Go ogle
This is a digital copy of a book Ihal was preserved for generations on libraiy shelves before il was carefully scanned by Google as part of a projecl
to make Ihe world's books discoverable online.
It has sm-vived long enough for the copyright (o expire and the book lo enter Ihe public domain. A public domain book is one that was never subject
to copyright or whose legal copyright lenn has expired. Whether a book is in the public domain may vary country lo country. Public domain books
are our gateways to Ihe past, representing a wealth of history, culture and knowledge that's often difficult lo discover.
Maiks, notations and other marginalia present in the original volume will appear in this file - a reminder of this book's long journey from the
publisher to a Iibrai7 and finally to you.
Usage guidelines
Google is proud lo partner with libraries to digitize public domain materials and make them widely accessible. Public domain books belong to the
public and we are merely their custodians. Nevertheless, this work is expensive, so in order to keep providing this resource, we have taken steps to
prevent abuse by commercial parties, including placing technical restrictions on automated querying.
We also ask Ihat you:
+ Make noncommercial use offheffics We designed GoogJe Book Search for use by individuals, and we request that you use these files for
persona] « non -commercial purposes.
+ Refrain from autorrtated queiying Do not send aulomated queries of any sort to Google's syslem: If you are conducting research on machine
translation, optical character recognition or other areas where access to a large amount of texl is helpful, please contact us. We encourage the
use of public domain materials for Ihese pur|X)ses and may be able to help.
+ Maintain aHiibaiion The Google "watermark" you see on each file is essential for informing people about this project and helping them find
additional materials through Google Book Search. Please do not remove it.
+ Keep it legal Whatever your use, remember that you are responsible for ensuring thai what you are doing is legal. Do not assume thai just
because we believe a book is in Ihe public domain for users in the United States, that the work is also in the public domain for users in other
countries. Whether a book is still in copyright varies from country to country, and we can*t offer guidance on whether any specific use of
any specific book is allowed. Please do not assume thai a book's appearance in Google Book Search means it can be used in any manner
anywhere in the world. Copyright infringement liability can be quite severe.
About Google Book Seareh
Google*s mission is to organize the world's information and to make it universally accessible and useful. Google Book Search helps readers
discover the world's books while helping authors and publishers reach new audiences. You can search thi-ough Ihe full text of this book on Ihe web
at http: / /books ■ google ■ com/
-N r
! r-
SrmnCAL OBSKRVATIOXS.
CASES AND OPERATIONS
lit
J. MASON WAKREN, M.II»
MWIFO^ rtt THE MAMjWIIISETTH ('fJSKBAl- IIHSPITAL ; rEl.tJPW I'V THK
WKRItAS AC lURSlV i>V \HT!* AX|I M■|ElfC'E^. im -
NKW vim; K :
WILLIAM WOOD A roMTANY.
I sc;.
Eatend sccordin^ to Aat.of CoDgrcBB. in the jrar iW7, Ivy
J. MiSON VARBEN,
in the Clqrt'h Office *>f the Dirtrict Court of the District of MiuJiKhnnett*.
TO
ROBERT HOOPER, Esq,,
PREalDENT,
EDWAItD WIUGLESWORTH. Esq.. ViCB-PuftTDSTCT,
J. THOMAS 8TEVESS0N. Esq., TtBASDum.
THOMAS B. HALL, Esq,, Secbetart,
& tfie fHafiftad|u0ett0 BttttxH J^oftpital;
And to the TnMea,
Hurftr fi. RaaRn§, Sahuel G> Howb,
JaXD U. BeEBE, JaIUQ L- LlTTLEt
WruJAu S, BuujLRD, Jonn Loweu^
Chaulei H. DALTOHt EzBA Fabithwortb,
Samuel F.uot, Charlea S. Sronsow,
Geoboe HiooiiriioiT, Hehbt A. Whttnet, Esq.'g,
UitdB- wkoK vae manayemrBt rAc Inililution hai attaintd iti prtieni imporianoe
fs llwnattitff ami Sciota,
S^ 0'olanu
It inKfibfdf ru a Tettimanial of rea/Mct and fjifffm,
BY THE AUTHOB.
This volume contains aome results of aurgical experieni^e,
and develops And illustmcee what was ndranced by the author
m an addreas delivered before the Massachusetts Medicil
Society, and eotitled "Recent Progress in Surgery."
The cases which are c'lted have been mostly derived from
prac^ce in the Jlasaachusetts General Hospital; and some of
tbem have been previously published. Many others might
have been given ; but it has been thought proper to relate only
those of which the histories have been well ascertained.
As a convenient method of classificaticn, the regions of the
body have been used ; and this order has been kept through
the book, except in the last chapterSf which relate to Gunshot
Wounds, Tumors, and Miscellaneous Cases. It is not pro-
posed in this volume to comprehend every surreal subject, or
to enter into much descriptive detail; but simply to indicate
the chief points in the cases and operations which are recorded,
and to add such remarks and conclusions as have seemed to be
pertinent.
PjiBK Street, Apiil, 1867.
CONTENTS.
CIIAPTEE 1.
THE UEAD.
Fractures of die Cranium ............... 1
Tr«pbj]ung for Epilepsy ^ - . . . ^ . ^ 7
InjuricH of the Scalp ................. 15
CooGuuion of the Brain . 16
CHAPTER n.
THE FACE.
TUrinopIaBtic Operations . 18
OperatioDs for the Reatoration of the Lower Ejciid . ...... 42
Epithelial Cancer and Rodent Ulcer ............ 47
The Eye 68
TbeEar 69
HoiM 60
D«viadon of Septum of Now 62
Tumon of the Jaw-bone .,............> 64
Eputis 70
Cjstic Tumors of the Jaw 72
CaDceroqs Tumors of the Jaw 80
FibrouB Tamora of the Jaw S4
Apparent Tumors of Lower Jaw, secondary to Removal of Cancer
of Lip ....,......-.......' B6
NecrosiH of Jaw .........,.....--■&&
The Tongue 02
SaliTiry Calculus W
Xn CONTENTS.
CHAPTER HI.
THE NECK.
Foreign BocUea tn the Air-paBsagta ............ Wi
Croup. Tracheotomy -.,.-.... 106
Foreign bodies in the (EKophagn.i ............. \'1'2
Strirture of the tEaophngua -,......, 114
TutitorH m tho Qi^BOphagus ............... llti
Removal of Tonriilji .................. 119
FiMurcof Soft aiiil Han! Palalo 126
Harelip 14^
CHArrER IV.
Parwnteifb Ttiorauia ................. 116
CIUFTER V,
THE ABDOMKS'.
II<>miA, — Strangulated Hi'm in . 152
Radieal Cure of Hernia 164
Artifii'ial Anus 16S
HkcTuuior 179
CHAPTER VL
A SUM.
Hemorrhoids ]@3
Fissure of the Aiiuh IS6
Fistula in Auo 1^1
FiBluloua Opening conUioing Hair ............ 192
Prolapsus Ani 194
Polypus of the Rei-'tum 193
Lnperforate Anus ind RctCuin .............. 196
CIL^TER Vn.
OByrro-cniNARr omnNf*.
Stone in the Bladder 204
Stricture of tlie Urethra, with Ret«ntioa of Urine ....... 226
CONTENTfl. XUI
Periiietl SettioQ 230
Diaeaaea of the Prostate 240
WouDdoftheBMder 241
Vesieo-roL-tal Fistula 242
Cincer of Rectum 243
InduTUled Tumor of Penifl 245
Tumors of the HSpermatic Cord .....,,,.. ^ - - , 348
Phimoai 250
llydrowle 251
lIeiiu(ocel« 252
Vflricocelo 254
Retuaed Testicle 257
FKtfALC GENITO-UBISARY ORl>ASS.
Rapture of tJie Ferintcmn 2A8
^'"wt'th'VaginaJ Fiatub ................. 2G3
ProUpseofWaJl8ofthvVag!Q& 2U3
Vascular and Sensitive Tumor of Female Urethra , , 270
Cancer of Vulva 272
TomorofVa^a 273
Polypus Uteri 274
Foreign Body In Vagina ..... 276
Ocdaaion of tbe Vagina 278
Occlnsion of Ob Uteri 29X
Hypertrophy of Cervix Uteri ...,...,..,... 294
Ovariotomy 300
Cdculus 303
Absence of Vagina and Uterus .,....., 306
Hennaphrodiam . . . - - 310
CHAPTER Vin.
THB EXTKKMTTIBa.
Fractures 318
Dislocations .,, 348
Ajnputations 384
Excisjon of Joiiitd .,,,...*.. 409
CHAPTER DC.
ARTKmiE^ AVD VRIN8.
Aneurismal Tumors, and Ligatures of Arti;ri<^ ........ 424
VaacuUr or Erectile Tumor . 441
XIV CONTENTS.
CHAPTER X.
INJURIES XND D18EASE9 OV NEBVES. 4Cfl
CHAPIER XL
TL'UUlfH.
Tunjora 479
TiiQiorn in tbc; I'arotiil Rfgjoii ,.»,. 488
]>f'iicoi'ytUicJ»ia .... - Af>l
Oporaiionii fur Cani'er (Tjkblc) . .....,.,.,. , . SM
CHAFrER XII.
« U NHIIOT WOUXDtf. 542
CirAPTER XIIL
MIHCELLANEOUS CASES.
Pon<^lrating Wouncis of Cheat flild Abriomi'n 569
Hip aiid Spinal Diaeasoa ,,..........,.., 573
Appi-ti'lix Vomdfurniln . 575
I[ydropbobifl .... ^ ,........,.,.. . 584
Extra tion of Noedltn 590
InjurioB of the ih Covcy-i^is 593
FrarturpoftJieBaso of Skull 597
Wn- Nc<'k 601
CoDgeaital Fuaion of Fingora .............. 609
CHAPTER XIV.
Ether and Chlomform 613
Local ADvathcsia , . 631
ILLUSTRATIONS.
FBONTI8PIECR.— Fungoid Tumor of Forehead, See ^83
Wooi>cuT. — Deatniction of Nose, Case XIII 20
RJiinopU^tlc Operation for. Cast XTII £5
Taliacotian Rblnoplasty 33
37
Tuiiior of (£sophagi]A t . . , . . ^ . . . . ^ IlT
Section of Neck representing the Tumor *n stVw . . . UB
Ton§illotorae 123
Median Fisiure of Hani Palate 140
Plate T. — InBtniments used in Operations for Cleft Palaie , , , , 142
WooitCUT (after Hugnier), — Hypertrophy of Cervix Uteri .... 298
,, Dislocation of Thigh Downwards 37B
Platis TI. — SubclaTJan Aneurinu ............ 425
„ nL — Erec^le Tumor of Face and KiH'k 446
„ IV. — The same afler Operation 449
Wooi>CTrr. —'Tumor of Head .........,,,,, 4ftfi
„ Parotid Tumor 493
„ Tumor of Arm 520
Pi.ATR V« — Tumor of 0§ Frontis, containing Air ..,,,,. 576
SURGICAL OBSERVATIONS.
CIJArTKlt L
TUK HEAD.
FRACTUBES OF TUB CIEAKR"M,
LT ie Tcrv frequently ofj^ervcJ, that cxtcnpivo injuries of llio
head, ivitli comminuted fnicturc of tlie fikull, Jo reiiiurkjtbly
well, even vpHcti there ha« been laecratitin of" ihe mcnibrnncs and
considemble loas of cerebml Bubfihince. Tlje cnscs w!iii:Ii ure,
jjcrhn]*^* moat to he drcndcd arc thoee in wiiifli the de])res^iou
ie liniiteU, and the frti^^iK-nts eo firmly lacked as to rtqiiii^c the
0|>cratiif[i of trephining for tbcir repkccnient. In those cuses.
the rc*iih^ appear to be generally unfinoridjlc. The qucfititm
of trephining in c^iaes of injury of the ekull with depreeaion,
both i in mediately ot^er the atvidcnt where no cer<:bral JiFiturl>-
ancc IB present, nnd at a later jjcriod wlicn epile|>tie i*ym|itomB
}iave come un in conacqucnec uf tJjc irritation produced by the
(Icpre«pc<i pieec of bone, it^, however, atill an o[k-ii one. Many
civiea in whii;li there is considerable depression of the ?kulJ. and
in nhicli not the BJighlest eei^bml JidtiirUuicc has appeared nt
the time ijf the awidontj are Bubjcct, after the lirst deprcBsion
cmiQcd by the injury bae diaappenred, to chronic heikdac-ho«;
and I have ocen a numhcr v*ho, a year or mure a^lcrwarJi^,
hav« been eei-ted with epileptic eonvultiions^ and have then
urgently eougbt the relief proTuiacd by an operation. Extrenie
d<nibt niusl ahynya exist, in these caaee, na to the probable buc-
rp'"- uf any operation for elevating the bone after ao long a
2
TH£ inrAD.
perio*!, eflpecially us we muat almost aJwftys be in total igao-
TitncG of the extent to wKir:h the dura luaicr unJ arachiifnij
membranes are implicuted in the original injury.
pLLlicnts are ufton so excessively urgi^nt^ however, in their
deeirea for relief, and their lives* are rendered so wretched by
their Bufferitiga, thsit it seema fair, in certain coses, to attempt
the operation, wher we are sure that its Jann;er and UDeertninties
are liilly understood by themselves and tlieir frienJs. Sorae-
tlnies, however, & «tfite of partial dcran^ment aeema to follow
flrom the eflecta of Liic injury ; in wliich vii&q they may icsiat on
an operation where there is little or no ehtinee of beoe£t.
Tlie diagnosis of fracture of the eraiiium Is occasionally ex-
ceedingly difficult, enjiecially in the cftse of children who have
Buffered from blows on the head. After these aeeidents, we
very oJ>en observe a remarkable phenomenon ahout the sealp,
Huggcsting a depression of the skult : thU appearance in «o
deiaijitive that practised surgrfmj* will often be at varinn<w in
the opinion whether the skuJl i^ depressed or not; a matter
aometiniea of conslder^le consequence, if eymptoms of com-
pression happen to l>e preseut. Some rimes, however, with
ynnng children, even if the akull h depressed, it seems iifier a
time Co rise up, and resume its natiind position. On the other
hand, in one iriHt.ance which I remember, where it was suppoaeil
that the appeaininces of depres^iJon were entirely caused by tiie
injury (jf the acidp and perioateum, ami where no symptoms
ejilled for un opemtlou, it was found, that at the end of three or
four weeks, afler uJl swelling had subsided, a depression really
exidied.
C^EK I. — ^xietUive Crjfrtpojiti^ Frtcture of the ShnU.
liifcovf^rtf. — May 18, 1832, I was nKjUested to see a tine,
handhome boy, aged 12, who, the night before, had fallen a
distnnce of tweuty-flvc feet, striking on the right parietal bone,
and producing an extensive eompound comminut&l fracture- He
liad been inseuftibJe at lirst, imd in a t^ollapMed state; but had
griLdually recovered vitality, and, wheu I saw him, was sensible.
Portions of brain escaped from the wound. By the aid of in-
dsionti, loo^e bits of hone wei-e removed, imd a large {]uad-
(guIflT deprcMod poriion — oxtordinjf up to^vrmls tin? yertoac
was elcvftied- Acother portion, di'ivea umler the adjacent
inea, was removed. The rough oclges of bone were sniuotLed
off with Hey's sjiw. Cold-water dresnings were npjjlied to the
wcund, lie was kept under strict diet, very carcftdly watched,
, imd recovered eotopletely.
B Ten years afterwords he entered the army, wlien ho suifered
the first inconvenience from his former injury* eonriinniona of
I c«nnon prwlnoin^ sncli a stunning effect upon ilic Irain as to
Beaitae vertigo^ and uUimutcly obliged him to quit the sGrviee.
H Cabe it. — Extensive Fracture of the Brute of the I'y'htU,
Horif/ iitipture of tfte Opposite Side of the Hi-am- Death
^ after ten dat/i. liemrtrlcahle Ahuetice of StjinplOTHs indi-
»cath'e of /lo severe ati lajiiry. — May 18, 185^, n woman was
)>n)u;j;ht into the HcBphal, and died after a few days, with very
deiyqitive aymptonis. A week beforB, while reaching out of a<
tliinl-etory window, ahe lot^t her balanee^ and fell, first upon %
toehe{], and ilienee itito the street. She was tiken vip bsensihle,
but soon recovered herself suffieienily to itpeuk, though inco-
herpntly. Slie was snppowd at firiJi to l>e laboring under the
edcf-'ts of opium, which slic was in the habit of raking freely,
a large bit of which was found in her pocket. Wlicn
^brought into the Hospital, a wound was discox'ered over the
right parietal bone ; hut the finger, being paeseil in, coidd detect
no fVaclLire. Tlia head was carefully examined in every direc-
ition; but no fracture could be found. The patient exhibited
■igns of concKPsion, hat none of compression, of the braiji.
Th<?re was no vomiting, no dilatation of the pupUs, no blec*!ing
Irom the ear. She was uneasy and restless, like a poraon under
the influence of spirit, to which, and o|iium, her symptoms were
tnaJnly acmbuted. She gradually iniproveJ, and, after a day
^tor two, got out of bed to search tho drawer of the tabTe for
the o|aum which had been tnken out of her pocket- On the
tcTilli day after the injury, whco slie seemed much better, and
anawercd the ijiiestions of the nurse coherently, a friend mndo
her a vinit, and brought Jier a bit of opium. The same night
ahe Hudilculy iheil.
TOE HEAD,
At first, it wa* very natuiTillv snpposetl tliat the opujra whicli
elie hail taken v^ns tlie cnufie of the sudden change in her avmp-
tomA ; but the post-mortem cxAminntion , made by Dr. EUia, re-
vealed the fallowing very acvcre injuriea of the jskull and brain:
An extensive fra^tui'o wns found nt the base of the skulli
on the right aide, passing l>eh[nd tlie auditory foramen, atid into
the for.inien magnum ; this wtia net by nnother fracture at
right angles to it. On raising the dura mater from the opposite
aide of the brain, a layer of blood was seen spread over tbe
whole of it; and the middle lobe of the cerebrum waa mvet
extensively Iacerate<l.
In this cn^, nearly ah the eyraptoms scorned to be ei^ilicn-
ble by supposing concussion combined witli a. state of delirium
tremens, eau^etl by the constant ui?e of nnrtotic-s; and, without
an examination at^cr <leatfi, the fatal termination would have
been attributed to thia cauec, brought on by the shock from
the falli and assisted by the doee of opium givca to her that
Cask III, — Exicmive Fmcinrc of thtBasc of the Sknll^
and of ikti Hones of the I'^tffx. Death after ten hours. J're-
vioiie Injun/ of fli<^ Mtad, with proloitffed l/ncoitsciirnttncaft*—^
A gentleman G8 years of age» while driving a young horse» and
being unable lo cimtrol him, was eeen to jump out of the eJeigU
in which he was riding, still holding on to the reins. A person
aeized the hori^e by the hcitd, and requested the gentleman to let
go the reins, whieh, however, he either could not or would not do.
