rit  liuine,  and  making  ftomr  exainiiuiiion  iiii' 
his  bii>iiK'-M.     '  Dii  vnii  t't'cl  iiiiy  pEvin  ?'  —  *  No/  —  *  How  U  rh.ni  timiT 
of  yourjs  ? '      Tliu   puiionl    rJii<oiJ   lihnself  in  bed.  lo^ikoil    iil    |ji,i  tlii"!i 
for  a    iimTi]L'ii[»  and   Mud,   *  II    is    gone,  and  i'ln  ghid    ol'  tt/      I   liun 
iiiqiiir*'d    if   hu   hud  fell  any  pain  duriug  ihe   opcrafion,  to  xvJiidi  lie 
replied  iti  The  ne;^iilive.      IJe  soon  recovereil   hU   njitural    sl.ile,   expe- 
nuucetl  no   iiieiniveinenec  from   ihe   iuludalioti,  xvus    rem,irkiiblv  fri'O 
from  |i;iiti»  and   in  three  d,iy,i   wnui   home   inio  llie  couiiirv." 


617 


Tile  preccilirg  oj>eraKons  \H  the  Ilaspifftl  were  folluwed  by  & 

iri«(y  pertWiued  tliery  by  ll:e  oilier  siajrcona  of  llic  Institution, 

Drs.  iS.  D.  TowiiaeuO,  S,  Parkiuau,  IL  J<  Bigelow,  atid 

lyaelf. 

Tilt  life  uf  etliei'  iii  *urgirftl  6perfttii>na  bcinj^-  Banclloned  by 

jtbt:  i[fdical  Bounl  of  the  Ilosplrd,  the  Consultin^j  lionixl,  and 

fthe  Bliaix]  of  Truflteefi,  —  the  last  composed,  as  it  alwitys  is,  of 

llstinguisheU  nnd  [inidiiaent  men  of  IJostoD,  Imving  in  charge 

linportuiit  irusle,*  — was.  after  some  little  reaialancc*  gradually 

adopted  throughout  this  counCry,  oiid  nt  once  iiiiide  use  of  by 

Itirgcona  in  Eurojie, 

About  u  year  after  the  diacovery  of  the  flna^sthetic  pover  of 

'her,   chK>rof(inu   was    iiitioduced,    and,    from    its    fascinating 

[LULlltiee,  seemed  likely  to  displace  ether,  wLidi  had  the  dii^ad- 

[Vanlnge  of  being  disn^Tceiible  to  the  emell   and  t;vite,  and   ob- 

jeeliunable  under  certain  ciix;umatftnces,  from  ita  inflammability. 

Vary  ADon,  however,    fatal  accidents  began  to  be  c&uaed  by 

[diloroforrn ;   many  of  them   occurring  where   it  was  given  for 

linor  0[j6niti<jn8.      The  proportiou   of  deathfl  had  continued  up 

the  present  timet  ^i^d  may  be  estimated  at  about  one  a  munth 

For  the  lafit  twenty  yeara  ;  wliitb  ratio  seenia  scarcely  reduced  by 

le  uae  of  any  care  or  ingenuity. 

Dr.  Jolia  Ci  Warren  and  myaelf  introduced  into  practice, 
^and  Uflcd  for  about  five  years,  concentrated  chloric  ether,  pre- 


*  OrriCKHS  QF  raB  UA^HAcnDBstra  GEVkajhL  HoiSriTALr  IBJt,  —  WiLlliin 
[Ap[iJe[t)i[.  Prcfjrffjir;  Tlicoriore  Lyman,  Vtoo-Praidtiit ;  Henrj  AmJrews,   TVboj- 
■;  Marcui  Morton,  Jr,,  Srtrrtnry. 

Trm^fTi-  —  Cli4rIo#   Amory,  William   T.    Andrew*,   Xjilhnniel   I.  Bowdilfh, 
M.  Dexter,  Raliert  Hooper,  Tiiomu  LiLmt>,  Fmndi  C^  LgirelL,  JuIlji  A, 
r^vrell.  ll^nry  B.  Ruytra,  J-  TIjuium  SLG^ttismi,  J.  Wile/  Eduianib,  EJward 

Boatd  of  CvturtirnTi'Tt.  ^  Jamm  J*eluori,  M,D. ;  John  Jaffnotj  M,D.;  George 
:,  ShAlliiclt,  M.D. ;  Edward  BerDoHn,  M.]>. 

(tfFh'Rj  Phgiickim.—Ju-iih  mgelim.  M.D.;  Etiuch  Hale.  M.D.:  John  B,  S, 
rukion,  M,U-;  Honr.v  I,  Ba*dii4.>li.  M.D.;  John  U-  Fitber,  M-U-;  OUver  W. 
[oLmtfl.  M,D, 

Viiit\rii/  Suyiffuna-  — Juhii  C»  Warren,  M  D, ;  Geur^  naywird,  M-D-^  Sulomon 
».  TortnBond,  M.D,;  J.  Muon  WiureBf  M.D-;  Siiiiiwl  l*irkiH*n.  M.U,;  llenr/ 
r.Bigelotf,  M.I). 

Of  riJb  MtLs&M  AsvLCWr —  Luther  V-  Bell,  M-D>,  Plijeiciaii  ukd  Skiper- 


618  ANAESTHETICS, 

p&red  by  dietillntioTi  nfler  a  process  recomroendpil  by  Dr.  I 
Hayes.     It  had  tlie  advantage   of  being  very  a^n^eiUe  \. 
taflte,  not  mH&mmablef  easily  manag^abJe,  eafe,  and  a  ^\i: 
stitute  for  chloroform.     Its  liability-  to  aduIteraciaD.  lo^^ 
accidents  which  subsequently  occurred,  probably  from  thiical 
after  ita  use  became  extensive  through   the  countrrjed*"] 
abandon  the  responubility  of  recommendiug  it,  and  u  mz] 
to  the  uae  of  sulphuric  ether. 

Ether  was  first  adminiatered  by  an  apparatus.    The  o^'^i 
this  was  inconvenient,  especially  with   children,  and  led  w 
administer  it  on  a  eimple  sponge,  which  immediatelT  loat  ^ 
plikce  of  the  apparatus  everywhere.      The   sponge  fint  nxAi^ 

j  the  Hospital  is  still  preserved  there. 

I  In  the  course  of  twenty  years,  as  already  stated,  not  t  si? 

