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Full text of "Surgical observations, with cases and operations"

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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 


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 th e 
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, 






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 pt iW ^ g i 

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 p c r feaJj 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 cn tire h" 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-yamm gtX t 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 lat ei tm e , 
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 ^ pr uoied . 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 preawif e 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 ahMt pck ia 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 fo rMaiionrf paa M dMum t 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 hora cb a ck , 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^ log u ker. 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 fay ai 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 r unning 




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: n a MT Ttaee 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 fljaUaia tic 
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^a fc a^ 
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 din gg-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 t