The horse going on, he wna brouglit up violently against a tree,
striking' the side of his head. iVrtsistance arriving, he gave his
name and residence, was taken home, a distance of three milce,
all the time making violent muscular movca^ents. Ho lived
twelve hours, dcprcd&ion coming on very suddenly. The cii'u-
aion of blood under the skin of the face waa bo great as wholly
to obliterate his features, Blood ran freely, also, from the left
ear.
On examination, twelve hours siHcr death, it waa found that
the whole frii^nt part of the face had been broken away from
the bones of the head, the friu;turc eiteuding through both
I
I
orbits. The fracture waa fouud Aho to f^tcnJ tlirounrli the
botlj' of tlic sphenoid, nnd amother ihrougfj the lictroua portiitn of
the tcmporrJ bono* ao thikt a probe passed freely from the exter-
md amiitory meutus into the tavity of the cranium. The
midiJIc lobe of ihe left ^^crcbrsil hemisphere was filled with co-
agulated Llood. The amount of injury was greater llian I have
ever witncsacil in a cnec of fnieliirc of the altLdl ; yet he waa
able to give \xm name mid addreaa, and lived twelve hourd after
the receipt of the injury.
TliJ^a i^entlemEia, thirteen montlie before, wa.a knoeked down
by a sled, striking the letl eidc of hid head, imd breaking the
k'ft dnvicle near ita outer third, witli great diriploecmcnt ol'
tJic Irugmcnta, Jlc tcmuincil in a partially unconseioua atAtC for
three wccka, and ^vcndd nut euhniit to any treatment for the fruc-
tored bone- Ilia li.-\\. le^r he moved with (hHieidCy, either from
eome blow which lie hud received upon it, or, aa waa supposed at
the limC) from a partial paralyaid dcpcmlont on the blow on tlie
iieod. During the greater part of this time, he conipkined of
excessive pain in the head, requiring the eon^tant nae of coid
opplicationBi lie finally eomplcteJy recovered, without appa-
rent symptomd of having sustained any severe injury. Aa
AOOQ as he would allow it, ius arm was kept confined hy
biuid&gce, hr a period of three wccka. At the present exaininii^
tion, we were naturally desirous of invefltigating the cause of the
extraordinarily priilongccj cerebral aymptoma; no signn, how-
ever, could be discovcredi oitlicr of old Ihicturo or ol' tliiekening
of the doiii mater at the epot where the blow Imd lieen rceeivcd,
fior were there any other inarka of Uiscaao in the iamiediatc
investing membi-ancs of the brain. The only appcanme^i of
disease was a strong adhesion of a sm»ll portion of the right
eidc of the bnun to the dura niatcr, bo fxrui that a part of die
brain Avns torn away in ee|jiinititig it. The elaviele, which for
three wccka had had no treatment, and in thct had been vich
ly thrown about in nil dii-cctIon3, had tirmly united, and wufi
rAortenL-d about tlireo-fourtha of an ineh, hut wilhout any pro-
jecting angle, — a good commcotary on the Bulwetjuent neeeeaity
for using complicated bandages in the treatment of these in-
juries.
6
THE HEADi
It miL^ Ve alaled, tbat, ju^t LcFore tlifi rccei[)t of Eua fatal in-
jury, lie lofornied mc that he could ecurcelj' tell on nliich «lde
the clavicle had been fnictured, rctuni of power in the injured
limb havijig been so com pic tt^.
Case IV, — Chtmhoi Fracture oftht Occipkal Bone loilh--
mil immediate Srfinploms. Denth n/ier iwcntn-Jtve day 'i from
Ahvct^e of the Ifratn. — Dr. VVhcclcr, of Chelsea, gave me an
occipital boDG, with a fracture throui-h both tables, caused hy a
MiuiiS ball- On the mner aurfacewere several fraignieiita TvliicL
bul been driven inwjtrda, wilb rough eptculo;, encroaching nt
Iccut half an inch on the cavitr of thcr cranium; on the outside
was an indentation corresponding in size and t^hape to die flat-
tenctl ball. He also sent tlic following account of the caae : —
"A captain, 3^ jcara of age, iK'longing to the Thirty-fifth
llcginient of MaasaL^biisctta Vohinlecre, in a moTcment ^ith
the Ninth Army Corpa, on the Weldon Ifailroad, near Peters-
burg, Va., in action on the nineteenth ilay of August (1^64),
received a wound of the scalp npon the back of tlic hcid, by a
ririe-hal] ptriking the occipital bone near the apex, and juat with-
in the lanibdijidal euture of the rigiit aide- The immediate efiect
of the coaeuaaion caused luni to tail, witli a momentary faint-
nesa and loss of his eyesight ; but hia coneciouencse was retained.
In a few momenta he was able to get up, and walked to the rear,
where the bidl waa picked out trgm its bed under the ecalp<
No Bjniptoms of comprcaaloo were present, no fracture wna
then euflpectcd, and the injury waa recorded na a Hcah woundt
He waa transferred to City Point, Va., and from thence to a
general Hospital near New-York City, wliere be remained, very
comfortablci eomc eight or ten diiya. He waa then furlougbcd)
and arrived home fncnr Boston) <in the first day of Soptciiiber
folloiving. lie cumplaincd but little of hia bead, but said tiiat it
felt heavy at times, and that hli3 cycaight was not quite aa good
na ueuoJ. These symptoms did not confine him at home: be
walked out, called to see hia friends, and alflO attended in
person to some business matters, The wound in the scalp was
suppurating moJcrutely, and was looking well. The day he ar-
rised boue, a fissuro and depression of bone were didcovcittl to
I
I
TRGPTUKIKO FOU BPJ
cxiat ; but, lis no Bjrn»ptoiiia of comprcseioE or cerehrul diatLii-b-
nacc were present, it waa tboiight that surgio-al Juterlereiicc wua
harjiy called fur. But abuut the 7th of September, or aoEue
cigbtccD dnye ofier tlie dutc of the injury, he corapJaiacd of a
chill, wbirh wjw followed by fever and pain in the back of ilio
head : nnd, in a few hours, slij^ht iklirium canic on. The de-
lihumi heat, and other eyniptomfl became more severe from day
to day, iiQiJIy ending: in i^rofoiind toma, with slight convul-
eione. He died on the 15th of September, jual twenty-five
days after the injury."
An autopsy uxhibitod a fracture of tlie occipital bone. In
addition to the appcaraacca meniioned above, ■* the dura mnter
gave ei^s of active in fJ a tarnation in a ciiTidar apot of about
Iwo inehed in diameter. It wa& not lacerated, wfl» quite dnik
in color, nad rftidily aeparateil from the bone. Juftt bcneiuh
this portiou of tlic membriiQc vfus tbuad a wcll-flcfiucil abacess,
Containing about two ounces of pus, formed ia tlie subatancc of
the brain.
"'The history of this case, with but a glance at the bony
fipecimcD, will at once euggest the tre|>hine and its eady use aa
the beat mcana to ward oil' inilammation and It^ coni]equenee«<"
TKEPlIlX'iSa FOR EPa,EPSr,
Case V. - — Operf/titnts on th^ //eW for Epiltp^j follo^c-
it9ff lujanj iff I he Skull. Tr^p/tininff for an old Deprc^-
non cftuein^ Cotivalaioue aiid Idioctf^ — Thia girl, 10 yenre
of age, was efruck in infancy upon the hciul ; and, although the
corporeal facultica bad dcveiope<l normnlly. there had been little,
ii" any, nianifeatation of iniclli*fcnce- The child recognized im-
perfectly her parcntrt ; was a voracious eater ; eiceaaivcly strong,
vrild, and unnianageable, at times so violent tliat it was impoa-
aible to restrain her. She was unable to articulate, but would
frequently nin through [he houae, uttering a kind of bowl, and
leaping to (he diatauce of niauy feet like a wild beoot. She
Wiia al*o eubjeet to the moat diatreeaing convulaione. Under
tlicflc cireum*taucca she was brought to mOt with the carncat
rcqucGt that I would endeavor to do flomcthlng fur her relief.
i^&
B THE niUD.
Un examination, there wns found, extending niToss the heaJ,
jaat behind the coronal «iiture, a longitudinal dei>re3tiion, three
to four jnchea in length by one in width. I suggested to the
porcnlti — giving them ii> f\i\ly iinderfitfjnd it^ djing<»r — tlw
removal of tlie depre9.«H3 porti<Jn, na the only reniLnly whieh oc* ,
curred to mc- This being eubniittt^fl to a (consul tiatinii of thi9^|
surgeons oF the ITofipitnl, it wna deternnncd to ndvise it, ^lon- "
aidering ibe despernte nature of Clie rase. AVhon brought into
the arnphulti^uire, the piitient rushed in with her head down
biirdly re^trnine:! hy the Jitrength of two men. After she h
Leen hroiigbt under tlie inrtiiene*^ of ether, the nci^es^^ary inci
ions were made throngh the inlcgumenta, the hone wms eia
through wiih two iTowns of the trephine, unl the opening*
joined by cutting ont the intermcdiflip pieee with n Hey's saw.
For the first &ijl davfi ^hc did well ; but died, on the ninth,
^om a bleeding from ihe longitudinal tsinu^i whieh ruptured al\
Bfinie Kudden mid \!olcot miivcjueut ni;bile by the [inlient in
bed. The fiither thought there was nn apprecinhle ineiMPJise of
the amount of intelligenee after the operatitin ; nnd it wiL>i ohv
oUH to every one, tJuil r*he took I'ognizani^e of pJiTSons and tliln
about her in a way she h»Ld never done before.
I p^irtly attribute tho failure of tlitu opcmtloti to my folio
ing the siiggestinn of a bystander, nnd sewing np the wouniI>
instead of allowing the flap to i'all down, and Jidliei-e to the par
beneatk The coneerjuence was, tbnt pns tolleeted in llic cavi
formed hy tlic t^alp, eaii^irig derooipfiH^irJon of the dura ma
wbieli nKstHted in eroding the tcAtures beneath.
Case Vl, — T}^phiituig fnr Dt^jn^xttmn of the SkuU cum
iutf H^pihpfiif. — J. C.J 21 yearj^ i^ age, apjjlicd to me, Octi
25i lbJ)Oi and gave ibe following aecnnnt of himself. FouJ
teen years before, he Lad fallen Againj^i a poet, and received
flevere blow on the left eide of hU liciid. His ecaJii was cut
ojx^Mf but tlicre waa no pereeptible fnieture of the Hkul!. ^Vith-
iu a year ailer the aeeldent, he waa attaL'ked with epileptie iits,
to which he waa suhgetjuently subject, at inlerTalti of one or
two monllie> The attacks were fulUiweil by pain and drowal-
iieM. The paiii wua felt cliiedy at the point where the iu-
THEPllJNO'O FOK TPTLET^T,
9
jiir/ waft received, and also over ihe rigJit orbit- IliB memory
ilVfbs iiiipuircfl j be was erratic, impetuous, nntl unniana^^cfiblc.
I'be bone, at llie fcat of tLtr mjurv, apjicared tljickedCil aiid ^n-
Dtive. FiuJiLig that lie was bctM>utLUg n burden ti} himaelf,
iftiH] in iluiii^er ul' luoiiig bis iiilinl, lie iip|)lied to niu tu JK-Tfonu
iJic opcrulion of Irepl lining, having iiii'urmed Ijimaelf on all
IpomU wtlb regard to it. Oct. 2fi, 1850, bein-^ edieriaed,
110 ACalp *v^as rtii^eil hj a V-abaped incision over the injured
pftTt; aikd a trefjlunc, oue incb !□ diameter, was applied
over ibc suture between tlie frontal and parietal bones- On
trailing tbe bone, the frontal wad fuund to be uiorc than three
timcri a» thick as tlie parietal. A t^imple water dressing was
applied to the wound. Oct* 27. the day lljllowiug the o^jera-
tion, the Hospital record Plates that be had severe vomiting;
lii* pulac was ninety-six. On tlie 28lh, be complained of bcad-
aclie, but had eeme sleep through the night. Tbe next week or
^ptwo, be bad more or leas pain in the bead, hut graduaflj im-
proved. Nov. St^th, he seemed quite well* and the inciaiop
^_ made bjr Uie operation was bcakd- lie remained under my
^Bcogntzance a month longer and was iuially discharged Dec.
24tl], lumng hod no epileptic attack during the two months
Umt be remained in the lioapital ; and hLs moral and physical
condition otherwise matcriaJiy unproved.
^B 1 heard from biiu some months aBerwards, and be made a
good report. He auhauquenlly, however, as 1 understood, fell
into irregular babit;^, and dieil idtimately "with a cereljrjil attack.
Case Vn. — Optt-tdionfor Depr^tfsion oj" the ^kuU cfzuffsd
btf a rtd-kot Pvktr pa^dlnfj cUroif(/h the liontiii and jKnetrat'
inff the 3raln. — A finc-luoking yomig man, ^3J yeara of age,
Nova Seotian by birth, applied to me in December, 1S57, on
mat of severe epileptic fita, canecd by a depression of the
from an injury he had i^x^elved three yoara before. liis
iftcXK^UAt of tho circuuistuncc was thid : He wae by trade a
tsmiUi; and, while enj,^aged at work, phiyfuily threw soma
[l- at a fellow-workuiun near bim< ThU person returned it,
by throwing at him a red-hot poker, which he hod in his hand.
[The p[>ker atrudc bim on the frontal boue, Juat above the orbit:
10
THE HEAD.
il passed tliroiigli tlie bone, ami catered about lliroe irichoe into
t]ni cerebral flul.>9tanco. He inimediaLtely aei^ced the iiistniiiient
hinirielf, and drew it out bj mniD forc^c. Tliere waa but ]ittJ«
bleeding fnirn the wounJ, He did not at tbe moment become
insensible ; but, an hour afrerwiirde, he fell into ft comiitoae
state, in wlucli he remained for u part of tUe reat of llie day-
He was Ten- earelully attended by Dr. Hooker, of East Cftm-
briJi^ ; and in nbout threo lutmlhs llie wound was Kutficienlly
well, and his health so far restored od to allow liiiu to reeuine
hid businesa.
About four months nfter the injuryT he was seized with a
severe epileptic convulsion ; and theee attacks have followed
pretty regularly since, at intervals of three monthd. He
says he falls very suddenly without the sli^litest warning,
and somelitues injures him^lt^ severely. He lately fell bnck-
wanls u|>on his anvil, etrikinij; the back part of his head, and
cutting the Ht-.alp, behind the ear, down to the bone. The
conTulsionB, of late, have increased in fi'equenoy ; aud be feared
lest bia mind should become affected by tbem- He was aldo
apprehensive that he might some day, while at work, fall into
the fii'e» nnd burn or seriously injure hlmeelf. Vmler tlieec
circumstanced, both lie and his friends were very urgent to have
an operation performed.
On an examination of his head, a depressed portion of ^kull,
of the size of half a dollar, was found just over the ri^ht internal
angular process, partJy iinplioating the fronlal sinu^. In tlie
centre of this depression the skull was deficient, nnd a ttiick
Btrong eientriK indicated the point at whieh the dura mater Wiia
adherent Ut the lEitegumcnt. The pulsations of tlio hriuu were
here distinctly visible.
After seeing this patient onee or twiee, and carefully investi-
gating hi^ casCf I tiaidly advised an opemtiDn, fullj' informing
Lim of the liazard of it. He entered the Hospital ; and the
enrgeona, in consultation, having concurred in tlie propriety of
my opicion, the operation was jierfbrmed on Dec, 24t[i.
The principd dit!ieulty consisted in £xia<^ tbe trephine so its
to make it lake hold of the akuU, on account of the impossibility
of using tbe pin, from tlie bony deficicticy in the centre of the de-
TnEPIIIMNa FOR EPILEPf
11
prcMion. To meet this difficulty, a bit of tblck leather, wliich
Jiad tM^en prc™usly prcpai-cd with a hole m it tt» receive tlic
ircphine, iras fixed to tlic head ; Imt tliis, iti practice, was found
&ot to &n«wcr ite intended purpose. Allcr coumdcrable labor^
the trephine was maJc to take hold ; and the rest of the opoiii-
tion was done with a modcnite degree oF fucilitj. The portioQ
of bone reoiored catirc comprised about half a cirole; the
antcriur part, being tliut whieh formed the roof of the fri>ntnl
einiLa, came a^ay in bits- From the interior of the portion
removed, a sharp apine projected, which waa imbetlded in the
brain. The memhranca of the brain, where they penetnitcd
the boue and ndhcred to the ecdp, were cftrcfully separated from
their attachment to the bone by means of a probe ; being at oae
point 30 exccaiivqly thin and deJicate aa to have hardly the
coiisi&lency of blotting-paper. Here an inevitable tear t^Jitk
place, with the esctipc of a yery minute quantity of Limpid iluid
from within. This was Htc only unsalisfaotory occurrence m the
course of the operation- The wound waa very lightly dressed,
and no suturea usedi
In the aflemooD, the patient was sitting up in bed, quite
bright, and aecmcd ecarcejy atlccted by the operation. On the
lollowing day, he aa'id he wa& doing well, otid lind pa^acd a
good ciglitp On Uie third day, he was not so well : his face
wii£ tludhcd, pulse ninety, akin hot; and he ficemcd indi9{>oaed
to talk. There were evident aigna of inflammation of the mcm-
bnuiee of llic bnun* An active eatlinrtie wae adniinidicrcd» and
cold applications were made to the head* On Dec. 27th, tho
third day after the operation, I found him almost inseneible ;
pupils ni>t dilated ; pulse one hundred aud nineteen. Sistccn
ounces of blood were taken from him- The symptoms hod
increased in wvetity by the following day ; and, in the course of
it, lie died*
By permission of his frienda, an examination of the body
was made by Dr. Ellis, on the day uftcr hie decease. The
whole surface of the arachnoid, on the eidc affected, waa covered
with pU3 ; and eome waa found underneath that membrauo. At
the point of injury, extending two inchca into tiic brain, there
vTAd an orgnnizcd clot still retaining somewhat of its color, and
12
Tim HEAD.
ahowmj distinctly the course piiretied hy the rerl-hot iron lliree
yeara before. The inner siirfjioe of the ekiill waa amooth; Jiml
ftdiicrent to the edrrog of it (where it hud been dLvidt;d hy ibe
saw) were two amall, fljit^ ivoi-y-lookiag pieces of bone, alioui the
cite tL inference of n pea. These bits hod prolwiblv been ori^jin-
ally detached by the poker, but were now firmly adherent to
the bone,
Hejuiti'Jcs. — In view of the ^ront difficulty of fixing the treJ
plitne ill tliie operation, it occurred to me afterwards, whi-tfier
iiny other pinn could have offered better cbancea for despatch.
The only one which siiprrrceleil itself wru to have made n mini-
ber of holea around tbe circumferences of the opcriiip- in
skull, and connect these differont pcribrationa by a fimal] saw.
The non-sueeeea of the operation must be attributed to the
porfonition of the membranes, nt the point of ihair intiinnte
connection with tbe aperture in the bone, where they passed
tlirongh to form a, union ^vith the ficatp ; and this, apparently,
no care could have avoided.