[  death  can  be  fairly  attributed  to  the  use  of  sulphuric  cthw.  Si 

1  the  Massachusetts  General  Hospital  alone,  it  has  been  cid|^ 

^    ^  over  twenty  thousand  times,  without  a  single  unfavorable  orr^ 

rcnoe.  In  some  cases,  particularly  iq  young  pcF^oid  v^ 
females,  I  have  seen  disagreeable  and  troublesome  lymputf 
occur  from  prolonged  etherization.     From   the  great  tHqueo^ 

'  of  tlie   use  of  artificial  teeth,  the  followiu^   not   unusual  sra- 

dent  may  be  mentioned*      In  one  instance,  after  operating  upn 

;  a  lady,  under  other,  for  a  tumor  of  the    thigh,  1   found  her  a 

an  M[)[i:iR'iilly  (lying  state;    respiration    liavinn^   aJuiOft  c^^^''- 
:ind  ibe  jmlse  bein;j;  ju?^l  perceptible.      Passing   my  fiiij^cr  J-^ 
tl^o  throat,   in    i>ixler  to  admit  a  current   of  air   to   the  larvni. 
1  dij*covcrod  an  cntiic  upper  set  of  artificial  teeth  oloriclv  tVW 
down  on  the  glottis,      TJieso  Ixfing  withdniwn,  it  waa   onlv  ain'- 
ft  long   [>crsistcncc  in  the  use  of  the  usual  remedies  empluvcl  i" 
rei^i^vcr   a   person    from   <lrijwning»   that   the    re^^ular   course  >^ 
respiratiiin    and   cii'culation   was    restored.       She    then    bttMin^ 
vldloiitly  ilelii-ioiia  for  a  time,  but  recovered  woli.       J   have  un-.v 
or  twirc,   111   ibe   Cfnirse   of  clbiTization,   found    ;iriifiiial    loitb 
loo.*e   in   tlie   moiilli  ;   ami  now  gfufrally  inspect    it   i>rov]ou?lv. 
wlieii  1   liEive  r»us|iici<ins  of  their  presence. 

Patients  riulyocted  to  lung  operations  —  sucli  a^  diffiouh 
ve^ico-vaginal  listnla  in  wtnuen,  and  ax.-'G^  requiring  I'Onneii) 
Jicetioii    in    iucu  —  sliimld    be    iilloweJ,   from    tiim?    i,j    liun'    i^. 


ANESTHETICS. 


619 


partly  ircovcr  from  the  ctlier,  and  get  a  supp]y  of  fresh  atraoj'- 
pheric  lur  into  the  lungs,  Othcrwiee.  from  the  pr>silioii  of  the 
patient,  wliich  incerfcreH  with  llie  abdominal  respiration,  and 
fi*om  the  pj'stein  bceoming  completely  BiituruteU  with  llic  onica- 
Ihetie  ngent,  I  Iijlvo  seen  an  unplcnauul  and  prolongcii  deprea- 
eion  occur  a  number  of  times,  cftuein^  eo:iaiderttble  aiixiotj-. 
For  amiy  uee,  ohloroform  will  umloubtcilly  take  tJiC  place  of 
ler.  FriHii  tho  prejudice  in  luvor  of  rtlior  ia  tlii:^  countrv,  it 
thought  that,  diirin;;  the  Jatc  war,  it  miijht  be  eubetitutcd 
tor  cblorolbrni.  This,  in  priwticc,  hoe  been  found  not  to  be  the 
case;  the  greater  portability  of  the  iiitter  outweighing  its  dna- 
gcre.  In  fact,  to  a  eur*^con  on  the  field  of  battle,  it  would 
probably  have  been  found  nocc^aiir)''  lo  huve  abstained  from  the 
use  of  nmeithetica,  if  But^h  a  bulky  and  explosive  article  aa  other 
hud  required  tmnsporttttion. 

Tlie  I'uUowiug  is  the  rcgtilt  of  the  use  of  aniEiSthotiufi  in  thti 
'ftrmy,  aa  given  ia  Circalar  No-  tl  :  — 

**  There  have  been  t-onstulted,  in  regnrd  |o  the  emjiloymeof  of  flnsea- 
'tholirj,  ihti  rqiorttt  of  23,200  surgical  o|n!raTiii[is  perfunnfd  mi  tkfl 
F^ficld  or  ta  genemi  hoapilnls.  Chlaroform  wn^  ueml  in  sixty  per  eout 
of  these  Dpi.-rai[one,  ulhur  ia  Ihirty  par  <^um  ;  jiud,  iu  tcu  per  eent  of 
the  cases,  a  miKtiira  nf  Ih^  iwn  was  administered.  At  the  general 
,l]Oftpii»ls,  ih&  greater  sufeiy  oPeilier,  a«  au  ann^adieiic^  was  conimouly 

CifQCfldcd.  Il  vriM  nflua  i^EnploycrU  aiktl  do  fatal  licoidi^nt  from  ltd  usq 
has  been  reporlH<L  Iti  iIiq  lii'lcl  oporaiionB,  chlorolonu  was  almost 
excUiBtvelj  uHed.  The  returns  ladieate  that  it  waa  adrntuLmt^reil  ia 
not  le^!]  thnu  ui^hEy  tbouttand  cases.  Tu  fte^eii  jastancca,  fuful  r«Hulta 
bare  bcF:a  oj^criHctl,  wilh  apparent  (airueas,  to  its  [iao." 

In  Hix  of  theae  fatal  cases,  the  operations  were  triiliQg;  and 

|in  one  oaly  was  it  adminiatercd  for  a  capital  opem^oii. 

In  civil  practice,  ether  will  pmbably,  from  Its  greater  safety, 
;nidnaUy  take  the  place  of  chloroform  ;  und  this  is  iilrc'^y  bciiiig 
jdoDe  in  Aome  of  the  great  cities  and  hoepitala  abroad-  Fr<H 
fcssur  P*;tret|uin.  CA-ehJef  sur^^eon  of  the  Hotel  Dieu,  of  Lyonrt, 
Laa  recently  preacnteU  to  the  French  Acadeiny  of  Stiieocea  on 
article  etyled,  **  CltmciU  Studies  on  the  Injurious  Effects  of  Chlo- 
iioforui  on  the  Best  Coijatitutiona  and  all  AgX'a,  and  on  the 
Necessity  of  aubstitutiag  for  it  Rectified  Ether." 


620  ANESTHETICS. 

Jt  wUl  he  obserred,  that  the  eupporten  of  chlnnte 
much  atreu  on  the  method  of  its  Mlraimstnuon  h  t 
etniment,  or  otherwise,  in  order  to  measure  the  quu%r 
find  proper  admuture  with  fttmospheric  &ir,  fromi^Kt 
dangerous  conaequencea-  No  fear  or  precoudon  of  ^ 
ia  to  be  apprehended  or  required  in  the  use  of  etber^  Ic 
the  more  liberally  it  i*  poured  on  the  Bponge  or  towel  ui^'^ 
more  rapid  and  perfect  i»  the  etherization, — the  i 
stage  of  excitement  bein^  avoided,  —  and  the  quicker  tbe 
exi>el8  it  from  the  ayatem  after  the  operation.  In  chilAwn 
reatst  violently,  one  or  two  screams  ao  efiectualty  enptr? 
lun^  of  atmoapheric  air,  which  is  at  once  replaced  bj  ibeii 
of  ether,  that  inaensibillty  is  almost  immediate. 

Previous  to  a  surgical  operatioot  —  which,  it  mavbei 

t  fluid,  id  always  best  done  in  the  morning,  unless  forced  otben 

\  hy  circuma1ance«,  —  the  patient  should  take  no  aolid  foodM 

^  avoiding  the  occurrence  of  vomiting,  which  not  only^ejw 

him,  hut  much  embarrasses  the  proceedings  of  the  opermom 

After  the  operation,  it  is  best  to  leave  the  patient  to  nt 

gradually,  and  perhaps  to  sleep  off  the  effects  of  etherin 

;  rather  than  to  rouse  him  suddenly,  and  subject  him  to  a 

I    .  ment,  nausea,  or  headache. 