Case Vm^ — Case of Depression of the Inter7\nl Tahie
the Skiifl, cattsin^ Epihpitjf. — M. N., \^ yours of nj
entered tlie Hospital in April, 1i*(>h'5, for the purpose of havu
an o}>eratinn done for trepbiniug tho ^kull, on aoeouDt of a
pre^sion cansinj^ epilepsy. He stated thai, eix years before, he
bad been kicked in the hcail by n horsc^ that his skull bnd been
fractured and dcpresac*!, and that he had been unconscious for
BcvcraJ weeka. There ia eome doubt in roi^rd to this part of
his account, as ho was seen by practised surijconu, and no opera-
tion was thouglit necessary. Ho recovered from tbe accident in
about four months, and returned to work. He remaEued well
until March, tf<6-t, when he wii^ seized with an epileptic fit, and
rcmaiaed uuconseious for fifteen minutes. He hod two similur
attacks in May, one in December, and one in February, 1365.
Since the 1st of January, 1865, he had miffered from general
weakness, lofla of appetJto, tcndcrneaa in tbe epigastrium ; hr*
ej^eeeh was stuttering; and he complained of a constant ticking
sound in his head. An examination of bis head disclosed an
L|>parent extensive depression of the parietal bone, above and
FOH EPTLEPBT,
13
tjchind tlw! left cnr, Althuugli be was urgent for an operation »
and, on a consultntion, it waa Oeddecl Uiat an operation was ap-
pri^prmtc. 1 was very rcKictaiit U> proceed to it, Jrom the great
unccrtaiTitj attending openirions for trephining in tbcso caeeei
ami tlici-eforc decided first t<» try the efiects of trcntmcnt-
lie was kept- quiet, dieted, hnd a scton put in the back of
Ma neck, and took ten grainfl of bromide of potai^ftiiEm twice a
day* At the end of five or six weckrt» an eslcnsi%'e eruption
of oene nppciircd <»n the face, nnd tiie bromide was Jiacontiniicil.
He retrained in the Hoapital three wecka, under treatment,
and, during tbat time, had no ronvtilsloiia ; it was therefore de-
cided that he should go into the country for the eummer. and
continue the treatment. Throughout the eummcr, he had but a
single convulsion; but that looted an hour and a half. He
enlercl the HoJipital again in January, 18IjC, inflating on an
0])oriition. Since hia la^t attack, hia eymptora^ h^ul all been
aggravated; his liead ''felt nn if it would split open,'* and he
wafl almoet afraJd to lie down, on account of the flggi'avation
of thid etcQ^alion ; the ^tonmcli waa mucii dieteuded with thitue,
Kwl he had naiieea after eating.
'Ihc sculp having bten shaved, the vacuity in the bones be-
uiore evideut, and a pulsalion was detected a» if coining
the brain ; this wne not constant, but naa most obaervi^
priacipally when he roi^e up suddenly- On deep preaaure, a
resistance was ivlti aud It wtia not possible to savt witli Cer-
itainty, that nuy p;irt uf the (^kull wna delieient at thic^ spot.
The potieiit, having heeu properly prepared for the ojHjnitlon
by a purpiiivc the day befure, and taken nothing but liquid for
brenkrafitt was etlieriKed. A circular inciaioi], describing two-
thirds of a circlet was made through the scalp, with the con*
fcrexity t^xti^ndiiig hthiw tlte depression i the Hap, being diseected
" lip, unciivered a space about three inches in diameter. It was
at once found, on raising the tla[j, and scraping u|> the penos-
Itenm at the edge of the depression, lliat the bone was completely
deficient ai that point, which waa dlled up with the [ueuibranes
oftlie Itraiu, thnmgh which the pulsations of tliat organ were
'diatinctly observed. The external table of the skull tb'd not seem
'depressed, and it was impossible to say what had become of the
11
THE HEAD.
deScient frjtgrierits. A email quaDtitj of the amcbnoid fluid
could be aeien inckling oui, exactly from nbat pc^fnt could not
be detected. As no tre^luring opemtion gecmcd iiidif:Ai€(I^ a.Dd
as it was impossJUe to proceed williout opening ike eorebnd
coverin^H, it was decidod to Jcsial from farthur proeeedingSi
The tiap wa8 aeoordingly brought down, and £j^cured by sutures.
In the afceraoonf he had recover»I from the etbar, expressed
himself relieved, and the folJowing day wiua in a TCry entisfoc-
tory coiuiition. On tlie 2*5Ui of January, two days after tho
operation, he be^n to be confused in lib mind : his utren^Lh
seemed to fail, ond he could not answer queationa. On iho
27th. he had an epileptic fit, lasting half sui hour. On the i'^lh.
he had a continued bucccseIou of fitd; the left pupil w&s dilatedf
iLnd the urine pn^^ttd involunUirily ; pulfic one hundred and
twenty ; the right leg waa piiralyzed. On the S'Jlh, iie died
nbout 2J, P.M.
On post-mortem examination of the head, there wo* an ex-
tensive inilummatory deposit between tlic aruchnoid and pia
mater; tho veins of tho bntin, on tho left side, were grcntly
engorged- The cftcctB of tho accident on the skull were re-
marliiiljic : fur a space of three inches or more beneath the
opening in the sknU, the internal tabic wjis depressed nearly
thrce-ijuorttra of an ineh below the level of tho external table,
this depression extending oft' on each aide for some distance;
tho dura mnlcr and arachnoid projected throu^li tliis iiseure,
and were attaehcd around the margin of the external opening,
which, at some port^, was simply Eilled \nth the arachnoid alone ;
throngli tliii, at one [toint. Wits a uuiintc afKsrture, cansed very
possibly by llic Jisflcction of the tealp, which hod been made at
the time of the operation. From the condition of the ekull, no
opcrationt of courae, which could have aflbrded bini relicFj v^ould
haye been practicable. The caec is an inetaaec of tlie entire
unccrtuiuty which wo must be pre])arcd to encounter when wo
proceed to an operation of this description.
INJURIES OF
15
C/ura Df TrffiJiinirigJbrEjHifpBf tuTHtrinifHt the Af'txtirfittMrtir Grnftfil If^mpiini.
rn:tt.
•ti.
AQK-
(■ACTBX.
UEBtTLT-
TtME,
Fell. 31, leaa
P.
ZB
Dejircfiniriu wlUa Epilrpey
Cored
4 monibi
Svpl. Ift, 1M3
u.
la
Eplltpay
Tilefl
s w«t<kfi
uaj or, lus
M,
94
I>0pTi^iunD wJIhKpHfpsy
Cun-d
flj wi'tki.
OvL U,1«U
H.
31
Epilepg^
RclM
3 □ii>n(bB
Dta. 1«, leU
F.
SB
Epilopv
Curti
Aj jniiiitbH
Ch-c. 14» L0fi7
U.
%%
Dtjirwislon wlUi Epfleimy
Piud
* (ixya
Aug. U, IfiM
u.
U
EpllepBj' af^ Kncture
Iliad
lOdifB
Ju. 13, 1S61
u.
W
£pilep9j HltDr Kn^turD
Dit^
£f wv«kB
Ans- 01, 1603
u.
U
iHprefibbu wiili K|filei»>-
R^^l'd
I niH^ki
JftH. — iet»
IL
31
Dejircsflon wilh EiiLlejuy
DkMl
0 lUj't
C^TFll I
Died - . - . . G
Wbulo nuBiti^grcucB -...,. Iff
iNJUKIEa OF TTIE RCAI-P,
IHjc fijilowiiig aista of cxtfosive laceration of Uie siinlp, witli
rt total (Itmidnlian of llio hoiicd of die henil, arc rcix^i-tcil
lowing: liow prmiiptlv recovery may tjikc pliice atlcr sudi
linjunea, cren under circumstances eeeiiuiigly moat unfuvorfllile.
I
Cape IX. — A boy aged 12 was knocked over by a wagoa,
the wheel pnflaing over bie head, rcmovin^^ the whole eualp, fixjiii
the top oHiid hcjwl, comiijciicing at tlic occiput, and carrying it
d^iwn over bis cyca, Wlien I sjtw bim, about nn hour nFter-
warJ*. the surf^ice of the inverted iiwilp and the Jcnuded ekull
■were etili covered with dirt aud gravel, iilthou^'h n partial at-
tempt bad hccix riiide to cicaji it by wiishiugp After cleansing
it etill fitrtbcr, the skin wil^ roplaccd* nnd secured by a great
Dumber of auturca. The whole united by the first intention,
and witb ficarccly any Euppuration or dcformltyi
le
T>IE tlFi:Al>.
Cask X. —A mnn was hmiiirht into the Mftssn**hiiwt;Ia Gen-
eral Ho,Mpitnl, iiml i-^mc unih^r mv cnre^ who biul fallen fnmi ilip
tangUG uf hia cart wHIIb unleep, the trout fdre-wlioel of which
hud pik«si>d iivt^r l:is heiid, teAriti^ iitid rolling up the «nrire acaJp,
nnd IpftTing it ;:overiny his fiua:-
After bein*r llioruu^hly cleaned hy having warm water
Hijueezcd ovor it, ant! the eponrpu heing u?ed as h'ttle iia possible,
it WEis replaced and t^eciired l)y a large niLralier ol' aulurea.
He recovered rapidly, without any Muppuration, aud with
sltnoBt complete union by the firi^t intendon-
OOSCUSSION OF THE BRA[N.
Case Xr. ^Coanixition nf thfi Uriiht, with roftJpfi^/c J^cnf"
9i€/is^ and iiijiri'if iif Sea/ p. ^ A gendeman GO y^nrs old wa*
thrown frcnn a chalae, in JiEoe, 1861 , striking his head , tearing
the &c\il]t Hhiui&t coitjpliftdy off'^ ani1 prmliiring a ojinciission of the
brain, nnder whirh he remained in-ii^neiblo one or two weeks. He
wan aftenvards irirnnried by liid medieid aittendant, thiit there
had been some blewling from the ears. The aealp was re|iliiced,
and nnii.ed perlet-tly Jn afnnLt two montlw. He ha^ nerer l>een
nh\e to lieiir tlie Hliglite.HL sitiind Hinou. lie speaks well, how-
ever, and with a good intonation of voice. He is a clergyman,
and is able lo preach.
In February, IHCrZ, he applied to me for advice- On exam-
ining the ears, tlie drum of the right one wils foand to be
uninjured ; the left waw piHumteil, aod red and fle.flliy in sippcftr-
atice^ with a jiundeiit di^ehjir^re from its sorfliee. 1 intiirmod
him, that bin little bn^nefu was to be expected from treatment.
Case XII. — The following ease of eoncussien ia on instance
of severe eymptonia coming on a week after the injnry; show-
ing the iniportaii^^B of care in the rannagement of persona who
have received severe hlows on the haul, though in* symptoms,
for the momeht, are preaont : —
A nmn agol 35 waa bnjught to the Hospital, April 9, 1804,
having had, tho diiy liefore, slight convulsions, drowsineaa,
and an unwilliagnej^rt to talk. A week before, he had fallen
COXOTTBSTOX OF TRE fiRAlN.
17
I
out of bia wagrm, strikintr liia liciul on llip pin'fiment. For
eix flays no iin^oEivenieucf foUuwral llic HwHeiil, nnd be iliil
hb work as u.sual. lie \^'jtlkt!d i'n>iii his 1ji>eu(c tu tlit^ lluf»|)i(al
with the Msifltance of Ms wife. Hi* apjiwinince wa* sleepj.
He compliuiieil of jiain in tfie Imck of liLs hcail, where an eleva-
tJoa of the cranium was fi^lt, wliicfi might be normal, — nil un-
usual (Ieveio|im(.'nt of tUc uoui[>iNhl protuberance. Pressure upon
this part cuu^Lil liiui to tluxjw \i\s ar[iiJi Eibout, and coriipliLui of
pain. lli& pu|jiU were roiitrai^U-^I ; ptilse Ad\\\
April lOtli, lip was lying on his bai:k, with hts eyes eloscil,
nia pupiiti were contracteil, und the urine was pu^aed involunta-
tHy. He wju ordered li dor^, len graini^ eachf of cidomel wud
jalap. On ilie 1 1 th, ihi- UHfilidnc hiul o[H'rsitwl freely ; he waa
mure sensible, and nnsweretl questionti ; urine as before* On the
12th. he was again dnin^y. and eould not l>e roused to uiij^wer
qu<!aLiuii^ ; juJse iilij-lwo, f^iiiall. Aiiril l<lth, still di'onaj.
He vfjis imlen*il nn lnjci:tiun of weak miiMartl and witter, ami ii
Mislcr u|iplieil tn the hiiek of hw neck, April 14ib, wind he felt
& gn-at deal hetUir, April ^3d, he was aumcwbat stupid ; pain
iu hi^ head; piiUe ftixty-^ix. On the 28th, he vta^A up loid
dresaed- and Ins iniinl wiw dearer, aiid s[M"4"ch was inuth im-
proved. A[iril 2Dlh, he was dischargi?d, — well.
CHAPTER IL
THE FACE,
KniNOl*LASTIC OPERATIONS,
The operation of rittnopksty is of very ancient date. It hnd,
however, for various reaaon&TfuUen into moat unmerited diercpute
until between tliirty and forty yeara eince, when it waa revivwl
in Europe by Grsicfe, Dieffenba^ch, and Labat on the continent,
and Liston in Great Britain.
In the ancient operations of thia kind, the lost organ wn*
reBtore<I at the expense of the inte^njentfl in ite immediate
neighborhood. Advantage Iwing taken of the extensibility of
the skin of the clieeks, the integuments were diaeected up on
both sides of the nasal fos^a, brought forward, and united in
the centre by points of tlie interrupted auture. If the extensi-
bility of Clie integuments was not sufficiently great, tnciaions
were mode in front of the cars, so as to diminish the tension of
the ekin ; the wotmds thus made were afterwards allowed to
fill up by granulation. This opern.tion, however, did not restore
the form of the lost organ ; and the only advantage gained was
a flap of skin to eover the existing deformity- The operation,
which was afterwards adapted, and whicli now bears the name
of the author, was that of Taliacutius. In this operation, it was
required that the arm should be conflncd in contact with the
face for ten or fifteen days, or until union had taken place.
The disadvantages of this metliod ui'c at once manifest : the
length of time during whieh it was necessary to keep the limb
in this painful condition, sufficient in some eases to produce
partial |)anilyeis, and the danger that ensued in the too early
separation of tlic transplanted skin from its source of nutrition^
were, of tliemselves, reasons of sufHcicnt weight to cause it to
fail into disuse.
i|ienilii>n whirh lias nttnincii the mo?t cdcbrity* imd
wliioh has bctn muet trcfjucntl}' practiced in Fraucc onii Kng-
laml, U iLat whidi p^ocs bv the nitme of the Indian method^ iu
whioh the Hap ia taken from the forehead*
It wFia niy poud fortune to witness a vcvy Inrgc number of
pperatioiLB by the Indian method by the dislinguiehcd M. i>ief-
fi^nbach, of Berlin, at the time of hie visit to Paris m 1*434»
Soon after my return home, I had an oyiportunity of |>eH'ui"m-
ing sevend oporations for the restoration of the noae; em-
ployingf in one case, the Tahiictitian or Italian method ; and, in
nuother ease, taking the rcffuieile material from the fore-arm.
The Indian metliod I have very frequently employed ; in uioet
ra^es, with cxcdlont rc^ulta. The ^eur loft on the forehend is
much Jewa conspienonH ihan might he cxpeetcd, and the great
eurtiirin-r to the ^mtient whieh results from the confinement of the
nrni to the head in the It^itian method ih nvoide<l. The principal
jneonvenienee wliieh I have observed in theae operationt^ dc])en<lfl
iij»un tlie faet, that the material for the ecptmn* and often for the
lip of the nose, mn^t be taken from the sonlp. The conaei^iienec
is, tliat the hair tiontiaues to grow upon these parts j requiring
frcfjocni *liavia;;j, or t'straetion with fuivepe. DepUutoriea 1
have often tried, but Imvc never found that tbcy produce mote
than a transient eETcet.
The Ibllowinp; and some of the Huceeetlin^ eaECa are tlic first
performed in Ameriea with eiicce**^ anil probably p;iive the im-
pctiiA to the inlruduetion of tliis ela^fi of operations. The
Taliucotiuu operation, a« performed by the diEcovercr, of trnufl-
planlin;^ a portion of the akin from another part of the bijJy,
had DOl been ndo|ited by modern European surgeons j so that
the cneea of thnt (jperation mentioned below were probably the
t^nly oncd thnC had been succcutifully done for a, number of
jcara: —
Cakk XIII. — Rhinoplaatic Op^rttt'tmu — A young man.
2#1 yeare of age, in the aprin^ of 1B34 received a blow on the
noac, whieh dialoeated the cartilage to the left eide- Thld was
tiillowetJ hy l>rief influnmiatory action. As be was out of town,
find at a dUtnnee from medieal adviee^ nolhing wa^i done to re-
place die eurtilageT which remained permanently displaced.
20
THE FACE.
In the fallowing spring, a reJ spiit apjienred nn Llie ngli
cheek below tlie eye, which very floon increaHt^l in size; ihe
i II fla Hit nation gradually apread, ntta<:k«l ihc lip, and llien L"i-
tcnileil ta the ncBe. which became reJ, t^wulicn, mid fiii;Lli^^
ulcerutcdi ^^
It will be iiTiiiccesBnry to go further into the dctniU of tlie
cnee : ii U EUJfivient to euy, thut, h\ ihc (bourse of ei<rhtcen
montlis, all the
textiiren of '^^|
nose were piircee-
aively attacket
and fiunlly
jstro^ed* Sul
r|uently, cjcal
zatLui] took ph
leaving the
tient in tlu; btute
' '&>* in whiuh I 8ILW
liim, fiix mom
lifter his recnvi
I'roin the disease,
At I hid [lenj
h living aocideni
eoino aercsa n dc*
^cription of tJie
Tulincotifin oper-
iiliiin in nn old
mngnzinci he wua
dcBiroufl of know-
ing whether nny Mng ol J\ aiiiiilar kind could he done to remedj'
hia frightful deformity. The fL»ll*>wing was his ^tatc as ho a
pcnrcd on the fii-al examination : —
The noBc, aa already etntcd, was completely destroyed, lea
ing in the place it ori^rinally occupied an opening about tin inch
in diameter, bordered hy n firm eieutriec ; the eeptiim o\ the
noatrila was gone, ond the two na«al cavities thrown into one;
externally n Finall ciealrix de^^ccndcd from the lower and left
cd^ of thid opening to the angle of the moutli. Jo the eourao
t
]
KHIXO PLASTIC OPfillATIONS.
21
of tho disease llie futir front tenth bnd boon lost, whtdi, to-
gether with the abfiorplion of tho alveolar protJeBSPs, hndciiused
the upper li[j to *ick much below the level oi' the lower
one- An openbjj exiitod betwten the lip und upper jew,
through wliich n probe mii;ht be pnfi^scd from the rnoutii into tho
niitful eaviiies. The ecnee of emdl wae quite lust ; und ho was
Bubject !i> a How of learB over tlie fuce, nrisin*; undauhtodlj ft"om
the too t^ndden conlaet of tlic jiir with the liiehrymal ducts.
A lburou<^h c^uniitiEitJon of Ula vaac having been made, and
findifi^r thero was no obstacle to the poi^eibility of a fiuocceaful
opemtjon, ita diflioullioa were distinctly stated to him, — the im-
prubftbility of its eiicceedinp; so f\s to restore the organ in Bueh a
luimner ihut the dcn^rmity ebould not bu knciwn; that the new
nose luiglit beeoQie very mueh fattened, nnd, jierhups, on the
np|icarunce of cold weather, ^in^cnc nu^ht take pincc ; and,
findly, that even h'v^ life ini^'hc be endan^^ered by It. I felt it
■■-inydtity to «tatc tbc i^se plainly, having Been all these accidents
iKt'iir (ihruad from lijc operation ; in two enbes death bein^ the
eoii*ci|Heiiee, from severe erypipdatoufl inflammation i?f tljc
ecalp.
» Notwithstanding nil tliceo objections, be decided to Ttinir any
rif>k wlii^'h ivould give btLii the ten^t chance of baviti^' the tletor-
inity uuder whieh be labored obnutcd. It was thoui^^ht exjx;-
dient to delay tho operation a few wocksf in order to prepare
bim by a courac of diet and regimen. At the end of six wcektf,
IIS ho utiU persisted in the determination of having it pertornie:!,
■ prtptirationa were made to do it at once, eiace, on account of
Hthe approach of cold weather, no lime was to be sj>art'c!,
H The prcpanitione having hiien nuvde, the operation waa pcr-
Bformed on the Ttb of September, A piece of paBtebonrd,
cnt in the shape of ihe letter V, that ie, of a triiingular form,
and with n projection from its base convepomlJiig; to the columm*
<if the nose, w/is pineed U|>on the forehead, and a truce made
li[\>i]nd it vrilJi the nilrale of silver, which was used in pi"efercncc
lit ink. a» rceonimcaded by Lififmnc, in onler that it might net
lie eflaced bv the hlood, A ti-aec wod al^Kj made around ihe
'p|ien]n^ of the atisnl fo^iaa, at the points whore it would be
.'tii'ccsaary to remove the integnineiits lor planting the new ekiii
22
TllE KACE.
taken frrjiTi tlif* roroho;»i.U Tliis wns done on llie nij^lit prevmua,
in f'rder to prevent anj undue delay on the day of tlie ope-
mtion-
All iinnert'ssiiry nrlidea of clothing hflving been i^crinved » the
|ia(ipnt «'iis pliirwT on ii table in a recnmljont position, biw lace
towards tlio windtiW^ nnd tlio operator behind, so as In havp the
full cominnnd of the hend. The traces made hy the nitrate of
silver were about tu'o-thirds nf an incli apart between the eye-
bruw« ; oacii ^ide of tlie trian^idar portion jf skin was three
itichea and a quarter in length, with ft base of three and a lirdf
int^lies ; and the projeetion for the t'clumnn of the nosp, whieh
was to be taken entirely from tlie sealp, previously shaved, was
Hn inch and a half lun^, and two-tliirds of no ineh wide.
The bond t>eing finnly sujtporied by two assistnats, the in-
cision waH c'oniinenced hetwoen the eyebrowrt^ and the flap of
j^kin dl^^-'eeted uji srt as to isolate it entirely from the skin
of the forcheiid, except where, for the pnrpoae of nutritionj it
w!iw left adl^crent ait rlie ro<it of the nose. The incision on the
leW ^hXq, Iwtvveen tbo evelirows, was extended a little fiirtber
down than on the ri^ht^ lo faeilitate the twisting of the flap.
Tliin ineliLded the skin, f^nlx'ntimeous eelhilar tin^ue^ and n por-
tion of ihe oei;ipito-fronlidls iuu>iele ; eare Itoing tukeri not tu
raise the perinsieum, from fear of neerosis, i
Thi? flip tluis diiijierted, and twisted round to the left, side, wa^
Ciarefidiv wrajijted in a compress uf linen ekifh ; and, before tJie
operation wn^ proceeded w]th^ attention wiis given to diminisb*.
ing the liirge wonnd made in the sealp. Little hrmorrbai^a had
trtken pbiee ; and the leinpora! nrteHes^ which had been cut, very
aonn T-erracted, :md eejised bleeding. The anirles jf tlie tvoutid
were firat broii^dit together by the twisted suture, two pins being
emptoyp^l on eiihcr Ji^ide. Its etlges between the eyebrows were
i;]mi> approxinniied in a similar manner : by this nLeana the wound
in the forchejul was dlminisbed tit once to l&ss than half its origi*
n;d hixe ; it wa.** still further rediieed by the nue of a few strijw of
ndbeHive plaster, and ji tittle serapeil lint lilled np the remainder
*if the wound. Lint spread witli cerate waj^ npplied over the
whole mirfiu'e, a compress, and tlie whole i^eeured by a bandnge
tiiiind the head.
RH1V0PI>ASTIC OPERATlOSfi-
23
Tho upkI object, wae to fix the bon-owed nkin m its plnoc. In
|<trdcr to do i\ii&t it was iicoc^EAry to 1'rc:^hcTi tiie bur^Icrs uround
[tlie D[>€D:n^ of the uatia\ Iobbh, the tmcoa oi whichf oa etated
above, liad been previously mncle with nitrate of silver. For
ll»ia purpoacr. n ebort narrow knifo^ soniowlmt ^imUiu' to a cntanict
krufo, was used, and a utrip of iiitopninicnt, a third of nu inch in
broadlh, removodf mdudin^ all tbnt portion wbieli hod huGH
Itidiirutdl durin*; the ckMtrizaliaii of the ulwnitioiis. Th<^ knitc
^as jdso jmsricd between the iiji and ii|pptt jaw, m which exist-
ed, as before fitalod, an opening Inrgc enough to paes a probe;
and tJie adhesions botween tho two^ fur the epat^e of nn inoh,
eaiircly cut away. Thia was done for the double purpose of
Igiving the colunina of the nose a more deep and ^rm adhc>:iiori,
[«nd, in the intlnniiLintioD whioJi would t^ubscqu cully ensue, to
up the unnatural eommunieatlon between the mouth and
cavity.
The 1!ap vfHA now brought down into its place, itii ODi^les a
little rounded with the scisaora, the hotter to r^iinuhitc ilie ulu*
of the no8o» und the wholu secured iji itti plnee by pjn^i, nud
iinta of tho interrupted suture. ITrom that portion of the akin
■which was to foriu the coluuma of tho noae, the cpidermk- side
ivins pared, ao that it nilglit form nn adheaiou, not only uuder-
[jieiLth to the jaw» but on its sides, to the quudran^^ular wound
Lade for it iu the upper lip.
Scraptil lint wii^ now plaf^cd under the ends of the pina, and
* rtrip of oiIe<l Unt introduced inti> each nostril^ to prevent
odhceioD ; another strip was placed upon the nodc to prcacrve its
lemporalurc. The drcaaiui^f* were aocured by a band of adhesive
plaater, Hxed to the foreiieiKl above, and pai-tialty divided in the
middle, eo that it nil^dit descend on each eido of tho nose to
■ the lip.
H During tlic whole of thia long and painfid operation, the pa-
H tient kept up hU eoura^'e, and nut a cry was uttered, nor the
BlcaAt etru^'gle made that could at all impede the motiona of the
oj>cralor. Not much blood was loat, and hia strength waa ao
Uttie exhausted that he wue able to run up atau"a to bia chamber.
He waa ordered to go to bed nnmediutely, to keep perfectly
quiet, nud a watcher IcH witli hiDa^ who hod dircotione, iu cose
n
THE FAHE.
of hia fiiUin^ nsWp, to prevent liirn fr*im either rullin;^ over
his eide, or r.iiaing his hand to the tioae. so as to derange the
dressing; nlao, to woke him imnictllntely ^houh) he broathe
through the nose. To have arrow-root, or gruel rmd leiaoujiJe,
for nourishment.
On visiting him in the aflenioon, he wns found comforlJible ;
the new nose wns wflrm, and hfid hied a little from the edges
whioh formed the nostrils, both ahowing that the circulatioa wm
not at flll impedetl.
Sept, 10th. Passed a good nif^hl, elept wt^ll, pulae eeventj-
nincT Odmpkinfl of no pain ; the no^e of about the nntiiral lem-
periiture, A pier>e of cork waa confined between the leetb, so as
to keep the mouth o|>en , and prevent him from hrenthinp; through
llie uosG during sleep. The introduction of the eork prov^
BucecasfuL
12ih, The first dressing took pince four dnv^ nfter the opera*
tlon, nnd t!io folkiwinp; was found to be the state af the pat<t« : —
The dres«ing^ on the forehead, after being well soaked, were
firfll ronioved. The angles of the wound were found to Uhtc
united throughout, so that two of the pins were at once dis^wnsed
with. Union had also taken place in iini liiwer part, just above
and between the eyebrowa : tlie rcmiiuJor of llie wound, thai is.
ita centrfil part, in which union by the first intention could not
take place, was suppuriiting well, nnd filled with healthy granu-
lations-
Upon reinovuig tlic lint from the nose, it waa found that en*
tire union hnd taken place on botli ^idea. The alx and the lower
cdgei4 could Tiot easily he seen without niaklng use of too much
violence. The oohimnn was curved inwEirtls, and the eiitures
concealed. The nose was of the natural color and temperature,
und (be circulation through it seemed uninterrupted.
Two strips of lint, dipped in oil, were laid over the cicatrix
on each etde of the noae, and no other dressings uaed. The
patient was altowe^l to alt up a little, and to take any article of
lic|Tiid food lie might fancy.
On tbe 13tli he was quite as well, with the exception of a
little (edema of the upper eyelids, arising, undoubtedly, from the
prcflsure of the bandages and other drcasinga on the forebeatL
RBn^OPLASnO OPERATIOXB.
S5
I
One of flic pins was removed from the forehead on the 15th;
and nnotbor, the only reniainlng odCi on the tbllomn^ day.
The doeailfi of lint which hud hoaa pkocd in the nostrih still
remaintHl th^^re. £riii]y caked in, Theiic were not removed until
the ItJth, when ihcir places were supplied by two pieces of hol-
low eouod>
On the 14ib* » quantity of hair began to appear on that por-
tion of the dlun forming the coJumna of the noec, whieh, &om
time tu timCf re-
quired lo be re-
moved. He vvae
put upon a nour-
ishbg dict> Willi
tJic caution tou«e
the jaws aa little
as pofiHiblc, lie
itated that occjt-
ftionally* when be
Dwtkllowcd, he had
» flcnaation bb
though iie would
■* swallow hi?'
nW."
16lh. The re-
fcwoycd l'n>ni llii
e of the noee.
•nd the two eu*
nw wliich Cun-
the aIid ;
thI on ibe 17th, ten i]xyH .iftor tlie i>|ientlion, ihtj two ligatured
diioh cuiiHneti tlic coluiona in [(« plact were alfio removed.
At tliifl [>eriod. tiie ^tJlte of ihc parts waa aa follows ; Tlie
ound in the forehead had diminished to a thiiJ it£ oiiginal size ;
nd the Bznall triangular epaec which re»iained* together with
at portion of the si^ilp from which the colunma of tlie noeu
hml l>ecn taken, wae ftUed with litiidlhy grauulatioiifl. From
ihc wound to die root of the noee waa a linear cicatrix nearly
S6
THE PACH,
two jnchee in Iciif^h, nnd continuoua wilh the ci^-ntruc on the Ii
eido. Adiiceion of tbc intcguinent^ liad taken \Aace on botb
sides of the noao : at the ri<rl»t nlii, however, the union ww
not quite eo perfect »ts at the left; that ia to say, the whole
thickncas ctf the ekm did not nppenr to have unitcdr To aasiat
the unionj tJie akin of the fni.'e whicli lay under it waa slightly
senritied with die point of a, knife.
Tlie cuhiinnn. was a little ci)rve<], and ite cd^a had refrncted
inwards upon them^elvee. Tho inwidc of tho noee W!i& suppura-
ting wqQ ; and, at ita upper part, iidiimoD Heemed to have takfifi
plftue between the two bleeding eurfucee whicii had been op-
posed to each other. The tip of tlie noae waa weU defined, and
ita edgoa were curved inwurdflf so ats to eimulate the natuml
appeumnee of the uhe ; and just above the iiln>, ajipnrently from
atmospheric pressure, a deprei^ioii was taking; pluce, forming
their sujterior boundary. Tins was assisted by the patient
inakinif lUi oceosional pressure witJi liU ^n^eva at these points-
He fdt well, had a ^ood apiietite, and eat up all day* Ho
breathed freely through the tube« plaettl in tJio noAtribi, which
retjuLred lo be remuve^l daily^ in order to clear out obstm cations.
At the end of a month, the wound in the forehead had eon"
traded to ub<tut u ijunrier of its ori<;inal size ; adhesiim i>f the
notis was perfect al all pointa ; the noBtrda were re^darly round-
ed, and BJnmlntai weli the natural contour; the tip of the noec
wuB well preserved, and the eur\e from its root to tho end of
the or^aD was regular,
Tn six week^T he wa& able to go out ; hut, as the weather be-
came cold, he waa advised to confine himself to the house,
fiince cold evideiitly had a very f;jreat etieet in retardir^ ciejitri-
zation. By reference to the second figure, a jtretty correct idcn
will be formed of the state of things six weeks al^er tlie opera-
tion h
At the ead of two months, it was tl:ou;^bt time to proceed to
the second operation, which was req^uired lo remove the twist
at the root of the nose. Underneath the pedicle which con-
nected the noflc with the furcliead, a sn)an portion of sound
akin remained; and. of course, no adhesion had tsdcen place be-
tween this portion and the jjediele tying over it. The method
fiHlKOPLA&TlCi OPERATIONS-
27
oeually a^lnptcd by opcmtora hae been to cut the liodiele, nfter
IlUa Du^ hQ:^ united sutlicicnlily to Justify its sc|»ariLtioa from tlid
«ourc(? Cff Dutrition, nud t<] fix it duwn at tlie root of the nose,
in a traD«ver«e inciaioa madi? for it nt that point,
Tti thifi metJiod lliorc are some eorloua objections- First, tlia
dan^r of inflnmraatioa in bcparritiiig tlic }>cdiole; eccond, of
aloQnrhing of the or^ron, on Jividing its vflsculAr connGCtions;
and, laatN'T tho very f>ercoptible trnnsverse oiaitrix whJdi re-
niains. Tlic coureo rojsorlcd tc> in the [trceeiiL ciisr ie liable
to none of these objcctione, except perhnpB the fret one, in
which the dtuiger is much diuuniehoi:!.
This was ns I'ollows : An incision wna milder conimenolng
■nenr the internal an^Io of the eye, and extending to that piirt of
the baso of the nose w^here ndhceion had not taken plaeo ; a cor-
^re^pondiii^ ineision wns alao made on the pedi<^lc. The skin
g dieeected up, tLo wi'inkle iu the into^iiment nt tlte upper
of llie wound was removed ; the edges were then broug;ht
"^gether by euturea. Union look place, throughout, by the
firet intention.
B Four months after the oporfttjou, he was entirely wcli. There
Hwti« no eeerction from the nostrils; and, on h>oking into thase
"cavitiee, a new ekin was found to line thcin throutjbout- Tho
noso itself gradually contractcdf eo that, first ^ly the ehrinking
of the inti?gumcntH, and Bubticquently from suppiiralion, it de-
Icreuficd to about two-thirdii the gize of the Hup whieh was
laken from th& f.M-chcad. CoiitriLCtion aJi^o took place in ita lon-
gitudinal oji'is* The Doeo was much improvccl, when the four
front teeth, which bad been lost, were repJaued by the dentist,
which brougikt out the ueiOct lip, und at tJie same time raided
Bthe tip of the or^fan. The cioatrix in the fjrelkead became very
etnall, and gradually aeaumol the eolor of the surroundmg integ-
fumeutfl ; the acalp Irom which the columna wo^ taken was lost in
tlic liair; the noee was quite firm, of a good form, and the
Dicnti-LX on each eide aoju'cely pereeptible. At tlte root, on
the left tfide, and nt that portion wliich furmcJ the |>edi<.'le, a
snmll iiflaurc romainwl, which woa concealed by a atrip of coiirt-
»[Euter.
Hi^ health had never been better, hU eeruse of amell gradually
28
THR FACE.
returned, and the t^&rs remimecl their natural cliannel ; and he*
DB well ns his friendB, utmgratulated thoraaelvefl, both on the
mornl jn;d i>JjyHir;iI tifGCts of tlie operation.
At the end of tliree years, no senstljle alteration had takco
place in the reatured pEirt. The aha|]e tif the nose was perferfJj
preserveil ; and there was none of lluil flattening which has usu-
ally been brongljt forwanl, by tlie opponents of this operation^
as one of tlie greatest aljectiorift to be preferred against k- In
thoae caseE where this Raalty oceurSf it almost univerMnlly ariBcA
froiEi tlie flap. In the fir^t pliice, heiug tiKt stnall ; and, the inter-
nal burliiccii not heing wetl oppjsed, adhesion fails, and, as soon
OS the swelling sidj^idea, the nose ia left flat and defiirraed.
In the present inslanee, the operation was alnioet a new life
to the subject of it, restoring him to the society of hii^ liiendst
and enabling him to eaUibli^h htin^elf in busine^.
Re^mtirksM — One of the greatest diffipiilties of the operutioii
was the management of tiie t^iitnres to close the wound In the
forehead, and to confine tIl^^ iifw nose in its situation.
At that [mrt of tJie flap which was to sinmlate the a]a^. — as
it was necessjiry that the integument ehould be directed inwards,
— pina^ of course, could not be used; and here a plan recom-
mended hj M. Ijahat was adopted, which weis followed by
partial success. A tlrcnd being paesed, first tlirough the integ*
uinent of the face, and then through the flap, at about two lines
distant from their edges, the ligature was so tJed as t*: produce
a fold; and, the better to oHect this, n small cylinder of adhe-
sive pla-^ter, was confine<l under the threads, so us to make a
strong rainniression on the wound, and to force the edgea into
their places. This succeeded completely on one side; on the
other, union was not so eEitire*
During the whole of the treatment. It was necessary to keep
the nostrils distended by small tubes. The substance which
answered best fL>r this purpose was the barrel of a qiiill, the end
which remained in tlie nose being aloppiJ up with melted sealing-
wax, and a small aperture cut in tlie side, dirough which tlie air
cuuld paaa freely. Tiie tendency to contraeticn whh very great,
so tliat, at one period, the tubes being lefl out during the night,
it required considerable force tu rephice them.
EIHDJOFLABTIC OPERA-TIONS.
S9
As tlje new nose waa formed entirely of akin, it will per-
ps be eupj^Bed, that tlic integuments camposin^ it wera
id» and the form of it cM^ily deatroyed. Thia, however,
ircm reasons easily appreciable, was not iJie caae. Tlie integu-
metkte of tlic scoly) bein^ natarnlly of trreiit tliioknoss, by the
Guppur^tion which took pkcc ii-om the inner aide, assumed a
H|£rmneft0 almost fiimilnr to fibro-cnrtilage ; and, at the root of
the nose, the internal surfitces coming in contact, contracted
adiieeions, eo aa to m^ike it perfectly aolid at that part. The
Golumnii alao formed a round and solid pillar to support the tip
of the nose.