;  A  caution  may  be  given  in  regard  to    the  inflammabil 

I  ether,  during  the  night,  where  artiHcial  light  is  necessarv  (c 

'  performance  of  opemtionB,  and  in  obstetric   ca^^es.      In  on 

stmici!,  ^vhiie  oporating  at  the  Hospttiil   nt   iiiirht  on  a  miit 
tin^^or,  tlic  lamp  being  thrc^  feet  distant^  and    n    sponirc  i 
over  tlie  piiticnt*d  mouth,  the  air  in  the  vicinity  became  ftatii 
witJi  the  ether,  ifriiited,  slotting  fire  to  the  spon"-*?,  bed-cl 
ami   even  face  of  the  patient.      The  flames  were   tbrtunate 
this  ease,  extinguished  without  any  injury  to  the  patient,  bi 
without  oausiug  grCnit  friglit  to  those  in  the  neighborin--  bed; 
nn">tlier  instance,  ibe  same  accident  took   pince   from   the 
ducliou  of  a  re<l-liiit  iron  into  tlic  mouth  of  ;i  patioiit.  fnim  i 
the   nj«mge   coutaiuin;^   ether   had   just   been    withdrawn, 
flames  wore  furtiuiately  at  once  extinguished  with    wuter    i 
was    immeiliately   at  hand.      These  accidents   imed    onlv 
mentioned   to  he  avuided. 


ANiC&TBETICS. 


621 


The  importance  of  havia^  tlie  ciher  properly  prepared  and 
thoroughly  x^'fislietJ,  so  an  to  tree  it  from  alcohol  and  otlier 
irritating  aubstnuces,  should  be  carefully  lonked  to,  Otliervri^, 
the  action  of  it  ia  disagrccahle  nt  the  time,  hi^'hly  irritatin;;!  unil 
lie  eub.nequent  unpleasant  effect*  more  protected.  Tliis  wua  a 
fact  cfti-fy  puiiited  out  to  mc  by  Dr-  ChaHea  T.  Jaiikdon. 


Tlie  nnjLv*t]ielic  nclion  of  cold,  developed  by  n  refrigeratin* 
mixture  of  ice  aiid  eall,  as  ftuggealed  by  Mr.  Arnotl,  may  be  .id- 
vAtita^:eouflly  aubfltituted  jbr  ethcriEation  in  uijiiiy  casea  of  slii^ht 
opcrntlond  confined  to  the  skia  and  ^ubeutnncuus  tisauc3.  The 
operation  nniat  be  performed  quickly*  as  the  parta  thaw  with 
great  rapidity  as  soon  aa  tlie  warm  bloDd  bcglna  to  flow  from 
the  divided  vca^cid.  h  For  opcmtionfl  rc^xuiring  nice  diaaection, 
the  method  is  inappliciible,  owin^  to  the  ri^^dity  of  the  frozen 
purtfl.  There  ore  many  eaues,  however,  eepwially  [ninor  opvra- 
tiona,  which  present  themaelvea  at  the  house  of  the  Burgeon, 
whieh  scarcely  authorize  the  distarbance  of  ihe  systeni  or  delay 
which  the  administration  of  ether  would  reniJirc.  For  tbeac, 
loc^al  anroathesiA  ia  of  gi'eat  vahie. 

In  1^52,  1  operated,  at  the  Maaeachusetts  General  Hospital 
and  elsewhere,  with  Mr.  Arnotl's  freezing  mixture  of  pounded 
ice  and  salt ;  aod^  from  that  time  to  the  present,  have  frequently 
need  it,  OA  have  mitDy  other  eurgeood  in  thia  vicinity,  both  for 
removing  small  tumors,  and  making  inciaLonj  iu  ijiflauied  tissues. 
It  IS  beat  applied  by  placing  the  mixture  In  small  bags  orgause> 
Rnd  having  a  number  ready  to  be  applied  succeasively,  rather 
than  to  depend  on  a  single  one;  the  freezing  process,  hy  tliis 
meaijt,  being  more  rapidly  produced^  Irately,  a  nmch  more 
convenient  method  of  effecEiLng  complete  local  insensibility  has 
been  deinonstrated  by  Dr»  Richardson,  of  London,  by  tht^  in- 
vention of  an  apparatus  for  the  riij^id  evaporation  of  ether, 
applied  to  the  diseaseil  part.  This  has  been  improved  on  by 
Pr,  H.  J,  Bigelow,  by  substituting^  an  agent  which  he  has 
named  rhigoiene.  which  produces  a  much  more  rapid  reduction 
of  temperature  than  nny  other  substance  hitherto  employed.  A 
temperature  of  — 1G°  of  Fahrenheit  can  be  arrived  at  in  one 
minute  with  this  «ub&tzince. 


^2W  A>'.EdTHETfC3, 

Oac  of  the  objections  which,  it  was  thott^t,  wikM 
tli«  tree  uBe  at  rhi^lcne  was  itm  inBatntnable  natun,al4 
ilun^r  of  expJoaiou  in  warm  weatlier  ;  ita  boiliug  poinl  ^ 
70'.  J  have  kopt  it  dm-iii[;  the  Bummer,  u&ed  it  in  nttcii 
and  hnve  thus  far  expericTieeil  no  accident ,  nor  bcaj^  if 
o^wurring.  I  huve  tried  it  iq  oases  of  caucer  of  tiie  tj,' 
aind  nose  J  and,  with  proper  manag^uicnt,  and  enffiooi 
for  its  Buc'fpflsive  npplicntioTi,  it  ini^ht  be  emplovcd  in  li 
icov&l  of  large  tumora  involTing  superficial  texturee. 

The  nitrt>u8-oxide  gas  is  qow  bein^  very  cxtenHyelv  it 
tho  dentists  of  this  city ;  iie  inhalation  being  much  &» 
by  recently  irnfjrovcd  valvidjir  wpparatua,  which  allows 
constant  supply  of  the  pna  unmixed  ivith  tJic  pulmow 
hahitioUH.  Thus  fiir,  I  am  not  fiwarc  of  any  fatal  reouLt 
ilw  use.  It  ie  very  pleasant  to  ichale,  an  J  tbe  recoverr  fi 
effects  is  usually  iraniotliate*  It  le  very  doubttal,  howeT< 
it  will  be  adopted  for  aoy  of  the  greater  operations  in  soi 


i/^^ 


INDEX. 


HII 


li/ 


INDEX. 


Abi)oiD«n,  Chaplvr  V. 

,,        (jannhot  Woand  of^  Ml. 
Sttb*n»S7(>.  fi7l, 
Abiance  of  V«j:ini  ^nd  Ulflmi,  £0S,  SOB, 
Adipota  Tumor  of  Huid,  Ml- 

f,        Tuman  of  ^ptmijitlc  C(>rd,34e' 
Air-puSHKu,  Porfiign  BodLei  tD,  M. 
AldBTi,  Dr.,S4fi. 
AllKrtozi.  Ur.,333. 
AmpuUtlon  of  Arm.  3S«,  390,  141. 

orbiirhlblgK^Ol- 
„         Hip-joini.  4Uf,107. 
„  or  Le^,  Bei.  3B9,  304,  SBfi. 

„  Shoulder-iairt^  aST^flfi, 

^  of  ThJeh,  SOAh  897,  «00,  bK, 

6»,  A3A,  £37,  MA. 
AiApDtfttLonif  864. 