Great precautions hod been tnken to guard against exposure
[to cold, which, by atopping tlje circulation, might at once de-
feat the whole object of the operation. Aa aoon, however, as
ndhcsiau had taken plaoOi it was perceived that no danger irora
tbia source was lo he apprehended; anJ, although during the
winter he slept in a room in which water frequently froze, and
■waa repeatedly exposeJ during aomo of the ccldeat days, the
tenjperatui^e of the organ was never greatly diminished.
The cicntrization of the wound in the forehend was retarded
~by the cold weather, and Ich^ rhan half the lime would have
been required , had the ojxiration been performed during a
wtLrmer aeason- When it had diminished to a small size^ and
» cicatrization — -aa ft'cquentiy ia the ease in the lilling-iip of large
wounds — seemed to have beer arrested, great benefit was found
from the uae of an ointment composed of siic dropa of creosote
Kta an ounce of simple ointment. On the application of this to
1 the wouml, the effects were at once apparent- A small pellicle
formed ovi?r iis whole surface, which was shortly replaced by a
£rm, consistent cicatrii.
In one or two caacA operated upon by DiofFenbnch, much
ewollin^ took place in the new-forniefl Tiose the day after the
opemTion, ariaJng Irom the difficulty with which the blood wns
conducted off by the veinB- In one case, the noae became so
enormously distended that it was fe:Lred the adhesions would be
entirely destroyed ; and it waa only by the repented applicition
of leeches, fleventy or eighty being employed in the course of
forty-eight houre, that this w:ls avoided. In the present caae.
so
THE FACE.
from tlie citcnHon given In the indsion on the left eide,
Lehig tjiki:n Lli:it trurtinn siiuuUI lun he madi.^ tou trt'iUy ijn ihe
part. BO aa to coinpresa the pedicle at its baee, tLe circulatioo
wa^t from the firat, uurjbf^tnictetl.
Tliia case, liavinj?^ Leen tike first succraflful one m thiH oomtr
try» has been mr>re fully relateil. It must be remenibtred diot
it wad done before tlie dayH of etlier. \vbicli gn^dv facilitatcJ
Bubsequent tedious o|ieratiu[i!4 uf this dcsuriptlon.
Cabe XIV. — IlhiHfipliL>*lle Oj/KrtUion^ by ik^ Method of
Taliacotius. ^ This wuh a cajie of lupua of fifteen jeara' stand-
ing. The commenceniCDt wae by a spot on ihe very tip of
the noee* which gradually e:^te[ii1ed, becoming fiuitLly of a livid
nal oolor, and having its Hurfiu'e (covered by imiiicrona elevationa
of a tuberculu.r apjicarauue. In his ordinary state of health, and
when jiicrfectly quiet, the only Henaatioii in the affected part wa«
thiit of heat and itcliing : hnU on the slightest derangement of
the fiystem, and upon any extratjrdinary exciiiun, ain intense
burning and atJiiglng was felt, nut only in the noae itself, hut
in the surroiiULliJig integuments; and oflen so int^upportublc as
to oblige LliEi tu desist from hiti work, and bavc recourse to
cold applications, for Icmpofary relief. lie submitted to a great
variety of treatment, continued for ii number of ycar^, hnt with-
oiil the {«ljghtefit hent-Gt. A cuubtiu bad been ap|ilicd, a. year
before, nhich destroyed a pitrt ol the tskin. and the eubjacenl
cartilage ; most of the disease remaining undisturbed-
He came to Doston, dcLonuuicd to have the uflcctwl part t&-
moved, and the loss of Huhctunce supplied hy ihc Taliueotian
upcnitiua. At tlus time, tlie nose had a very pinched appear-
ance, the skin being of an intense red towards tl»e tip, and liav*
lag in ita substance a number of hard, tuherculnr bodies. A
slight reduces extended o\er the ida naKi uf tiie right aide. In
the centre was a dej)reas]on, and loss of substance, where ihc
caustic had been used.
The operation was performed on the 8th of April, 16-40. The
diseaae, which eAtendcd up na far aa the na^^al bones, waa recy
carefully removed; and the cartilages below, not dtistroyeJ by
the caudtic, were founJ to be In a pcrfecdy healthy state.
IU1IN0PLA9TIC OPERATIONa.
81
[iTDCn^iona of the flap were carcfiiU}' taken, and marked out on
he fore-firm. The traces were maJo on the radiitl side ol" the
;ft arm, about two inches from the styloid proccBS of the m*
LLUfl. Thia 3rtp was ilia^ectcd up, iududing with Uic ekin, tho
[mb-cutAQcous celKilar mcmbrrLDc, and woe eccn:\^d in its new
^*itnntion, in conlatt with tlic fiice, ljy five etituroa ; the arm being
finnly fixed in thia position by ftpproprialo bfl-ndngcs. Nour-
it<hni(.'nt wn^ ia be taken through an cliLstic tube ; tbc mouth
^^jcin^ BO covered up aa tu pi-evcut the direct introduction of
^Bbod> He woa pinci-d in bed, and supported in a sitting poa-
Hturc by a common bed-ehairp
' On the tbilowing day, the !Jih, there was some a[>pcarjince of
errsipclatouE uiflommation on the bridge of the noec : iie had
been pretty quiet, and had slept a little^ but required constant
I watching to prcv<int him from i^lippin^ down and doubling him-
self up in tJie bc<l. He cumplained much of a want of solid
support to tho olbow; and iliereforo a wooden apparatus whb
conntmcted, and placed acro&e the Ixx), wliich aervcil aa a
firm renting- place for the *utq, and enabled him to maintain
more eaaily the pn>[>cr poeition. The pulae wae sixty; and,
throughout the whole period of hie confinement^ it remained
^ below the ordinary standard, On the lOtiii he complained lesa
H-of hifl arm, but wne exceedingly reatieas* During the <\Ayt bo
HwAd removed to an eaay-ebair, and the change afforded great
Bxclief.
■ The state of things varied littler from that already dceeribcd,
iiniil tiie iiftb day, the period appointed for separating the coa-
ne<'(iim fMitwecn the ftfm and face. On ihia dayi the base of the
Hap wuf* di\-ided : a perfect adhesion had taken place.
The wound in the arm was dressed, and a small portion of tho
pkin which projected bound down in its place by ndhcaivc etra]*a.
The irregiilur portions of skin atlnehcd to llio nose were ro-
moved ; and a sVv^Ui compression made on the cd^jca around the
noftriJif, witli atnpa of ndhesivc plaster.
The arm, on being relieved from its continomenlf was not so
pHjnfid OS might have been cjs peeled : tiiorc was an almost
entire loss of |wwer in the rttxor muscloBr In the course of a
few days, however, it rc^'ained ite hcalUiy etate of feeling and
mutton.
32
THE FACS:.
By the 20th of April, the newly tranaplunte*! skin h«d con-
triiGte*! Ut nearly the natural kjzc ; lite line of union wflli the ekiii
of the nose was perfectly Hneai; nil the al^rupl and useJe^'fl j>or-
tions of akiD on the lower &\ge uf ihe no/sc had h|i>ughed off,
teAving u jMrrfccdy even and rDiinJed edgi^ tu the nastril«.
On the 23J, I w^a auqiri^, on removing the green f^i
whidi covereJ the JresatngSt lo find that the whole cuticle cif the
reat<ireil jiart hiid peeled iiK, leuving the aurfftce quite raw, und
covered hy the green (xiloring-niatier of the *ilk- This at firal
scemeil likdy to jiruhing the period of recovery, but h jirovEd
of niiiterlal heDcfiL : :i flight su|ifiura,tiiin conimeuced, which
hroiight dov^n the skiti to a natur^ ihieknef^i^, aud rounded
off, in the moat periecl nianncr^ every ineqniility ; and eeemed
itlHin lo melt tlie akin ljlIu die luljiicent inlegunieiiHK, so t\s ahnnsL
to dt^troy the tr,u:ee of the Viae of union. A new cuticle ra|^
idly formed; liud, by the end of the month, he wu^ ^uite wdL
HubACiiucntly, havia^ c\|io^ luuiself to the fluu» he vk&a
troubhil with itching in the right ida o|' the none, where a flight
redness reniaintd^ He ciiuie to me, very du:^iroua lo huvc the
akin c>f thii^ pnrt nl once removed, lie vma miAJoua that tlie ex-
periment should be tried of cutting a picec of akin from the
urni, and ininie^liately placing It ju the wound, lo supply the lofi*
of ftubBtance. Although I did not consider this part of the
operation necesaary, I yichlcd (o hla deftire^ and made tlie at-
tempt. The diae.x^ed tikin was removed, aod itd place supplied
hy 11 piece fn>ni the fure-iwni, kept in place hy Ihil moistened
in hlood. On removing tlie drefifiing, al the end of four flays,
a GOitd uniim h^d taken place.
It will he perceived, thiit, in this caaef the old operation, aa
performed by Taliacotius, of taking the der^Lrcd inte^^uinenb from
another part of the body, wiib prefen^l lo the Indian methrxl,
tn whicJL tlie &kin la horroivcd from the forehead and hairy ^csilp.
The reasDua are perfectly obvioua. The loss of aubHtaucc to be
HUpplied waa email. By tlie course rcaortL'd to, a M!Jir on the
iJjreliead was avoided; and that on the arm waa of no impor-
nmce.
The operation was not precisely that of the Itjdiim surgeon-
Taliacotiiii^ preferred taking the skin fnmi the arm near Uie
isfrtion of the ddtoiJ rajsde; and, by adoptirg this mothmlt
limb caa he much more ecGuroly Bscd in contact with tho
lead- In llie present caee, llie patient bcinf* a, niuacular man, the
arm could only be brought to that position with great difiiculty.
■ It alar> differed from that of Tnliacotiiia, ia the early scpara^
tion of (he transplanted skin from its connection with the arm,
on the fifth in^ti^ad of the fourtoonlh or fiflccath day ; and, as
tLe princ7i)>al o^jeciion tu hie method la the poeitioo in which
^tho arm is eo long and painfully confined, rhie is ccrtninly a
^t-Tory important consideration- The Italian surgeon raised the
Hflnp gradually, allowing it to suppurate and contract. Tho
"most iuapoptant poiut, however, the adheniye process, must by
thifl means have been rendered much Jess certain.
The accompfloyinff print will atJbrd Bome idea of the position
if the patient while tlie arm wns confined lo the face.
Gabb XV. — Rkinoplaxtic Opertstwti. — A young woman,
17 yeara old, from Maine, applied to me ia 163da having loat
d
Zi
THE TACE.
her Doae in ibe followinp manner t Sixteen montlia before, hav-
ing a wjirt on her nose, she wna induced by her frienJe to appW
for mlvice to one of those quac^ka fityletJ cancer doi^torsj who
eaeily perauflded ber (liac the nflcction was of a cflnceroua na-
ture, A i^aastic wna usQtl, wlilcli produced bo grcni a. degree
of inflammation as to akrm her, and cbli^ ber iigiiin to Luve
recourse to him. His Einswei- was that the npplicaiion should
be continued, not only to the witrt itself, but over the adjacent
parts, "so that none of the roots of the diaejwe mi^dit GEcap«."
It wna therefore [persevered in ; mid ao cfiectuiJIy, thnl, at (he
end of n fortnight, all tbe tiesb of the nose sloiij^lied off, leav-
ing her in a must deplorable condition. On rt-ap|jlieniiod to
the quack as to wbat was to be done under those cipoum-
Btnnces, he assured her that it was a most hnppy lernoinatioii
of the di^ense, which, by tbeee means, bad been wliolly eradi-
cated ; and that the noee, in the course of time, would ffi-ote
out again, nnd be perfectly restored.
These aeauraneea, ns may welJ be conceived, were not dei-
tined to be realized : [he cd^es of the wound gradually cica-
trized, leading lior in the state in which I saw her siAteon months
alter.
Her condition was much as follows: The tip of the noae,
together with the ala> nasi and corresponding portion of the
septum, was entirely destroyed, leaving the nasal paseagea ei-
poffod : the oflsa nnsi, with a araiill portion of skin covering
thcmi retrained entire, tlieir edges being lined with a Riin mid
eoniewbnt vasculnr cicatrix. In other reflpecta, she was ri good-
looking woman ; und her henlth as little disturbed as couid have
been expecteil.
The o|»er!Uion was done on the ITlh November of the same
year. The patient was placed In a recumbent position, with her
hcail well sup|Kiried by pillows. The dimontions of the flap
were traced on the forehead, nearly ooe-third larger than was
necessary for the formation of the new nose, ThiB was dis-
sected up, nnd evory precaution t.aken to leave the pedicle of skin
between the eyebrowa sufficiently large to allow free vascular
communication. Care was also taken to leave the angular
arteriea unwounded, aH upon these depended the principal meonfl
R HI so PLASTIC 0PEKATION9,
35
\
support to the Hup. Before proceeding fardi^r, (lie odp;ea of
the wound in the fareliejul wore approilnijilcd by the twisted
mjtarc^ Tliis wua ficilltatetl by the incision in the eciilp being
proionge<l to n jjynimidiil form.
Tlie cicjitrix covering the nasal bonos was now romoved, iho
flap twiste4l round, !tod secured in its place. The etrip whidj was
to fonn ihe cohimna of the nose w^ deeply ini|]iantod in the
upper lip; (lie whole was supportetl by amoll atrip& of ndliesive
pUtril4?i% unJ cuvercd with Hnt, to preserve, as njuch as jtoe^ible,
lU lemperniiire; smnW tiibea were intro4]ucc-<l into eneh nostril.
The pali*>rit \rjia direi-led to keep in Led, to remain perfectly
etill, nnd to brcnthe througli the mouth.
On the following day, the nose wae swollen ; pnlse eeventy-
two: she waa rather rcBtloss. On the Sflst. the sutures were
removed ; eotiro union bad taken place. The fieiiJ*ation was
nearly nittural, and, as in the previous case, but slii^'btly referred
to the pfirt from whieh the skin Imd been transjjlaated. The
form of the noae was good, uirh a regular curved outline; the
alar nasi, also, were well defined. The no&lrils were kept open
by means of tiie small tubes, which were removed dnily, and
cleansed. The wound in ilie forehend was dressed daily with
creoeoie ointment. She aldu derived much comfort from a creo-
sote gargle, for purifying the mouth. On the columua, which
ivns L-iken from the scalp, hair continued to grow; hut was
ciuily removed hy seii>sorfl, so as to be ficiircely perceptible-
From this time, she gpidiiaUy p:aiucd m stren;^lh, r\nd was
Me, in a few daye^ to sit up. The wound in the forehead
slowly cicatrized, nnd the noae assumed n more natural stppciir-
ance. In the following Bjiriiig, I performod the comparatively
trifling operation whit'h was required for confining the pedicle
in lis phice- The cicatrix of ibe furchead wna then quite tirm,
nnd easily concealed by the hair.
The operation, in thla cjue, with some slight exceptions,
resembled the first. In the 6ret operation, the twisted suture
was used fur coikfiiiiii;r the new nose in lis place- Jn the present
instance, however, Tho interrupted suture was enhstilutcd, and
pnswered a much better purpose; tlie points of ulcerzuion, on
the removal of the thi^ads, being less.
w
THE VXCE,
Case SVI- — Hhinopfastic OpemihUy bif the Alethad of-
Tafi<icotius. — In tlua cnee, the operntion waa performed wv.
eordiag to the mcthcU ref^ommouJetl by Talkcotiua, rariJifiel,
bowover, by the expi>rieiioe wliioh niorlcrn prnrtitro haa siiggeal-
ed ; the sktn beinj^ bon"oweJ from uvor the hictjpi muscle, as in
tlie Talidctitian operation. It is more interesting, from iU beingf
30 fiu na we know, the only one which hsid been suc(*essfully
performed by this niethud far twenty yertr» previous, the aepa-
ratioQ of the tliip being' xumle nt axt eai'her penod than in anyl
enee on record.
The union was thonij;hl sufficiently perfect nt the end of sev-
enty-two hours, or three dnyg, to wnrnint the ^epamtion of the
new flcip. In earlier cfwes, reported by Graefe, Delpeck, and
uthers, ten to fourteen Uaya were thonnlil necessnry to secure
union. The advantage of this ejirJy tlivision of the pnrta will
l>e ensily perceived. The preference of this method ih, that no'
acar ia left on the forcheiwL At the pnnie time, it must h6
flcknowledg«l, thnt the skin of the arm ilues not possesa sufficient
firmneaa or elnsticiiy for the construction of the noae, wJiere tha
Gubgtrneiure, aueh us the bonea and caniliiges, have been do*,
Btroyed,
The patient was a. femnle 30 yenrs old- Hnving a warty
excreecenc^e on the na§e, glie iipplied, as in the previous caae, to
A quack, who enjoye<l uoloriety in the tretitment of onncers, aiid
■who, ns usunl, nt once informed her fliai the disense was cancer*:
ous, and ndviaed its remaViil- A can)*iic wa^ applied, but soj
badly managed, that nut only the djaease, but n portiun of thti
nuse also, wus destroyed, lenvJng the unfortunate eubject id h
most distressing HituaEion. H
It looked e3(ac(ly as if the nose hnd lx?en neatly excised i
the skin, a portion of the cartilai|;e forming the septum naai^ and_
about one-tliird of the cnlumna, were wanting. The nasal cavi-B
ties were exposed, and the deformity produced of a very striking
»n<] disagreeable :rharneter.
The loBs to he snpjilied wna not Bufficient to justify a resort
to the Indian method, especially ns the lady was not so stout
AS to render thai of Taliat^rtius insiipportP.ble,
I advised ber to return home, and to have a bandage madej
B[n?JOPIA8TI0 OPEIUTlOV6>
37
V
ftach aa is described and depicted m the work of Talmcotiua,
aod to exercise herself daily fcir a few weeks in keeping the
arm in eoniact with ibe Ince, in the jxisition wiiirh it would
be requisite to maintain after the operation. The operation
WM performed on the 21rt of October, 1840, Jn ihe presenee
of Dr. Ed, Reynolds, Dr. S. D. Townsend, Dr. FT. B. Inches,
and a nmnber of oiher molicnl gendeiiien.
The ciuQtrix iMivcring the eilge of the notitrils waa first re-
movedi and die apei of the septum nnd nnhininn nasi made into
a raw surfat^.^ A flap, nparly drjublo the size required, wna now
Olsseelefl out frora over the upper part of the biceps miisele of
the ri^ht E-rni, its haae, which presented downwards, beincr left
attache"!- The bleetllng having^ censed, iinil the flap hnving con-
Iracied nearly one-hnlJ'» the :irm wtis brought up to the faee,
and the edges of the flap contined in contact with the raw sur-
fu% of the nose hy aix sutures- The bandage of Tidlacotiua,
38
THE FACE.
of whi'^h the flccompiiij'iDg' ivoimI-cuI gives a gtM>d idea, as well
u of die getiertil nppeiirance &nil poBliiDD of llm pntlenl, ^tba
now .ip|»lii^il» mil] servcil to iiniiutaiti iIig arm iniinnvalilv fixed Id
contact with the head.* The whole of thw pinfiil opt^ralion,
which wiw before the daya of ether, waa BUjijjorted wilh the
most derermiiied fortitude.
Out, '22d. Since jeeterdayshe has remained in an arm-flmir.
preferring tlie fiitlirig posture afe the nioHt couifurlubic, both
for breathing and for taking noumhmenl;. For an hour or
two ahcr the operalLinu the tkrm was qniiu numb, from it« con-
Atrsiiiied potiitiun and the pressure of tlie bauda^. This grada-
dly changed to a puiTkfid ^ensntion,
25d. She complains t<>-day of severe pnin in the wrist,
wliich wjiA very so(>n relieved by wellin;^ die bAindarre^ wjih
kiidaniim ; and almost im mediately al\er each nppli [Ration,
flhe was nonnmseil io sleep. Tlie bandsiges were relaxed a little
from being wet, but not ^o nmuh as to do injury.
24di. To-day, i^eveiily-hvo liuiirs nfter t!ie cjwnilion, I pro-
ceeded, ill presence of u number of medicnl gentlemen, lo divide
the pedicle, and releiise the ami fmni IIa pidiiful position. On
fir.'^t letiinjf it douti, it appearwl qtiite pandvKed ; i>ut by gentle
frictior^ tlie power of motion and sensation was gmdunlly re-
stored.
A [jei-fecl Jidheeion hiul Ijtken place between the new flap and
the ri^ljt side of the nose> On tJic other ^ide. the «kiu waa so
wrinkled np from the preamire of the head, that it waa not poa-
sil>le to determine what was the state of liuioii. Out of the new
Il't[j a ]x^liele wfu now shapeil, Iii serve fur the coinpIeUon of
the ciihLrnna, and wafl cunGned lu contact with what remained
of the old one by a e<Lngle anture.
Tlie patient wa^ in good spirits, and appeared but little
fadgiitxl from tlie painful pouitiun in which she had been conSned
for fiuch n length uf tiinc. Iler eufTerin^rig had certainly been
I
* t fltn inil^brcd to th& kiiirin&iH of Tcy fl^aarl Dr. Ia?h« fat- a ca^y ai the
ori^nal fuliu uilitioii of TnliJiL^oEiiLs. WiLrin^ t}tc JaEc of ]5*JT, Irom nliJoh tlkia
wixwl-uiit i» cori'itd^ Tills v(.»rj mrv anJ Lununs wurk "as ablaincd, will* mucli
dimrirlry. in Italy; luid bac Ibv copiet htb to be fountl In prcBerTAtion m ibo
pr«eni d»y-
grcally nl 1 e vi ntod hy tho possibility uf hcmg nLIc to move aboul
the room witliout mtcrtVno^c ^vJtli ihe adliodivc proccBSj owing
to llic ptn-fect retentive powor of ihe ljftiida<^cB.
25llk Quite uotnrortablc ; the tip of the noao looked well;
the cdjjca on one ^iilc somewhat livid, but, on being couchccl
ii'ith iLe knife, bled freely ; a portion of the new uolumna in &
eloughin;^ i^tnte.
Sov, 11th. A email picL^e of the elfin which formed the
ecplum havin;:; elou^^hcd, the rcmninder hoa settled djwnt und
ot present i» iirmly united in its ettuiLtioni Tho nose bos n
good shnjKj, but ifl aVill a little awollcn.
Dec, l:^lh. She rotunied boina wall. Her no&o hnd cr-
tircly henlod; ita form waa pood; tlie tip was slij^htly turned
Dp, and the whole orp;nn a Itttio shortened when compared with
1(3 t>ri^nid Jimcn^lonaT but was KtiK ni^cnblo, and presented
nothing rcmiirkfible to a oji^ud observer; the line of union bad
so melted down into the surrounding pnrta as to be acareely
pcrceptihlc.
I
Case XVH. — Mi-e. F,, 30 yenra of age, waa treated by
me, for a number of yeurfl, nt my hous(> and at the Hos|>itfll,
for nn uleeration of ibe noec looking like lupus, but probjibly
epceifie, which oho fiaye Hrst attneked her breast. The dlecose
of the breast eommcaeeil ci^ht years before. The whole nose
waii nttucked and destroyed ; the vomer, the left turbinnlcd bone,
and the orbit«r procefis of the Hupcrior maxillary. Th<j whole
poaterioT nflroa was exposed, And the opening of the Euatn-
rhiun tubes distinctly vieiblc. The pnlnte was thrown up in
the iiet of ewallowin^'. The left miixiUnry siniia was quite
open on the inner eide- The defltruetion of parts waa much
3»rcntcr than I havi ever Ix'fore eccn, and the openin;^ on llic
fncc larger. A euro was tiiiallv elfeetal by the persevering use
oftJie iodide of pota^^ium. When the opcrnlion wuh peHbrmed,
— Marob 28, 1855, — the ulcer had been healed up for eight
inonthfl* Tlie flap wne taken from the foi'cbead, as in two of
ihe previous eases, being somewhat nnHlilied in order to cover
the iiregular aperture. The part to form the septum wns taken
fnmi the aeulp, previously ahaved, and wns an ineh and a half
40
THB FACE.
long. It was twisted siround, and nicdy ndjuslod in Its p!i
wilh euturcG ; tlie edges of the Kkin on the Fnce having been
made rnw. She w^ much depressed hj the 0{>eracff>n ; ^4^B
thj? skin imiied well, and she ultimately rewH'ered, aftpr th^^
usual protriLclcfl treatment which these cases require, with ■
most excellent nose, and & very slin^ht scar on the forehead. A
small aperture was allowed to remain nt the left *ide ot' the
nose, at her own reqiipst, to fiirilitate the renioviil of the Ion]
blaek hair, whieh continued to grow from ihe septum,
direction down the throat, causint; considemblo irritation,
aperture referred to was covered with court-plaster,
Tfjis cftse, as most of the others, ha* a touch of romance
its suhsequent history. She called on me some y^^ars af\er, and
said that her good Looks hnd been so fur restored, llmt she had
nttraeted the nttentinn of a soldier, and hnd been a second time
married. The marriage, however, lumed out an unfortunate
one ', as I hav'e lately learned from mv hrotljcr, Mr. J. S. War-
ren (who was called on to administer charity to her), that her
husbflnd, in a fit of intoxication, had threatened her life in ibe
tniddle of the nijrht, and so alimied herns to make her jump
from & window in the tliii'd story, which nearly terminated
career.
Case XVITI. — A gentleman, 49 years of age, a tall, han
some, and powerful man, wrote to me in the early part of t
year 1657, to know if any thing could be done to restore
nose, the greater part of whi^^h he had cut off in a temporary fi
of insam'ty some vears hcfore. 1 described to him the nature of
the opemtion^ ns being a very painful and fatiguing ooe, and
requinng a giiod part of the whin of the forehead To he uswl in
the mannfatture. T i-ejirest'iiled tho very worst side of tlie
picture to him, fearing a person of his situation and npjiearanc©
would hardly he salisfie4l with the rough substitute made fi
one of the mont imporlant features uf the fiiee, however su
cessful the surgeon might be. lie answered me, tlail he w
determined, at, any rl^k, tii ha\~e the operation done; nnd, iQ
the month of Octid>er, he came to my house, having made
journey of frooi one to Iviit tijousand miles.
1.e
i
limyOPL-VSTIO OPERiTlONSn
41
tcr ttn exnminjLiion of the case* ami fimlin^ how miu'li of
tlie skin of llie foruhcnd It would tuko ta EuppJj llic luj^t orgjin,
I felt gjcut Jie^italiou ac tlie undertaking, lie stuted, Jiowevcr,
that lie had come n great dUtflnce for t\m purpose, that he plarjcJ
LimSflf (\i\\y under my dirfitlion. and wouM wait any Ica^tb of
tiDie till 1 hnd fuUr matured mv |ilau».
Having fiooJIj? determined to do tha operation, it was pei^
fomjod on OoC. 25th. with th(? ivtsistauce of Dra. Bri;;^e, Hay-
^':ird, and Slflde. Tho ranutin^ of tlic old nose were first slit
cpen in tlic ocntre ; mid the lateral ilnpe, which had partially
cave^l in, wore dissectod up from their itdhesions, A lar;::e tii-
BJigiditr flap of skin, involving nearly llie whole forehend, waa
LOW digsc^lcil up, with a Bmall goIuqid, taken from the hairj
I, to flcrve for tfie eoptutn of the nose. This tlap wns eii-
in n cloth imtii the wound in tho foreliead had hcen
The operation otherwise waa conducted tu described
la the previous cases.
From the tur;^id etate of the veeacle of the fjice, the operation
waa noeeseiinly n very hloody one. For this renson^ flnd from
the necessary delays in determining tlio Aize of die flupp^ und
filting them niooly hi their jilaces, it la^rCed nearly three houra.
The patient drclme<l to tnke cll»er, and bore the whole of thia
'long nud painful operation with the most unflin^ihin^r firmno-^s,
Bti that a bv&tnndor could hanlly h:ivc dolerruiiicd whether tho
'SLirpcon WHS opor;itiiig on a living or dead euhjoet.
Jle p:t#Hed a quiet night. The next d.iy his pulse wiia eighty,
Jind he hml vary liltie uneasincsa in the nose or forehead- On
tho li.Hili. the ftfrclkcjid w!W dressedj and all the an^^lcs nnd
pro^Linule jjarta connirtrted by euiui'oa found to biivo united by
Itlie iirat intention.
On iJie 29lh, the new nnso waa dreaded, and the flaps were
ffto well united to the cheek, tbat tliey seemed to have melted
ico it.
On Nov. 1st, the phiga were removed from the nostrils; the
LtJcnt noe up, and ftl>out the room.
Nov- 32d- He had been ont of doors for two weeks in per-
fect henlih. The womid in the foreheitd was hoaied, lenving in
illie centre n, scar scarcely perceptible. The noee looked well,
0
42 THE FACE,
the seTisibilit}' wqa natural, perhaps a Jittle dull, not referred to
tlie forehead. The twiet in the pedicle had become effaced hy
a most remarkable transposition of the parta ; tlie ecar^ which
originally commenced on the right eide, being drawn over to the
left by contraction of the tissues. Tiie small apertures which
remained on tliis and tlie oppoaitc side of the pedicle were eaailj
obliterated by aubsequent inanccuvres.
The patient was extremely elated by tlie eucceas of the opera-
tion, and by the very natural appearance of the Bubatitute- The
rc-action, after this long period of retirement, brought on con-
siderable excitement of feeling. Notwithstanding roy repeated
precautions, and advice to him to return home, he indulged
in a very free course of living ; which ultimately terminated in
an attack of apoplexy, which destroyed him.
OPERATIONS rOR THE RESTORATION OF THE LOW'EB
ETELID.
The difficulty of repairing the cversion of the eyelid after
burns and other accidents attended by destruction of the integu-
ments is well known.
Since the introduction of the autoplastic mctliods for the res-
toration of lost parts, the transplantation of cutaneous flaps for
a*ipporting the remains of the everted eyelid lias been attended
with euccetis- The two following cases are gi\'cn in illustra-
tion ; —
Case XIX. — The subject of this was a boy 12 years of a<re,
from Weymoutli, Mass. When an infant, he was dropped into
the fire. The couseijuence was an extensive bum of the left
side of the face, and a paitial destruction of the lower eyelid.
As the wound in tlie cheek cicatrized, the reuiains of the lid
were completely everted, and the tarsal cartilage witii ita cilia
firmly bound down to the lower edge of tiie orbit.
The effect of this was a constant epiphora^ cauJsiug much irri-
tation of the integuments. From the exposed state of tlie con-
junctiva, it had become thickened, having the appeai'ance of
epidermis ; and the cornea, from exposure to air, prescntcil an
OPEltATlOVS OS LOWKR EYELID,
43
opnciCy which wns Jiiily inorcaainfr, nnd thi^cntcncd iIp?tnjc*tion
of vititm. UnUi;r Iheec cirpunistnn<'es, the foilowin*^ opcmtion
tvaa pcrfurmcd *fn tlie 12tli of June» 1841 : —
All incision, iibmtt an inch mid !i h.ilt' in length, wiis made
pnrallc;] with the (jommiEj-ure of the eyelids, and nbout two linea
Lic]t»vv ihe ]Hdpo!jr,il mnr^in ; nnd, ailer u onroful direction, the
remains of (he eyelid were aepiirated fi"om llie ed^e [>f the orbit.
Til* disaocCiim wns then continued upwards between the tarsal
Gurrildgc and the conjunotiva^ and the connections so fur dea-
troycd na to allow the lid to be reelore<l to ite natural position.
Tho ihU'koDcd !tnd diseased subcutaneous cellular membrane
was then comijletoh' removed-
By the ec|>ai"aiion of the ed^s of ihc skin, a large ovnl-shapeU
wonnil now presented, nnd this xvas to be tilled by a portion of
ttin Inken from a neiprlihorin™ pnrl. To ctfeet thia, an ini'ition
H'B.6 commcTicod from the outer an^rlo of the wound, and carried
in n jeicicircular direction over the temple, at which point,
nndcr the hnir. wai* the only poi'linn of sound skin which had
not *urtered troiu the effeL-ts of the burn : an oval flj»p was here
diasccted out, ahour one-third larp:er in eize than was reqnii-ed,
ami, bavinn; fully relractod, was twi^te*! round and mninfained
in ita situation by means of sutures, aod n alight jiressure eser-
GLSod upon it with a roller bandage. Before terminating the
operation, the thifUcned conjunoiiva, whioh formed a priijeeliciii
henealh the lid, so as to prevent jt^ perfect application to tlie
eyeball, was raised up, nnd entirely removed.
Tl>e lemiination of tbia eaaa was quite sueecssfuL At the
eod of f n;r days, die dreaaings were removed^ nnd the arlhesiou
of [he tlrip was ahnosl complete; a slight ^u[jpuraiii>n only, at
ila inner an^le, baring occuri'ed. The parts were all much
swollim. At the end oE' a. week, the pedii^le which eonnecto'l
the newly iransplantctl flap to tlie neighboring" pjiTts was divided,
and bled freely. The patient was sufficienily well in a month
to return home.
About three months afier, he gave the followinQ^ account of
himnelf : He was able to close the eye perfectly, and the tears
had resumed iheir proper channpls. The newly formed lid
seemed to ftdfil all its functions, and there was no disposition
44 THE FACE.
to evcrsion. The opncity of the cornea had so far disappeared
as to be Hcarccly perceptible. The only circumstance which
required n remedy was a disposition in the new lid to stand
out from tlio eyeball, as if from a swollen state of the conjunc-
tiva : this was remedied by the repeated application of a pencil
dipped in sulphuric aeid, so as to destroy a. narrow strip of the
conjunctiva. The transplanted skin at first protruded^ but
gradually settled down to the level of tlic Burrouading integu-
ments.
Case XX. — The second ease was a young lady 19 years
old. The accident which produced the deformity was very simi-
lar to the preeeUIng one; having fallen into the fire when aa
infant, she had been badly burned in the face. From this
resulted a very extensive cicatrix, affecting nearly the whole
skin of the face, and tn some }iai-ts impliojiting the subcuta-
neous textures. The left eyelid was drawn down and everted
at its external angle, leading the eyeball exposed. From the
destruction of the intcgutnetits of t!ie cheek, the left angle of
the mouth was drawn upward in a direction to meet the external
angle of tlie eye, there being about an inch and a half distance
between the two. A large, firm band of indurated and thick-
ened integument extended from the forehead perpendicularly
across the bridge of the no,se. The external edge of the right
eye was also slightly drawn downward by a cicatrix; but, the
cheek of this side having partially escaped the effects of the
bum, there was no ever^ion of the eyelid. The following opera-
tion was planned and cxecutetl on the 7th of November, li540.
An incision, two inches in length, commencing on the cheek,
midway between the eye and upper lip, was carried with a
semicircular sweep in a direction upward and outward towards
the ear, its convexity beiug downward. The skin was then dis-
sected up, both above and below, so as to relieve the traction of
the integuments in either direction ; and, on this being accom-
plished, no difl^eulty was found in restoring tlie eyelid and angle
of the mouth to their natural positions.
From the separation of ita lips, the wound on the cheek now
gaped widely open, being an inch in the perpendicular, and two
OPERATIONS ON LOWER ETELID-
45
iphca in the tmnavcrac, tiiMnct(*r; nod tliia wn3 to be fillet! up
by hoiTowtMl intcguincDt. The oUbuts of ihc hum Ivning peuii-
trat<;<l iiil(] ihu niuficular ftub^tuncc, it wns ncccfiaory fii-at to
rcmoi'o all Hie indiimtcd eubt^tanco covering the iloor of ttid
vound- A largR oval-ehnpcd flap, one-third Inrgcr thno wna
iK-foesHry to fiJi the wuund, wati diti^eijlpd fVuai the tcTXi[dc,
■twiatcd round, and without difficulty adjuelcd, and eocurcd ia
lis new situntion hy mcana of Putiirc*, as in the preceding caeo-
Xhe wouad on the temple was drawn together by euturea, and
in A direetioi] to favor the tronii^plantcU J^kin ia remedying the
deformily.
The uneccmly cicatrix on tho bridp;c of tlic hosq waa nuw
completely dissected out. The vcpacle ivhieli were divided during
the opcraCioa were allowed to bJecd until they ceaecd Yoliuitarilj,
ijt being dej^imblc to ovoid ligaturea, Tho wound was di'c^eed
with f;raduiited eoniprCHapa, secured by n bflnilngo- Quiet was
tinjuincd : notwithstanding which, from talking, n ^ight hemor-
rlui^'o wjii* proiluecd, which partially prevented the union of the
trunH|>lntUtd ik[i.
Hitt httlc constitutional irritation followed the operation. On
ihe fourth day the UindaLxe was reitujved, and two-ihirdfl of tho
WJis fuund to liavc united: the inner portion, tovtards the
I, was raxecd up by a oon^ulura of bJood, and the union at
'^thid pojntf of course, defeated. The wound on the temple hail,
in A great rucaeurc, united by the iiret intention. On the sixth
iJny, the ligatures wei'e all remuve<i. and the inner portion of tho
flnp, which showed a dispoBition to Glough, was cut away; the
»^viiund at tbi^ point, where, foitunntclvi the support waa Icufit
revjuircd, U.'ing allowed to heal by the eeeoud inlcntioa.
At iLe end of eix weeks, the wounds hud all healed; and
ehc returned h*>me, greatly improved. There wae ro di^ipueition
to emersion of the eyclidT aiid its functions were well pedbraied-
The nii'Ulh was also restored to nearly its natur:il appearnnce.
Th<^ liicini rxprewioQ wiu^'greaily improved by the removal of tho
uoeighlly band, wliieli prejeeted out over the bridge of the uose.
The above ensee are selected from among a great number
of iiimllnr instancea ; the operations of a pla^tie character about
46 THE FACE-
the face bcingf as a general thing, tinueually successful. What-
ever operation ia used for restoring the eyelid or the mouth to
Its position when drawn down by a cicntriXf it is important that
the intogumeut ehould be freely dissected up from the subjacent
jMirtfl, so aa to allow tlte eyelid or mouth to be restored to its
po^'ilion by bringing the intcgunient on a different plain, as re-
gards the subjacent parts, from that wliich it occupied before.