„  Tabid  of,  409. 

Amoanat,  H..  197,  304. 
AnmLhuii,  LocaI,  031. 
Aiieilhetla,  Cbaptar  XIV. 
AiiuidilB,  Mr,,  nil. 

AnenrLiin  by  Anutomoils,  443, 4A1.  IST^ 
„  or  Abdominal  Aorta,  437, 

„  of  ropbtenl  Artery,  438. 

..  of  SnbolBViM  ArtfliT,  436.  437, 

430, 
„  r»r  Tborulo  AotIji,  404- 

„         VftrjccH,  or  II«nd  iknd  Ann, 
4fll. 
AnaDTi»n«l  Tnmon  and  Llgitura  of  Ar- 

IvtIh,  434. 
A  nut,  ChapUr  VL 

Artlfldal,lfl8. 18ft,  176,  177. 
Fluareof,  IBfi-ISu. 
KUtulaof,  191. 

ImpFrforatF,  196, 196, 199,  301,  303. 
Prokpua  of.  194. 
Apii«ndix  VQTmironiaU,  Guifcnnfl  of,  ftT6. 
Arm,  Tumor  of,  619- 
AniDtt,  Mr..  460,  631. 
Artariflfl  Hud  Vakni,  Chiptar  IX, 
Artflrj,  Vertebral,  Wound  of,  AfiB. 
ATflrj,  Mr,  139. 
AxiLla,  Tamor  of,  61S. 

RteoD,  Dr.  John,  313,  31 1. 
Ball,  Dr.,  5^3. 


f  Burnea.  Sqiy*"-**™""'  U.  S.  A.,  643- 
\    Bartlett,  Dr,  Jo«JBh,48S. 
btnon^B  CIpfitKtioD^  417, 430. 
BoanmODt,  Ur.,  3SS. 
Bvll,  Honjiunln,  167. 
„    John,  441,  443. 
B«nDBC,Dr,T6. 
Lteniutt,  J.  tiafbaa,  Dr.,  480- 
B4rard,  H^,  4ba, 

Blgalow,  Dn  Henry  J.,  4e«,  «17,  031. 
Bladder,  Stone  in,  304-336. 

„        Wonndof,  341. 
Olaka,  Dr.  J.  Q.,  163. 
BodBufaamer,  Dr.  Willlani,V)1. 
Bond,  I>r.  H^rr,  831. 
BowdLEcb,  Dr.  B.  I.,  147, 149, 161. 
Boter,  M.,383- 
braln,  Concutslon  of.  16. 
Breut,  C«nc«r  of,  fi13,  £14,  616, 617- 

„      Chroolo  IiLflaiDmatioii  of,  611- 

„       CvtlSo  Tumor  of,  609. 

„       KrecUlfl  Tumor  of,  610. 

„       Male,  Tumor  of,  618. 
Brijj^CB,  Dr.,  41,  497,  fil6. 
Droadbflnt,  Dr.,  488, 
Bmnchaa,  Foreign  Bodl«a  In, 97,  100,  103, 

104. 
BrovD,  Dr.,  109,  178. 
Brown,   Dr.    Buckmlniler,  164,  393,  434, 

460,  67S- 
DjTant,Mr..330,l48. 
Back,  Dr.,  «3S- 
BDiutHd,  I>r-,  889. 

Cabot,  Dr.  Samual,  108,  S64, 868, 404, 633, 

6*7,  C96. 
CbIcuIub,  Cntifl  0<ldv,  113, 314. 

„         Oxarat*  of  Lima,  307,  300,  316, 

330,333. 
„       Renal,  In  Kaqulfl,  B04. 
„       Sallvarr,94. 
^         Triple  t^hoaphate.  318,  331. 
Vealcal,  in  Female,  SOB. 
CancoT,  ICpilhallal,  47,  481, 

„      of  Bmit,  481,  433,  613,  614,  616, 

617' 
„       of  Kar,  69. 
„       at  Kj«.  66, 66. 
„      of  Ganltali,  344. 
^       of  Lip,  49. 

70 


1 1 1 

^^^^^^^D^^^^^^^^^^^^^irn>EX.                                       ^M 

Cunc^ffr  uT  Kc4i;,  &9, 

DifllocAlioQ  of    Feinar    kukvn*,  i^H 

^^1 

„      vf  fnroTia,  4&n,  iO],  4as, 

of  F*iDDrfatioF<nBBVK,H 

^^^ 

,.       of  HnctiiD>,  243. 

^^1 

„       of  Tc*npie,  «a. 

s«4,  sr».  aTK          ■ 

^^1 

,.      of  Ton-iilB  luiil  Tbrnac,  12D. 

f>^  l-'emiir  domniBfl^m  ^| 

H    1 

f,       J'lLlilf  of  Ufierafiona  far,  S^fl. 

^^1 1  ■ 

(JvKffniuft  Tiunors  of  Jaw,  SO. 

Swkec,  sei.                  ■ 

^H  ^   1 

CvMid^  LJgAUn  of  If^  «30, 

„          of  ShouMfT  btcknrii.  ?  ■ 

1      1'' 

Guroiidi,  LigaiiiT«  of  both,  t4«. 

Cufti  uf  Tnpbmiuif  fur  £p1jei>dv,  ThUv 

„            ttf    ShoitJdAT    fvwifdi^  C  H 

SAA,  iwt,                  m 

HP  r ' 

of,  15. 

Hi  1 

Ce}liiJRr  Tl&9a4,  IndumtloD  of,  QDU. 

Hi  I ' 

1                                             Ccrvin  IHaH,  LlypDrircrphr  of,  fl&4»  3^9. 

4t*l- 

Hn  1 ' 

DJfl]oeaLJ«pi,  S4fa. 

1    1 

,,            TBbl?  of,  m. 

rt      Btonrtoiit  Tuiflor  of,  VJ&. 

^^1 

Chnt,  tiunihnt  WniirtJ  □!,  bi>6,  EtflO. 

iJopuytren,   U..   75,  71,  iSij,  Ifij,  l"*.« 
3±fr.22Z,  332.  4fiS. 

^^1 

„      Slali  i[f.  &70.  C7r 

^H 

„      ibo,  Cli(ip(i-TlV, 

D^flt,  Dr.  Etm,  3ia,  405.  *«, 

^^1 

Cheevor,  Dr.  V.  W.,  ^03,  601. 

^1    1  1   ' 

CliLorJa  Kther,  «17.  Oli^- 

E_ 

H  u  1 

Chiofrifbfm.  613.  «IT»  fllS, 

III 

CtccTtlur  Nu.  CL,  S43,  fiflS,  918. 

Ear,  EpiihelinT  Cjincfir  oC,  S0. 

CivinlL'.W,,  301,212. 

Clarli,  Dr.  Henry  G-,  ^an,  IflBj  ftfiT,  B7n, 

„    Fibrout  Tamoi  of,  fi». 

„    th*,  ,ift. 

^H 

Coftl?,  Dr.,  6N. 

ELb^m',  Lhtent]  DJAJacnUnn  of,  Ml 

^^H 

Coecyn,  Tujnries  fif,  E&3-5»a. 

Ellis,   Dr    CftJvia,    n,  306,  314,  404. 4JI, 

^^1 

ColliFi,  Mr-,  l^U,  lAl,  IftJV. 

ftlifl.  rj^4,  e£<i. 