A simple di^tsiim of the scar, and allowing the edges to separate,
even if a flap ia introduced, would not remedy the difficulty.
In the eyelid particularly, tlie dissections must be very thorough,
and curried quite up to the edge of the lid.
During the past year I have operated on two children, a boy
and a girl, both about 8 years of age, in which the integument
of the lower lip ond entire neck had been destroyed by fire;
the mouth being open, and tlie edge of the lower iip in contact
with the sternum. In one case, tlic jaw had been completely
deformed by the tension, the two middle ineisora being some
distance in front of the lateral ones : tlie whole fiicc, in fact,
with the lower lida, was on a stretch ; and the eyeball was
strained upw^ards, in oitlcr to allow the patient to see objects in
front of him- In these cri^csj hy a semicircular cut at the base
of the scar on the sternum, and subsequent dissection, the head
waa liberated, and restored to \ts place : the wound being cov->
crcd by akin, slipped along from the sides of the neck, in one
case; in the other, two tunnels of skin running beneath the
sear supplying the requisite integument. In the ease of the
boy, which was the most estrcme, it was difficult for him for
some time to get accustomed to the new position of the head,
which felt to him as if about to tumble off backwards, the sup-
port in front being lost.
The cure of bnt few of these cases can he completed hy &
single operation ; a series of operations, extending sometimes
through a number of years, being required, if the destruction of
the integument is great, and the deformity implicates a nuntber
oforgana. The organs interested in the health and nutrition
of the patient must be first attended to ; the finishing touches,
afTeciing the ajipoaranee, being left till a later period.
Ki'tXriKLtAL CAHCEK AfiV KODE^\T LLC'EK.
47
EPmiELIAL CANCEK AND RODENT tXCEEp
TJiere nre three kitiJs of morbitl afFecliuns, ejit-h aroompitniod
wiih iili'i-niiicm, iind fticuntod upon naain portioti of rho fiwrp,
wliu'-h it U net^eAsnry to flisimgiuHli IVom each oilier, — ephholial
canctT, liipii*, nml rodent ulcer.
KpifkfUal cftncer is g-oni^rnlly foiiml upin the ekin, iind (?fl-
j>cciiJlj' upon die lower lip, though it is not conlininl To thia
8itU!)tif>n, but ocours upon other portions of the hody, as the
tiinjrue, till' at'rotnm, the Inhiii, anniiul the nniis, nnrl cvmi in
the laryin or |iliaryns, [jjkiii the itteriiw, and in the hludilt^r, I
bbre never aeen ii cme of It in tlio upjH^r lip-
Al rh(' njmnicni'ctuent i»f the tliaease, thrre [b notk'ptl n swell-
ing, with ii round or oval hard hiu^u; ^^r a wart, uitli a [in^
jffcting- dark, dry summit ; or ftitn|>ly a scale of a drirk color,
mu*t generally seen on tlie clicck, whidi, a(ler rtpcarod remuv-
al?*, periiMpfl ihruiigh a aerit^a of yeni's, nlnmately Itrniimitea ia
ulecmticiii : iIiIh cxtt^ids, InvoKing die jjdJiLcent tissues, till n
large nlctr is furim^d, with the edges evertc4l and eswivated ; the
hjuiv h rciMiiih, concave, and bleeds cuially ; it difichnrguu a thiu,
HLuii.>u« liijoid.
The difll^rent appearances dependent upon the variety of sitiia-
tjon, or the [jLiinner in nhii^h the pernli.ir rpithtlinl relliii are
eituatul, is fidly and minutely deacribetl hy Pngetj who slIao
give;* a dtiscriptiun of the mii^rorscopiL^ uppearanees.
Them IB no tendency Inwiinls healing; nnd» if leH to itself,
ihe drstnictiou of siihslanee betomea mere excennive, the iyui-
jilmliti glands connccltd with tlie diwaHed part eiiliirge, Kiiully
ulet-ndc, und dciitb ia the r<isult. Ejirly exciaiou wdl usually
nrre.'it, and fftotnelimes defitroy, the dbeaae, though it may return
in the nelglilforing ti^^^uea.
In regJird to cancer of the li[j, the disoaee u so fVetjuent that
IS Id hiirdly worth while to addut^e casea. So far hh my L»xpe-
ntncc goes. It J* more geuerallv aitimted on the left diiin on the
nght side ; having its origin in some irritating eauac fi'equenily
repeated, suiih us the flteuj of a clay tohiirei)-pipe, or tiie pM>is[ige
over (lie lip of the saliva ealuiiited with tubiiwo, in lohaeeo-
cbewcrj^.
48 THE FACE.
I have been much Btruck, in removing cancer oF the L'p, to
find how far, in almost every instance, the real cancerous de-
posit extends beyond the apparent disease on the free surface.
Too great caution cannot be urged in regard to giving the
ulcer a wide berth; and it will be found, on dissection, that
the sound parts have been seldom sacrificed.
After removal, it perhaps may be advisable to enjoin on the
patient a simple and uuirritating diet, avoiding animal food, and
all alcoholic stimulants, for a limited period of time.
Dr. Walshc says, "There is only one affection which may
easily be confounded with cancer of the lip ; viz., venerenl uloer-
atioQ, with nn indurated base. I behcve it will be admitted by
all persons who have had occasion to observe much of diseases of
tliis nature, that it is oflen impossihb to determine, from the
local characters of the ulceration, whether this be syphilitic or
cancerous," '
In tlie cases, however, which I have seen, the chancre was on
the upper lip instead of the lower, a circumstance which I have
never met with in regard to cancer.
Jjupus generally appears £rst upon the nose, or the check,
near the nose, aa a small tubercle, yellowish on the summit, and
reddish around the base. The ulcer wliich forms is rather more
superficial tlian in the preceding variety, with less swelling; the
edges are rn^ged, not indurated, and soinetiuiea everted and
excavated. Lujms, after ulceration has commenced, is not con-
fined to the integuments, but may also involve cartilage and
ligaments, destroying large portions of tlie face. Sometimes it
heals epontineously, though it is tJien more likely to return in
the cicatrix ; but, if extirpated by the knife or caustics, it sel-
dom returns. Cicatrization commences at the circumference.
The cicatrix is peculiar, usually being crossed by elevated bands,
and ha\'iug knobs scattered over its Hurfuce, at first quite livid,
eubsequcntiy becoming wliite.
The last of the three diseases received from Lebert its name,
— rod€t}t ulcer, — which has since been adopted by the best
autliorities. It is most fre<juently situated upon the eyelids,
sometimes upon the ciieck, or more rare/y on other portions of
the lace. I have never known it to occupy the lower lip. As
ErmiKMAL CANCRK AND nODE^TT DlXElt.
41*
llir JjHon^u is nu ifiti?ri?sUii*; une, and, in its dingrosU, ooinpara-
lively 11 new one, I will vl'IITui'i; to lyitulc tlie fblJowIn^r oxcclloat
"ijktioQ of it from Pa^C: "It is of irroguliir slmpts bat
genrriiJiy tmils luwiirtls ovjij or nrcular. The Uh^g, hciwever
dccj^ly mid mioqiiiUly I'jccnvntod, id iLsanlly, in niusi p:irt, not
warly or ntnlnlnr, or even plainly grimuktcJ : in comnist whJi
r4uux^m!i ulcer, one may esjjecially observe this nbsenfre. or Ips*
amount, of U[T-^-(m"di. It is :tl*o compamtivelT" *\vv nnil glossy,
yitUlinij, fi.hr ili exlcu^ vprv Uulo it^lior or otlior tlt^cliiii't.'e, s\ui\
has rommimly a dull reddish-yt^lluw tinl. Its burder i« uli^rfitly.
If at iill, plevnfed ; if <?lovata.1, it is not ironinionly. or inu<"ii.
t'lfJiur evertcti ur umiortiiined, bnt \r* sinoi^tiily rouinled or luwly
Cuben!ulLitL\]. Tbe immediately adjacent ekin u^unlly njjpears
fjuito Keidrhy. The biise and border silikc fen] touy;li and hnM^
iw if Ijonnded by n layer of induruted Tisfiue ah\ntt n line In
thickness. TbU Inyer does not tnncli inerea^^e in thicknenfl »><
the ulcer e^Etendr^ : ^md herein is unolbcr cliief cnntrx'it witli vnn-
cj^roiis nlo^*n^Lio^ t in tho pr^^rcea of rodent nicer, we see more
desinicEton ; m the ennc^erou?*, we *ee deytnietion witli t'liim-idenC,
and Eisually more tban commensurntc, growtk. It is imly in the
nu^st ensee that a i^rovvtfi 'is sHSOciatpd with rodent ulr^v-*'
Mr. Hiiiehin^on liaa also published an cxi;t'llent nrlicit? upon
tHU disease, in the "MediL^al Timca and Gazette" for Sept. 311,
Kiident ul(^er i^nires complete extirpation by the knife or
eiuutiefi. It ift veiy likely to reium j but, in the following
ttiws, did not rttiim, like cani-er, in the exaet spiit : the difieaiw
F^eemed to follo^v on at one >^ide uf il : ihere wn>i no glimdcilar
rximpti<'JLi]{Ui. (The tew caapfl which fullow will ft^rve to illiia-
trate aunic poinu In rcgsuvl to lliesc ditien»eH.)
Cakcei: of niE Lir. — The four followiirg cosea of i^anccr of
the lip nre principally intcrestin;^ from being all iliat have oc-
Cvirred nmnni; females nt the Masaai-hiiHCUs riciicnd Tlnspitid
for a period of over forty yearn, iind fnun the faei that ihrec of
the four were naeerlained to have »moked a pipe. They are
quoted from ilie Hospital rccoTNis : —
7
Case XXI, — Otmt^r o/ L^tt^rr Lip in FemriU. — "" P- G,.
aged 62t nianicd ; bi>ru m Maine. Entered the Ilo^jiiuiij
May 4. 1852.
"A heidthy-loDkinjj; old Udy ; knows oF no hereditary l^ii^
dcttcy to tuiUig'ikatit di^caee^ Two years ago tu^t auiumer, tke
Buffered irom ^caiiker' in the moutli imd inside of lipa, upon
recovering from which, n enudl ulcer was noticed on the under
lip, which wafi soon followed by a smnll hard 'ivart/ not pain-
ftdf hut troublesome from constant itching. Last aumaier, this
'wart* become detached, and woa followed by an uJcer, which
has prop-e^eed to present apijeaitancc.
"At about the centre of lip projects a red, fungous maaH, at
the haJHj about one inch by tlu'ec-fourtha in diameter; while the
everted and protruding fungus measures in cither diameter, over
ita convejdty, one and one-half inches. Tlic maw b soft, red>
and tlic baae ia not indurated. One or two enlarrfcd lympbatic6
are felt Lcncafh the jaw, lender, but not painfuJ. Tumor,
thoijf^h not tender nor painful. giYCft a seni^ation of wcigUt, and
maked epecch fiitiguing. She haa amokcd a yipc for years.
0[^erate<l npon, and diachiu-ged 'well.'"
Case XXII. — "E. C.» aged 80, widow; bom in Irclaad-
Entcred tlic Hospital, Oct. 3, ]S53, with qntheLial cancer,
which waa removed from tfic left side of lower lip.
''' Being an out-patient, the history of her disease is not known,
except that she haa been in the habit of emoklng n ptpc for
many years. ShG was di^barged well."
Case XXIU. — ''B. S-, aged 60 ; bom In Ireland; marric*!.
Entered the Uoapilnl, June (>» I860.
'^ Tlufl woman haa an ulceration on lower lip, which was Hrst
noticed about bvclvo months since. There ia aotac induration
around the base. No enlargement of glands about the nceJci
Otherwiec bculthy.
" She haa been in the habit of amokiog a pipe-
* SKe waa oi>eraled upon, and waa iii a few dnys difichar^ccl
KPITHKLLil. CAXCEft XST> EODEXT rLCEB,
51
»
_ ^ XXI\''. — ''K. L., widow, act?d 70, bom in Ireland;
■40^8 the Hct^pital, ^laroh 9. I^t56.
"Xine moDths ago, a smnll "scale" appeared on lower lip, at
the ruargin of the mucous meiobiUDe^ upon reuioviii^ wliich a
filight 'cratk ' wa* noticed. The scale wad in a short time rc-
Eicwed, nnd be^n^ii ^^ a^unte the appciu'aucc of a scab, vrhicb
inereflfcd in size till now.
"At present it resembles a wart the eixc of half of a largo
^wrry, circiihir, finn, ed^-cs ^haqjly ilctinet); surface ron^h,
aad of a brown color; eurroundia^ [issue not Indurated. It
ia about oDO-third of an inch in diameter, unU i^ miscd one-
twclfth of an inch from fiurfnce ; bleeds easily ; not tenJer nor
painful. \o hcredilary lendencv of any nature.
" She has never emoked a pipe cor chewed Mbaeeo. Other-
wise henlUiy.
"Tumor was removed March 10th; and, on the IVth, the
wound haling perfectly umicd^ and all the suturcA being re-
moved, ahe wa« dLsoharged well,"
.
Rrairdi'ii CtUGt optrait'.d on tU tka M<iasfich*is«tta Of-n^raJ ffospitfiL
WholvnombcTofcAses of cancer of loner lipu|i to Jan. 11, 1861 37
Ma[u 73
Fctnitki .,.«..-,.......,.. 4
Addicted 10 smokiD;; a pipe _.....,.,... 44
Not ia thci bnbtt of etuukiag . 7
Not a«c«rlaiacd 26
Case XXV, — CAa}tci'e of the Upper Lip j resejMiuf/ Oan-
etr. — Tn June. 18*>4, a aervant-^rl was lulmittoil into the
Hoepitnl, with a tumor of the upper and. left side of the tip«
which was eupposed to be cancer, an<l whi<^b she entered to have
remored, She stated, thai, during the previous winter, she hail
noticed a tisfiure oa the let^ side of her iip|>Gr lip, but did not
pny much atteniion to it ; nor dkl she think it nny ihing- serious,
until in May it enlarged, and the Bwelling ini^ilieated di4> juljoin-
ingpnrtfl: ^upjjuratiun also commenced, Ujjon entrance there
was an oblong ulcer, with an everted, fungous eurlacc, about
two inches by one, having a soft ba^e, djjw'barging m<x]ernte)y»
52 ^^^^^ TIJE FACE,
ami (vii;j<ing pnin ; ^ircsenting, IniU'Pil. ti]\ ihc Ji|i|ienrnjirc* cH»r-
hHe! tlmu^liC &\ic uiiglit Imvc cuD[i'iiGtc!d it wLile iloing cliambor
woi'k Ht ibc lic>icl> lleUiLiil bcr rl^^lit cnr, there wns a herpctit;
ufTccliuii irf (be akin.
Tim unUtiun of tlic parta waa Grst relieved by a p(niJtii;e.
and f^lic was put on a gi'ain of tlic protiudide of mertiiry tLtod
lime? a Oiiy. A week aflcr her entrance, sUe wiis ctlieiiKed, luid
Llie dlscaae tljuro uglily ciiuteiiiccd ivilh iIil- hciJ iiitratfj of mer-
cury. It uhnust ftt ont'e put qd an improved j^[i[)C!jni[ici;, aod
preecDted u liealtby, granulatm^ enrface. Ou the 4lh of July,
she began tt> complain oi' sure throjit, iiriuttiou altouL tlie *:]aiifU
of the iieek, and Iter Iiair began to flUl out. Tlie sore gradiudly
luaJeil, and llie diasiii made by the gival desijuetion of [larlj
waa almost entirely oljiiterated. She contiiined for aoun; tluic
afterwartls under medical treatment aa an out-patient.
CAi^E XXVI. — Ej:tcnsivc litvirrent EplthclUd Cdnctfr
of tht Nom^ and part of ihe Fact. Op^rntiitn. Cure. — A
rfrfpectabie Irishwoman, hi) years i>f age, entei'eiil tlie Ib».^pilal>
in May, lS[ti\ for a formidable cpitlicIiiJ cancer, which nicen-
pied ceiirly ihe wbole n(»se, and i;xtenJcd on the It^tt /side of
the cheek to about the middle of the lefl orbit- The nostiils
were completely ['iMniclcd by the tumor, "hlch pre«;nled tUc
ninet singnlar appcarnnce, ne of a round catdiHuwcr niaaa placed
upon tbc nose, with the two eyea peering over it, Slic anid that,
about dx f»r eight ycara previous, the diflease had commeneed by
a long, narrow wart, growing from the letl side of tbc nose.
This biul been rtraovcd, by aonie improfei^eional man, with a ligJ»-
ture. Kcturtitng aguin tivc or six yeara afterwards, it waa cut
out by a aurgenn. lt« however, vci-y slnTtly re-appeared, and
aoon a.*^umcd fbiimdafhlc dimciisioiiB, Her health waa good,
and tbc princiiial fluftcving waa from the irritiiting dlecharge
supplied by the extensive gnimdating surface.
Tbc tumor covering the left nostril woa held aaide, and the
ala nafi cut through cloae to the face. All of the remaining
portion of the niaaa was now encircled by an incision, and ihc
tumor dissected ofl' rapidly, in the nu(l&t of llic moet pi-ofuse
EPITHELIAT. CAVCER AlOl ROl>KXT ULCER.
53
hcmorrlia^. The vetisela bciug ?ecurcJ, the inrj^'c wound was
narroiA'^ \tj pacing fuiarc» About tm Inch apiirc. and lying
tlic wuuud up in ^cgnicnl^, wo as to oMitcratc niiont hnlf of it.
o the remainder was npplic<l aorapcd lint, wliidi was allowed
to liry on. She suffered very little pain at^er tlii^ operation,
thon^ eotncwhnt Ihchlc, and in a tew day6 was i\h\c to ha\G
er bod. The wound gradunlly cieatrued ; and, eo lon^ ne I
lept her in view, fho romnincd pedcetly healthy, and tlicre wiw
DO rccurreuce of tlie diacaac.
RoiniNT UlcbKh^Case XXVII. — Rodent Uh^r of ihe
3^o*e, K^diih* and Globe* — J» C., 5U yo.ira of ngc, npp!ic<l
lo me in IJJ^IJO, for an nicer, which implicatcii nearly llic whole
^B »ido of tlie noac. the lower eyelid, and the cycbnli of the rijrht
iidc, Hia father wae living at the nj;e of tfO yenr^ : hid mother
iliwi of consumption. Thirteen rears licforc, wliiJe cutting' Avood,
I A chip flew, and struck hira on llie cheek under the eyo. A pcd-
Itr, in the ynrrl at ihc rime, Jipplicd ft mixture of gTin-fottifn.