^H 

ConcuBftioif  of  xUe  Drain,  1^ 

Enclii'iidrvniH  of  Fin^rer,  StO. 

^^1 

CongGDJIaL  I'^ii^ion  of  t'iiigen,  60^. 

Eiifysled  Tumor  of  Todrtnt  W,». 
Epllupflj,  TrapQ*niiigfar, .. 

^H 

Cooper,  Mr.  flriDpliy,  ffJU. 

^^1 

t,       Sir   Aatlov,    2')*^    &S4,   A3S,   S£4, 

Epitlielial  Cuaoer,  47,481. 

^^1 

1                                                                S5H.  a^b.  ?T^,  t49. 

H 

i                                       Cord,  Tumors  (jf  Spcramiic,  i*9, 
^                                             Cft^lello,  llr.,  48  T. 

It                  M        Of  NaM>,  &1. 

*T                  1-        of  Vulva,  iTa. 

Epn^K,  7r>. 

1 

Cfiiilwn,  Mr.,  lafl. 

Cos.  Dr,,  aOC> 

EiecLih  or  Vascular  Tomor  nl. 

CTitfhptoti,  Sir  Phi^i[],  IAS, 
1                                       CtudIuui,  KrBctiir«ii  ul,  l. 

„         Tumor  of  Br^^at,  a|r>. 

^^M 

»              t»       of  ChMk.  &84. 

^^M 

„         Wound  of,  6,  Jj56^ 

«i              1.        <jf  Eur,  46j. 

1 

■■              «        of  Face  uttl  Seek.  M*' 
>i              "        oF  I4snd  And  Arm.  4SI. 

1                                      Crouri,  ]c>e. 

n              11        of  HtfBd.  4oK 

^B  1  a 

OniihihiiTib,ltir.,  iHR. 

pp              pi        of  Keioc,  -fcaij. 

H    f 

Curliiijj,  A[r.,  2&^. 

,,        Of  3ilnuth,  4^9. 

H  \ 

Cpttis,  l>r,,  £6fl. 

ti          <^      <^f  ^cjiip,  tia. 

H  1  k 

CnvJflr,  Ur.,  Surgfoti  (!.  S.  A,,  644, 
Cyfllio  Tumor  of  HrcjiAt,  608. 

F.TiL'h*«i.  Mr..  7.%  223,  aie,  i«. 

H  U 

Ellior,  flia,  GI4,  010,617. 

^H  fi  '^ 

„       of  Jaw.  7a, 

p       Finl  Opomtipi,  under,  *ia. 
Exalalon   of    l^;»<emfit    Candvl«   of   Ho 

^^1  li 

„           ^       rkf  TiLln,  A32. 

^H  '1 

.,    «i  v*«in*f  ara. 

meruH,  410. 

^^1 

■ 

,,        (»r  JninU,  400. 

^1 

T*. 

af  JoJatu,  T*hle  of,  423. 

"            420**^°'"'"  ***■  ****  *'*■  "' 
n         of  BhouIder-jfiin(»  417    45H 

^H 

Da-min,  Ur.  H.  F.,  tOl. 

^^1 

Paviiipon,  Dr,  H,  K.,  110, 

EiLiuclion  of  Keadleq^  690- 

Hi ' 

TJpi|»'rk,  Bfl. 

EnlrpiUlliftS  tho,  Chspier  VlII, 

Deptc^i'ion  of  Sktkll,  T-E>,  n. 

Eye,  Cancflrcf,  G5, 

H'    ' 

Dflhniili,  M,.  J!24. 

,.        „        of,  MelnnotJc.  fie. 

■  ' 

Def  liLiiun  uf  SH|<tuni  Nabi,  03- 

,.     Ihi",  ifi. 

■ 

Ditkf^ou,  Dr.  R.  K-.VO,  Hi", 

EycUd,  BesEamtion  of  Lawer  4^ 

^H 

lllPtfenbncli,  I«,  lU,  '^1',  121),  134. 

■ 

H' 

J)iKiUil  Kcivfl,  KxlIbIutl  uf,  47{>. 

F, 

„           „        Nouralffiu  of,  1?6,  476,  477- 
j                                          ilialDmlion  cf  l>rttli  1  filRlifl,  w^. 

H 

Fnre  md  K"cdr,  fiU-J. 

*                                                         „          of  KIbow,  Lalcrnl,  353. 

„     and  Orbit,  Tumur  of,  4BW. 

^^^^^ 

„           of   Ktnmr,    D'lrsal,    3Cl-3fi6. 

,,      il'jni  ii|wi.  i»l. 

hbl 

Sef^TM. 

„     EhCf  C^JL^|tl3^  U, 

L     F    » 


^p                                                                                              ^^^f 

^VMDar,  DUIouIlom  or,  3«3.  M4-*H% 

Ofmd,  Dr.  Juhq,  If  fl.                                                  ^^| 

V2>iVu«i>n>SirWl]lXBmH  d».  130.  U)< 

Dr.  S,  A..  3^2.                                                 ^^^^M 

^■u*]bru4a  Tiimur  "f  K«t,  6bd 

Gnnci.  Wound  of,  fii>&»                                                ^^^^H 

^K^              TiiciKirn  Eir  Jaw,  M. 

Grob,  rnif'pafi>ir,T3,  9^.97.  i7\  Ut^                      ^^^^H 

^1.    „       T-JniH.r  <jr  Tbigb,  &3tf,  b^h 

GitArlu,  M.,  noa.  UD4,  aoT.  OOA-                                  ^^^^H 

^■wi,  Mr, 

^^I^War^  tnclturidrnmn  oA  MQ. 

^^^M 

^^^^bn,  CoEi/^tiiiink  Fmk>u  ofi  I^OC. 

Oalbrlt,  Mr.,  &4a,  «eD,  ATS.                                 ^^^H 

^^^mSue  af  AiiiiA, 

^^^^^^H 

^^^,      of  Pulnm.  i:iO, 

^^^1 

B  PJMBlain  Ann.  lil^. 

m         „      UreChnil.  frflm  Waimd,  2S6. 

Hemntopf  t«,  u^                                                ^^^^^^| 

•          „      Vc^CD-mHiJH  W4,  343, 

naljfhEtm,  4E>1,                                                     ^^^^H 

*       n        p    vKvi"  J,  asa-au8. 

^^^^1 

*      FlnTiikiiu  OiieniD^  cuiiUtDiuf  ttklr.  tv3. 

HninliToii.  I'TuHwur.  H19-                                    ^^^^^| 

'        iwa. 

^^^^H 

•       Fl-ffR.  Dr.,  323,  al«- 

H>iix',  Ur,  A    A.  6lf.                                                ^^^^H 

V       yglti.  Or,  36", 

Rjivwiint.  hr.  ^^oi'i^i-,  IM,  OlA,                                       ^^H 

;        Kfrii,  MiiircriniLtiDn  <ir,  011L 

Kcj^ii.  frilDnllol  \Vl>UIii]  'jf,  <*,  A4S,  &au.                                ^^^^1 

ForaLgn  Ei<j<1tf!«  in  Arr-pM4fi{iefl,  OA. 

„            h       111  {£^<ifiUH^iii.  112. 

„       Body  iD  Vaglao,  SfO. 

nafnorrlinija,  l&«-ta«,                                               ^^^^^1 

Foi.  Dr..  ayi). 

Mri,                                                                 ^^^^^1 

4,     J,  L..  r:^urA;i-oii  U.  9-  'Strj,  6U,  &». 

HennapliroHliKni  010,                                                 ^^^^^^| 

l^rjicrirre  ni  Arai.33l, 

ina.                                                         ^^^^H 

„       of  Arm  [idLtAilrif;  T>L«|ocatlaii  of 

RiihcAl           of,  I'li'laH,                       ^^^^^1 

Klbtw,  tlU3, 

„        df  Hn»  nT  Mkoll,  fl,  4,  &aT, 

n        of  CliTrclfl,  BiO. 

H?vwo(i4l.  (>r.  C-  T.,  41.                                             ^^^^H 

„        vt  L'lT-cvx,  ^liG. 

Hip  iinEt  ^pirnil  L>iiMiAAO>,  f»T3.                                  ^^^^^H 

t,       or  CoDilvtA  Of  MitmrrQt.  »31, 

Kirvjoii}!,  Am  pill  nil  (III  ai-  4'y£.4ti7.                        ^^^^^H 

memft,  Bin. 

UudKfa,  l^r  R.  M-,  31B.  -1411.  40a.                             ^^^^| 

„      of  F«murH3:JS.ai4,fl4i,»:c,&iD. 

Hnrik  r>n  the  Fhf^p,                                               ^^^^^^M 

„         of  tDre^arm^  fUl- 

^^^^^^M 

„        af  llTimprw  dniiDilw!,  32S. 

Hiiuiok,  llr,  A.  ^..                                               ^^^^H 

»        nf  Mnlir  D^ii?.  ^20, 

liiELiicr.  ^1..  ;?4,  ^iiiv,  avB,                                  ^^^^H 

„        af  Arnlftr  |toa«  utul  Sun,  Mmil- 

EluiiL«nii»  AiiiiiuiniiDn  a^  &f^  31H>,  4^,            ^^^^H 
btflocnrinn    of,    Hn4,    Ififf-UA.                    ^^H 

litv,  !i'i7. 

„        of  Ni.T;k  <kf  [he  ynmar,  MO-343, 

flir>,  8411- 

,.       of  Neoli  or  tha  Femnr,  irith  In- 

onimdof,  til.  433.                          ^H 

virrAlon  uf  FiiDl,  J142. 

FrauluFfl  of.  Oitl,  £fla.                                         ^^1 
of  EpIphyslB  of  tloMd                  ^^H 

af,  aaan                          ^^^H 

„        of  PMflllH,  ail,  88a-3»S. 

,,        of  Pelu1t,D30, 

.,        of  Radius  Jlal.  SSDh 

,.       of  Shirll,  ^.  A.  yj.r^bs. 

nf  Qminltor],  S3U.                      ^^^^^H 

„          of  ^|kiMF.324. 

HuUiljln*ou,  Mr-,  4»,  CS,  aro*                                    ^^^^| 

„        of    Supcrof    Mftlillufy    Boriat, 

By  A  roe«lo,  ^  1                                                      ^^^^H 

SiT. 

or  the                                                 ^^^^H 

Fnuturu,  aiB- 

Hriropbobio,  Cfi4,                                                       ^^^^^H 

,,           of  Cmninni,  I- 

tlypOTtroph;  of  CBr*U  Uleri,  304,  »S.              ^^^^H 

7uiif^id  TannH-  of  Fonhtad.  lau. 

[line                                                                      ^^^^1 

G. 

'      'tbai^hp  oT  App'udU  Vttmtfarmiit  f»'J^' 

imrt^rlbrntc  AnaBUnd  kcctucn,  W\.                       ^^^^^H 

«*y-  r.lr.  <i-  W..  m.  *** 
GflbttjU  OrKiii's  Cwicar  of^  3tA. 

Dr.        tir,                                                         ^^^^M 

liidurAloi  Tnniur  uf  renin.  24J^^4t].                       ^^^^^^H 

1      6eiiJLd-uriuii(7  Or|nuit,  Cbtpler  VI[, 

InduTiUon  r>r  Celhjlhr  Tihub.  AOO.                           ^^^^H 

1 Fonalo,  lU. 

Injurtu  Hud  Dlmuu  o(  iterrt^.  Otup,  X.                    ^^M 

r          „           H           i.        UnlOiSM. 

of  Ot  Cnccy^i.  GOS-tM.                                     ^H 

H«nsoal,  Bfl. 

of  t>i*  Scalp,  Ifi.                                                     ^^H 

GIIjIhh  Mr-,  lin. 

^^^H 

OlUira,  Dr-  C,  B.,  64&h 

^M 

titlmiin.  Or-,  hi. 

Oordnn.  Dr,  ClLiirk*,  Atf. 

Jm:k»q,  )>r,  C  T-,  OIK.  ^]^  rial.                                ^H 

Gi>uIh|,  llr.  A.  A.h33',  «t<l- 

l>r-  Jkitio.  ISI.  INu,                                      ^H 
Pr-  John   b.  3.,  tUtf.  aui,  d]£,                   ^H 

<jriBf«,  ]«>  fi0H  126. 

-     Gndtjt  Dr,,  STa. 

aoSi&aa.                               ^^^H 

628  INDEX. 


Jav,  CfttiflaroDA  Tnmon  c^,  S<M4' 

„    C^Ue  TDmort  of,  73-^^ 

„    Fibroui  I'uiDon  of,  84- 

„     Myelord  Tumorfl  of,fl*-m 

„    Nacnuii  of,  »&-n. 

„     EomovAl  of  Lower,  flO,  70^  "»,  M. 

^  „         Df  Upper,  flr,  81,  M,  84- 

„     Trephining  Lower.  472,  474, 
Jnw-bOLifl,  Tumora  nf,  04- 
Jointfl,  ExiiIaIdd  of,  4M. 
JoDva,  Dr.,  4fll. 

K. 

Keep,  Dr.  K.  C-,  SQ- 

Edm  itnd  Llbow  Joint,  GoiuboC  Wound 

of,  6W- 
Kn«e- joint,  Excisi<Hi  of,  414.  ttlMir,  430, 
433, 

„        M       Nevuft  of,  440. 

,.       „      Ncvdie  paDstr»riDgr  AftO~6n. 

LHbiLL,M.,  18,18- 

h^my,  M.,  M8. 

LArynfrilrB.  Tnich«otoiny  in,  100. 

LjkTjnK,  Korfiiga  Bodv  fn,  10&. 

LatiA,  107. 

Uwrencfl,  WHliun,  Hr,,  IM- 

.,  WilhuD  R.,  Dr.,  00,414. 

Lebf  n,  U-,  4H- 
L<^,  AmpjtatJOD  of.  391,  aflA^ 

„    Re-^iaputAiion  of,  aaa,  AM. 

„  Wound  of,  &i&,  S4e. 
LeuEsocylhEmlft,  4Ttt,fiO]. 
Lip,  Cancer  of,  4fi. 

„    Ctncert  or,  Tflbltt  of,  £1. 

„    Upper  Chuncrfi  of,  61. 
Ll»fntnc,  M.,31,  S&l,  SH4, 
Litton,  Mr-,  U,  1 07,  880. 
Ulhotomy,  204,  ft  18-330- 
Lilhotrlj.  304, 207-31 S. 
LocB.1  Ansi^iheaiA,  021. 
LoThmji,  Dr.  J.  K,,  41iij.  428. 
LuiLgB,  Wound  or,  &U0,  Gi}4. 

M. 

MHlfonnntJon  nt  K<>ol,  'i\2. 

MHl]-ni>fiie,  M  ,  832,  348,  319,  3^,  853, 3AB. 

Mardi,  Ki^f,  73- 

Mjirrih,  llr-,  3UB. 

Metanu^it  of  Y^ye,  56. 

,^  of  B'jiroiiJ,  4B1. 

Martier,  Tkf,,  223. 
MeyiT,  4t'v'i- 

Mii'i"T,  Iir-  FrAiici«,  145,  U.ft,  808- 
ML^celliiiieciti^  (.'fl-c-,  Clinprer  MM, 
Mi>]|4  \'eiiBrift,  TiiTiLor  of,  '£'''j. 
MiTphiH,   lEvpchjeTEnic  U^Q   m   Npiii'algLA, 

4(i7,  4fiM,  4n,  A71. 
Mcirl'iii,  llr.  W.  T    G.,  iB7,  SOil»  fili-Olii. 
Mii-:ii!v,  iVfjlr,  40i-. 
Mj^eloiil  FuniOTs  of  Jkw,  ^4, 

N, 

Kn>viis  nver  Knee-joiiir,  4ljO, 

Neck,  tncjsled  TJiyroid   Tiimui-  of,  506. 


N«ck,  avdrocele  of,  Wi. 

t,      T&jToid  Tnnaor  of,  607. 

,t       Tumor  of,  49S,  Mr 

„      the.  Chapter  IIL 

„       Would  of,  G44,  658. 
NecroAlfl  of  Jaw,  SS- 

„        of  bkulJ,  670. 
Needle  penetfjirmg  Knee-joiot,  i»>-j«t 
NeedJes,  KxtmcCHja  of,  b>0, 

NeTTBt  ExcUion  of  Digitml,  *n 

„       Soivtic  Wonnd  JmplicEiiE^Vv 
Harres-   Ipjuriev  mid   l^ir nam  vL  lq> 

ter  X, 
HearBlgU,  Dlglta],  470-477- 
,,  FftclH],  4TS,  474. 

„  TmuEnatic,  of  Arm,  44^,  1^ 

Nitnc  Acid,  Poi»oninjc  bx,  £78. 
Nitrout-oxida  Gafl^  QftX. 
Nozrifi,  I>r.,  439, 

Now,  DaTiKiion  of  Stptnm  of,  41,  6*- 
,f     l^pLchelrnJ  GAnceroC,  fi^ 

o. 

OooLuion  of  Va^nB,  3T8,  UO,  TH.  i-'- 
3S7,  a8S. 
.»         of  Utemn.  191,  m. 
(Emphflgaa,  Foreii^ii  Bodiet  in.  in,  iV^- 
„  Strictana  of,  114-116. 

„  Tamorn  in,  116- 

Offlurt   of    Miua.    General    tfowital  m 

McLeui  Avjldii],  1840,  on. 
OliTflr.Dr.  M.  K.,  m,  ii7_  U9,in,tr.. 
Opaniuoa,  Barton >.  417,  430. 
„  PiincoAsi's,  184. 

..  Pirop>fl''»,  SOI. 

,.         Svme'a,  A»], 
^.,"^      Wiiiier>,  1*7. 
OrblT,  Tnmorof.  6T_ 
Orgnni,  Geiiilo-uriimn-,  Ohaptu-VIL 
"  i>  .T  Fflrnale.  lu- 

ll ,p  MaLe,  304. 

Oli»,  f:  A.,  Surpeon  U,  S.  V.,  543. 
OvariuiL>nJ%,  JOO,  3<ia. 

P. 

Ppe*,  Dr.  C- C,  134. 

I^BH^'l,  Mr-,  47,  la.  2T0,  466,  &3*. 

Palme.  Kis*urot.f  ^oft  atid  Huni.  iifi,lV 

140. 
Pnncon^ir,  Prnf.,  164, 
Knrncniresin  Thonicip,  146, 
Pjirker,  Dr,  WlHar^,  13^    ^53 
l^nrltmnn,  Dr.  Georce    i'-'7. 

„  Dr.  Samuef,  164,  487,  617. 

Pnrotid  Kej^jLtn,  Tumnr?i  of  4^5 

„       Tumor  of,  J8y,  490-4*13,  49o,  4'^: 

Scirrhous  4^0. 
Parsimi,  I>r.,fi|fl.  ' 

Pinchn  Dr.,  ins. 

pjii'-llH,  Kmriurp  of,  .T22    33'*-_3^:t 
Peirsoii,  Dr,  A.  L,,  143. 
Pelvi*,  KrrtcTiire  of,  33£t, 

„       WliiiihI  t>f,  ."pfil.  .'S07. 
Pen^lnitii,£  WRmiiU'*  of  Chesi  ni.d   Aid 

PpohotderrPmoved  from   Hlndder  600 
Pens',  iiidumted  Tumor  of.  3i6. 


^^^^^^^^^^^F                              ^^^^P                  ^^^^1 

^BR,  Wdufid  Qf,  Kt, 

Shurllcff,  Dr-,                                                                ^^^^^1 

^Vpflfiiirk'UEiL,  IfupEqn  af,  7fit*.  3M,  Vtil. 

*«1inp«Dri,  Dr ,  301,  Slfl,  S9T.                                               ^^H 

^P«iinoii]  S«L^DD.  U1V-2B1,  144-^0,  23», 

Sims,  Dr^  303.                                                                        ^^H 

*     flirt. 

Sktillk  FrftcluTfl  ufp  3.                                            ^^^^^^H 

*■-  Pmi#|alD.  FTOf..  aifl. 

»)  Rvt  of.                                 ^^^^H 

'  4    rhtmfuii.  ^AO, 

Slmle,  I>r.  D.  !>,.  «t,  U«,  1W.                              ^^^^H 

a.  Phyiick.  Dr.,  ITB,  S:a. 

Smith,  l>r.,  Sii.                                                                     ^^^M 

^  PlTnp:>lT'»i  Openlinn.  3l5[i,  ^fi2. 

tn^.i.v.c.,ni*i.                                     ^^M 

^    pFklwmDH  Ut  NiLiic  Acid.ATB. 

Smvly^,  Dr.,  ISU                                                                      ^^H 

Zi       PnMiwk,  Mr-,  130,  131, 

Hoii'h^rhielle,  lir  .60.                                                             ^^H 

ai     PutjpLtiijf  ItHcruQi,  l»fi,  IH. 

SpBnutLrc  GoM,  'TuaiDrii  Df.HS.                                       ^^^H 

t         „        of  lir^rii^p  aTJ-i'ri. 

Slbiili:^',  Mr,,  73,  S'f).                                                   ^^^^^H 

14      Prlully,  Ur..  ^I'i. 

^^^^^^H 

Pra]m]4e  M  Apil-,  iH, 

^[i»iie  III  DlHdiliir  (oira  Cnlculut],  104.                       ^^^^^H 

(       Pmrtilo,  DLiviiHci  uf,  210. 
^       Putniim,  Dr.  Cturlei  Q.,  S19. 

SlTJCtUTfl  of  lE^HOftTlMKUA,   114.                                                                     ^^H 

□r  L'ratJini,  Fcrii*«Hl  Section  for,                       ^^^| 

„         of  Urotlim,  with  ItoEbnltoii,  ;|u,                        ^^H 
Suticlnvinn  Aneuritm,  All,  43T,  43V.                                   ^^^| 

R. 

RnJluH,  Pnti'lUTH  oT,  £121,  330. 

Swan,                                                                                           ^^^1 

Riiyor,  M,,  BO, 

Swinbume.  Dr^saa^                                                       ^^H 

Ku^finipurHTJon  ct  Ld(£,  BV>X,  nU4. 

S/mo,  Ur-,  30d,  3aD,Sh6^4UQ,46fl,4f<3.                              ^^H 

Bvatuiu  nnil  Anu>,  Impvroralfi.  UOi 

„        Ciiiireruf,  243- 

^1 

„        Polvjiuricf.  IVfi,  l;w. 

^^^^1 

lUcarront  L^nh>Iid  Tutitdr,  11^7. 

Table  of  AmjiutPLiDn>,40D,                                        ^^^^^| 

Ramnvii]  of  Tfn^iU.  ilW,  rJI.  133, 

Cjmcer^nf                                                      ^^^^^^H 

„       at  Lower  Jhw,  Q!r.  04«  70,  7^,  91. 

|lMi>CHlJ01<f,  4M,                                                 ^^^^^H 

„      of  UpporJa*,*?,  81.«l,M. 

cF  lUiguiotiB  iff  .Milt",  43B-                            ^^^^^^H 

Krntl  CmIcliIu*  In  Fornilft,  3(H. 

cf  OpaTHliuntlikr  Uinpcr,  MIA.                    ^^^^^^H 

„     or  Oiitmlkn*  fat  E}iiluppy.  IQ.                        ^^^^^^| 

RvmnttDn  flf  EvHllil.  OpBTatium  for,  i% 

THlinDoliuft,  tH.                                                                         ^^H 

U. 

0[ifnUon  by.  HtUud  Af,  8o,             __^^M 

RffiiiPcilaTinii  Fiffor  brDwninift  f>nH, 

^^^H 

KfXHf'Nirl  Tcirklf,  1^,7- 

^^^^H 

KertiulUs  D^  t<lwnrii,  AT,  hi,  «|(t. 

TKylcir.  3dt,.                                                           ^^^^^H 

Bhl«Dl4ri«,  C31,  I3fl. 

TBiiilDit,  PArtlAl  Ruriture  ef  Oii»JrioBn.                    ^^H 

llhlhO|ilBiitid  Upentknna,  ]a. 

Bttt.  iJia.                                                ^^^M 

Bbiuoplul/,  latliiiD,  lU,  lia. 

HLiiiLurD  nr  QDBiLrlct|jA.  146.                     ^^^^^^M 

„            THlioofiLiiiii,  K,  M. 

Tendarir  Pninfut  Cr^pLfalion  of,  fifiU-A^il.              ^^^^^^H 

TllchiirdMii.  Dr.Cai. 

Teiiilcte,  KfftalnM,                                                ^^^^^H 

Rjchi<niml.  BL,  Mft, 

Thigti,  AinpiiiHiiiiEi  of,  fl^d.                                          ^^^H 

Rii^eri,  u..  sre. 

„       Uiiilocntiou  uT.  3^3,  Ki.                                           ^^^H 

Rntlvnt  UiGor.  4}i.  Cfl, 

Pm^iure  cf.az^.  d:4.                                                 ^^H 

Rous,  U.,  Lsfl,  13Q,  tnfl. 

(jbiijihol  Wuund  a(,  640,  &04,  G8T,                          ^^H 

KupEunof  Pertiiiriim,  ^J>M,  3flfl,  Wl. 

ThOTncic  Aiirlii.  Anflnniim  n(,  4S4.                                       ^^^| 

V           ,,        uf  Teiidnn  of  i^umLricapi  Pflmu- 

I'laaniDls  Pirvcan[ni#,  HQ,                                                   ^^^^M 

■                         ri»,  U^B- 

Thi-oa,t.CAD€trtif,lW,                                                   ^^H 

■          „        Ponl*!,  of  Tsnrtrpn  nr  (jLiiulTlecni 

Tlvtanmnn.  4n<.                                                             ^^H 

Toutue,  Cmicn' of.  tM^                                                   ^^^H 

■ 

Wound  cf,  &A3.                                                ^^H 

'                          S. 

ToDfElA,  CruicOT  of,  lU,                                                          ^^H 

Sitlltirr  Ctleiilbi.  M. 

Etomovnl  nf.  119.                                                       ^^H 

SaTimlm  Mii*ljIf,  Tornvr  of,  &lti 

ToHn^fln^^lJj.  S-  D-,A7,  944,  «fT,                                        ^^H 

Sn-y? '.  I>f,  A.  A,69&, 

Tn-'rhi.'ta,  Fr^rekfru  Do-lv  in,  104.                                            ^^^| 

Sriilp.  Itjiiiiuor,  Ifi. 

TnrliNininy.  l<l^  lire.                                                  ^^H 

SiiljwprJI,  :<n. 

TrnriF^HuHiuQ  «/  Oi^itii*,  J^,                                               ^^^H 

Srlrrhou*  Tuinur  qT  PHrafId,  41'0. 

Traphiqing  for  Kjilkptj,  7'\&.                                             ^^^H 

fi«C!li>in,  PrnriHl,  3:;i>-3ni.  3;t4-3aA.  SSfl. 

for  N^nL^lD.  471,  474.                                    ^^H 

«a. 

Tnbrrcif,  rulnrul  CvtontonA.  AAA.                                      ^^^H 

Baplun  Nutl,  n^TtKlinn  of,  03,  flR- 

Tdqidt,  AriiyiOB^,  of  llmmi^  £31.                                      ^^^^^| 

ShHlluak.  Dr.  *i.  C,  Un. 

^^^^M 

Slmw,  Dr.  »,  S,<W,  W7. 

QonlJiinins  Aiv.                                                  ^^^^^^| 

_   fifamlAai,  DlikHwCkoii*  nf,  ua.  :E£4,  ^60- 

K                  aaa,  mo,  ^n\. 

„     DrTtL*;^,;^^.                         ^^^^M 

■  „        joint,  Ampuudan  ■».  «8T-3«0. 

■  .            „    EialiJanof,  411, 

of  Vafrhn.ars.                              ^^^^^H 

EiLCifpbHlold.cf  Tlilgb,  KIA.                      ^^^^H 

;■ ! 


'    I 


ERRATA. 


Pap   4e,1lii*      a,|Dr"plftla.^' 


.>      M, 

.     lw(. 

M           W. 

.          ^^ 

1     w» 

18, 

,      8»>    . 

10. 

.    Ba»  , 

IS, 

,    10I>    . 

1£. 

.     3H4,    . 

IT, 

<^  ■urDitdnrDataDiit'^ 


t;,   „   "iiiibU/' 


•'  OtjHtlOb." 
''  pubrt." 


'    i 


'I 


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