A\ ni^dit, hi^ IJice ^uJled ; and, subsequently, the wound nleer-
•tcd, and s]>rcud to ^omc dUtanec down tlie cheek. For aevend
ycivrg it kept its plaec in the check ; hut g;radunlly, in apitc of
treatment, it invatlcd the eyelid, and finally nitocke*! the eonjunc-
y tiva, and ptnctnCed to the pcriu^tcal membrane liehind the eve-
^I^U. Dr. James C. White, by applicationa, had kept it at bay ;
^^T>ul finally referred him to me for opcmiioii. The appennince of
the ulccrntio:!, which now occnpicd the eiJc of the iioac, and
had destroyed the left eyelid, and conjunctiva, covering the eye-
ball, wa* unlike cither the mi^^ed disease csillcd epithelial can-
^^ccr, or liipu^, \vii)i jta cut edgca. It had nioi-c of the look of a
^Hdried ulcer, adhering firmly lo the deop-aeatcd parta, and with
' Iml little anbMaucc. It answered i'ully to tlic description of
" Uudent I'lecr/' deaeriftdl hy Mr. llulchinaon in his diffcren-
j tial diaynoeie of the diacaaea mentioned abovcp I removed the
^Bvholo di^eahC ^virh the cycbidl, cut itwiiy the cd^ of the upper
^^cyclidt with the la!*hca, dissected up the &kin of the cheek, and
hrought the raw edgca of the eyelid and cheek together. He
ft good recovery j tlie Boeket being gradually entirely filled
lip with an Ldvcntitinus tissue^ and tlic skin heinr;; stretched
u
TIIE FACE.
across its eitemal Aperture. The tioee cic&tmed well, and
scar aftcrwftrda remained heal thy.
On Oct- 10, 1^«*>3, a Bruidl ulcer, the eizc of the head of ft"
pin^ nppeQrcd on the cd^o of the f^ockot. This occnaiom
ejirciid, und was ohliteratcd Liy grinding into it nttrate of silvcTi
ThJa ulceration did not extend much iu hrcatlth, but sccmi
to penctnitc backwai-Js very slowly : cerebral eympComs
rurrcd, followed by general deterioration of tlic hcixlth :
he diedf about a year af^erwardsi with very littlo external mi
fe^totioo of disease*
Case XXVIU. — Tforfen^ ITtcer^- — H. R. C. was opci
on by nic, Feb. 8, lB(;i>, f^>r the lihovo cliecat^e* He waa 60
ycura of age. About twelve ycura ago, he had a Hmidl pimple
on the right cheek, near the nofle» This renwuned quiosc<?nt for
Boinc years, vh^hen he applied caiidtic Ut it, under which it di||^H
appeared. It was followed by an indurated tumor under it^"
Abo^it four months eiiicei Bnding thia inet^asing, and involviiig
the akin, he made repeated applications to it of the acid nitrat^H
of mercury, which cou&ed a Oecp niecratiom Thia inercafic^^
atYer tfje applicatioLB were ettip|)ed ; and, when I perfonued ih^
operation, the base of the ulcer was fonned by the |ierioatoi
of the malar bone^ and its aidea (which felt almo^^t bony) wci
of considerable thicknees* ToworJa the mouth, only the ini
coua membrane covered the indurated parts. The oritioe
the chcak was about the size of a ton-eent piece. The edg;cfl
were rather deprcsacd tlian elevated, not red, and very friablo.
The whole of thia dii^cnee waa dieaected out, and peeled ofi" troi
the bone, leaving it bare, and with a lar^c, deep, ^[>ii
wound. By eome lateml cntd and a little diesection, tite skill'
could be slid ^o aa to cover about two-tliirtia of the wound,
without tension. The microacopic nppearaneea gave no indico^H
tion of a cantcrous affection, I «aw this pati<inl in May ; the
wound on his ta<'c wati entirely heal(*d, and no tnarka of di^flse
there. An uleerution, however, aiill oiiatcd on the nose, and
aecnjcd disposed to extend on the inside, A eharjj crayon of
iiltrnte oi^ aiher was freely ground into it eo as to doatroy thoj
tieaueti as deeply us possible.
the
THK ETEh
S5
Case XXIX. — nad^ut Ufcev. —J, O. S., fiO yesrs t>f nge,
a|)plii?il to ml* in August, ]8fi3, for an ulceniLhin at the root of
t]ie alu of dir nght side of the ddag^ whiuh wa;) the continu^inn
«f a ili^eai^c of tim or fifu^en yeiirs hUMiding, It hiicl ctJinmenrcd
with an ulttr on llie ujjjier lip^ ivhich gra<Iii!LtIy EKlPndetl W ihe
»prt»ent t^i^ut^ healing faehmd, and coiitracting the lip bo that
the eilge wjt« uuw LiiujFcd up, and nearly in contact witli the
nose.
I made various ap[ilicatiunfl to the ultier, hoth cau»itic And
others, which only served to ag^iivjite It ; and I finnlJy Ue<<UI<^
to operate.
^^ The loop and hardened (liratrix, together witli the ideer, were
^B completely sLud tlioruiighly ext^iaed. Tlie edges of the lip were
^■brought together ;<□ as 1o rL-atore \t% uri^fiial Lirendth. The
^« ■wound hejdetl rapidly, :Lnd the paticut aeeined Lo he entirely
cured.
^K About a year aftcrwai-da, he applied to nic again with a j^mnll
^HuleeraEiunT jn^t witliiu tlie iila of tlie no.ne. After ViU-iouri rippli-
^HcatloiiH, withuut sui^ce^Hf it W!V* cut out, and at unee h^Eiled.
^HTwu montluf afterwitrdr^, it rc-^ippeitred ; and, extending f>oih
^^laleralTy jind In ilepth, a. third apcrjithKi wa*i [icrformwl, more
1^ esten^'ive ihiio those preceding. Tliin wus fcJlowed l>y an
^Beryeipelntous atfeetion of bis fiioe ; and tJiis» fiuhAiding, by albu-
^^ niinuria. He grachmlly, in the course of 80fne weeks, fell into
,a cauiito^e suite, and died.
Tlii* patient waa of a very florid <iomplejtion, hia skin very
licit, and easily dispoj^eil to inflame. Half of every year, he
m A hot clitnate. The edgCH of tlie nicer presented no
|(if tumor, iU6 in cancer of tlie *kin. but were fiLarp,
id hiid a mealy look, eaoily broken down by the probe.
THE ETT5»
Iaj^C XXX, — CdPceroas Tnun/r ttf (hn lifghl l^ifH. I^fl-
\vqL lieeoveiy. — A gerillemau, 73 ycara old» applied to
le, April 14. 18S2, on B<:c(uiiit of a tumor projecting friim
ithL^ right eyebilU l)etween the lids, sprijiging from the mir-
fiww of the globe juhc l>elow the iria. lieiwccn Iwo and three
56
THE FACE.
ycara before, he hod what he auppoeed to be a cataract, wlu?li
dcBtroyed t}ic B>'\g\it. of tlic eye. Aftorwarde, he ^criLlclicd the
conjuiielivn widi hia nail. This wne followc^l hy n smali pimple,
which aJowly dcvelojieJ hito the tuniori He wa^ finely Icii ta
ask advice, hy the recurrence *if fre<]uent and ecrioua hl^eding
from the eurihc'C of the tiiinor, Hiid (d^o by n. acvi-rc imiti over
the eyebrow, which preventctl iiim from attending to bia huai-
ticije, anil iJiaturbed hie rc^t at nii;rht. On acpiiratin^ the lide,
the ghfbo was tbnnd to be cnlarge^l, and protrudwl from tho'
socket; the pujiil filled witli a ycJIuwish-wbiLc fluhjstftnee. Very
Urge vcine ran fioni tho cunjuncliva upon the tijnji>r. ilc t^aid
he had liad on apoplectic attack about three montlia bcforCi at'
wliich time he fell upon the floor, striking the tumor, and eauaing
a copious bcniorrbn^e.
Operation. — An ineiBion was made at the external ftngle of
the eye : the cyebull was seized by double houka, and removed
liy tho ftculpcl and aeisaorJ*. The hlL-eUinLf waa ft'cCt but wna ^
checked without phi^^gin^ the orbit; two or three vesacU were-|
tied. He gradually and |jcvfcctiy recovered, and hved a number
of ycnra ullcrwardf^, and died gf other di^eo^e.
Case XXXJ, — Meluno^is of the Riffht Etfc Removoii
lir-covrr'/.^^^ ti.. 27 ycard oF age, entered ihc Ilo^pititl on
March 10» 1S5U, for a tumor of ilie riyht eye, ^vhlch coiiimcnccil
ei:c years before as a flight opacity, attended with neutttlgio
pains ; and, nfxtut four years after, a tmuor appeared juat hcicw
the cornea, seumini^ ta aprin^^ from the conjunctiva- Caustics
were apphcd, hut tmly aggravated the diacjwc.
Wlicn he entered tlie Uoqiitid, the globe wivj enlarged, irregu-
lar in eliape^ the anterior f;bumbcr was obhtcrated, and behind
the pnpil a dai'k-culored ^uhdtauec wns seen. Ju^t hilow the
cornea, two irregular tumors projected from the hull, between
tho Vnh, surmounted by a tranBpnrcnt membrane, dnd con-
taining dark-colored contents. Tho wbolc eye was the seat of
intense pain ; and an o|)cration For its roinoval was doeided upon
on tliia account, iVom the great irritation produced on the eye-
lid*, and from its probably mohgnant character.
An incifiioji an inch long waa made at the cstcmal angle of
THK KYK.
57
i-lid ; tlieglol)^ of ilie eye was seized by tiie double liooks j a.
inted bistoury was plunged in at one eide, and, tlie eye-
ball being tnrcumscribed wiih ilie knife, tlie temoval was com-
Ipleteil by dividing the aerve vritb strong curred scissors. The
use of the etroiglii, shflrp-jjoiuted knife in tlie operation in niuuh
preferable to the blunt bistoury uaunlly employed, which ia
tnanceuvretl with difticulCy among the dcep-sented tissues, end
prolongs the oper^ition. In the present case, after the removal
of the tye, the tissues, which ftn'mod llie bed of the glohe,
were oleflrcd away with seiseors. The opemtioa, as is often the
ease> wjis followed by very pi'ofuse hemorrhngGT which whb
te?isily Btopperl by furring one or two sponges into tJie socket.
Experience generaUy shows that aa attempt to seize the ves-
selfj with forceps i» useless, where the hemorrhage cornea frotn
^■uch an obscure **itimtlon as the loose cellLhir membrane, deep
^■in llie sncket.
The compressing hninljfcgo was remoyed on the followinjj; day ;
H on the third day, one of the epongee ; and on the fourth, the
^KremjLining one^ The patient lelt for home in about ten days, in
^tw goikd state of beallh, and entirely free froQi pain.
^B An examination 'if llje disease tiy the microscope disclosed
^Bcaneerous matter, wkh a melanotic cclorlng-
^^ The patient presented himself at the Hospital^ between one or
^Etwo years after ilie operation, in a good state of heiJth.
^1 These two cases *;Ik>w that rJiis formidable diHcasc may bo
^p^moveil, witli a prospect of prolonging life, and ivith great
t«lief to Bufiering.
Case SXXn. — Tawor of the Orhii. liemavaL —
lb, IflfiO, This caae was that of a gentleman, 09 years of
who had been healthy previous to the commencement of his
Four ye^irn hefore» after expotiiu^ to a current of cold
IT on his face while sitting at a lecture, he felt a soreness at
M* upjier [mrt of tlie orhit of the left ^y^- Shortly a swelling
ippeared nt this spot, which gradtially filled up the soijket, for-
cing the eye from its aiiuation, so as to project h forwards and
:wards, and prevent vision, except of objects on the same
M
THE FACE,
The *iirfftce of the tumor vfus irre^ilur, aud covered by iia-
]nvgiid \ciiiA. It WHS tennc, elastic to the touch, nnd il:« apprar-
ance at first wjlb that prefiputed by erinc[)hn]t>i(l drspaat^ when
mulcmg its vp-ay out fnun thfl interior of the cranium. It liad
increiLscd one-thinl ivithiii two niDiithtf. On a Citrefiil exploni-
Tiun, Jill iiidislinet fluctiialiou was [lerceptible, Tliere als<i pro-
jf('t«.I from iho iipjier put nf tfie sfK^ket n s/Tiall slicif of hone,
which cnU'i'Cil, anil wjts in<zorporatixl wilh, itj* pn.rietes- Thia
led me tu the belief ibiit it niiglit he a c&se of perio^tOBis, and tii
jwlvise tin ejtplomtory aponillnn.
All mci^IoiL wan niaik througli the akin and orbicular muede
of the eyelid- This at once diKclosed a hony aac, which, on
lieing punelurcd, dlscharg^cd about four uirnt-es of fclid pus.
Thia ffiiCy n& fnr as jwi^isibic, w.is dwsocted out. On carrying
Uie iiTiger upwards., no lusiplance was encountered fur two inrhes
above the niEirgiik o£ tbc orhit. The pressure of the fluid hatl
npfiarcEilly cuu^ed an abt4orE>lioii of the lower wall of the ii-t>ntal
RiniiM, and forced upwards Lh;it porljon u|ri:in which the anterior
lol)ea of the brain repose. Two opciiln;rg could he distmguished
williiu ihc cavity ; one leinling iiiUi the right fmntjd rsinus, the
other communicalin^, by a very-minute opening, with ihe uaeid
cavitiea : the interior wue lined witit a delicate iiiciubranc.
After being once empTJed, the cavity was a^hi filial with pus,
coming'^ as was supposed, from the otlicr sinus.
It was eatuniLtcd that from bix to eight onucea of pus escaped
from the tumor Ju the course of the duy. His physician in"
formed nic, tluiE:, for some days after the i>|>or;itio]i, the dlsi^ijir/^
was "iiujucudL' i '' but it theu gradually decrcused. The eye
neitrly retrained its natural {lositioii, and the sight waa as good
OS ever. Ilia health was uiiimpaire'K
I have once or t^vice eccn ca^^ee eimUar to the above, in whicK
iJic eye has bceu pnrttidly forced from its bucket by & bony cyst,
aucceesfully treated by a free incision, and removal of a portion
of the parlctes of die cyst.
THE EAE.
59
THE EAE.
Care XXXm. — EpithcUal diricer of tfts Him of the
Jiifihl Ear. — A *^i»llcji]an, 15 ycnrs of a^o, ivho luiJ aJwnyH
leiJ a vi'i-y leiu}^:"™!^ lito, but h^i been cspnticU n^ coiiiai.iader
of a s\x\\t at iBCn, iLpplicd to mc, iu JMnj, 1859, with n lnv^
ovtrhan^'in;;' t'|»ithelinl riwicor of llie u|>j)or [mil of tlif rim of
llie i-ij^lil ear. It Wi h>Ilowc<i proUy luiteh llit? course of (jiiiicer
of the lip, and very much roeemblt-U it. It ciiuKtHl nu very
Bcrious inconvpnieiioe. For hiilf tin iudi on ench *iidc, the tkiii
•was ecalyy thickuneU, and dnrk-culured, as it appears in the
coniiD<?nucDtcnt of this afJcctioTi.
With Bciasora I remuYod the tumor, topetlier with Jt portion
of the cartiian:G of tho ear, eo ita to be aure li> indude tlu- wimlu
tJiBende- I aUowcd tho nouiid to blued freely for ^oittc titnc,
without attcDiplin;^ to arrcHt Jt ; for I liave otien ohaetwdt in
operations about the ear, but loore especially in tho^o involving'
tlu? lifbt^, thiit a very 8lj<|;ht irritiilion of the wouud, ftiieU a^^ in
by the application of foreepj^f seGms to rouse up the erectile
tjttfluef and Jfi>'c rise to troublesome hemorrlia^^e. In removing
licndulous tuaiors produced by the irritation of carringa, and
vrbcre «uture« huve been iip]jlieil, I have been called to ]>ati(.'iitti
Bome hours afterwards, and fouod the cur in tho neighbor-
hood of the wuund "reatly swollen, the hcriiorrhfi^ proluae,
and isming Ir^im the whole surface ol' the wound ett nttppf ; nn<l
have been obIi;:je<l to remove the tbremU, and make eootldn^'
&nd cooling applieatioua. In the present instance, it wan ncoes-
»ary lo lie a number of arteries, and ^pply a little fnvpui-ed
fliuc, which haa been found very useful in obccking slight hleed-
inpt. and a^ an abdorljeut for dreaaiug wounds-
This patient did well>
Case XXXIV. — Ilecurre^\f J^Arovs Tnmor of thr. Eur.
JiemoL'ah — June 9, 1805, a young man» 25 yenrB of age, was
Btnirlc by a biUi in the left ear, in October, LStSO, eiiuHing a
fleah wouiLil, to which adhesive ploj^ier w:is applied. AtVer two
weeksT a small, hard rumor appeared at the seal of injury.
60
THR FACE.
When this was the size of a pea, it wns removed; nnd he
experienced no ineonvonicnce whacever till 1863, when, from
the srriLtfh of a etipk, ihe tnmor re-appoarpj. It wm« n^tdn
removed in &ii months aftpr the injury ; and, in three montKit,
re-appen.red for the third time. It was about the size uf a
cherry, hanlT well defir^eclT emfinicing the heliK of the enr, and
apparently eneoTHlnimatnns.
Tt VMS removeil hy a V indaion with 9<;w9ors, TVo hleeding
-veGvela were tied, and the edges of llie wound bronght to^rether
hy sutures. A microacopic examination showed it to be jibrous.
nofwa.
4
In thp conrse of my pi"ac[ice, I have had nn opportunity of
observing ri>nr or five cases of horny auLstnnreft deiclope*! on
differenl parts of the hoily. In 1836 I bronglil home from
Paris a wiLX model of Uie hejul of n woiniin* with a homy esere*-
eenee of from eight to nine inchefi in length growing from tlic
foreheiiil. It was removed, bj the celehnited Br, SoiiherbipIlF,
from ihti head or:Ln old woinun; nnd. ni \i\y rcquehl, the opera-
tor wrote out II denL'riptinn of the viit^fit he ifien heitig over ninety
years of Age. Thin case — to whieh I would refer aa one uf the
moat pplehrated cases on record — has already ijeen puhlishefl
ill the " Transactions of the Boston Sueiety for Medical Iiuprov
ment."
T>T, WiUiiim R. Lawrence, who ohtained this occount for
writes underneath it aa follows : " Dr. Souherblelle rjilh'd upon
me, Jind ieft the followin<r deaeription of tJie womun with th^i
horn. Tt seeni.>< thnt he hoA never puhlii^heil nn aceount of i^^|
Dr. Souherbielle is a eiiriosity of hhnself: hi; is 92 veura olJ,^^
and is still an ofieinlmg surgeon, in foil IkealEli, and does not
wear glasses ; waa an intimate friend of Robespierre; and Bays i
tliat he once examined Fninkliri for stone in the bladder. He
6ayH that he has pej'formed the high operation for fttoue i^etween
fourteen and fifteen hundred tiuiee ; and tbiit that ii the only one .
which rijght to l>e [lerfonned, esccpt in children." ^^^
M. liayer, in his work on diseases uf tbe skin, mentions tn^^^
case of a woman under llie care of Dubois, at tbe Hospice do
HORN!
61
"■crTcctlomicniciit, who hnr] a horn occupying tLo ForcScmJ eix
inches in diameter un<i aix inches in height. It was very bnrii
nt its summit, raid wiie cmhmced at it£ bnao by u ring of epi-
dcrmi*, euch as ie seen at tho root of tho nnils. This tumor
hiallj incrciLacdi £0 j\a Anally to pufiK down the t^kin of tho
itnd and cover ihc cyeliila : a fctiJ odor arose from It-
I have aocn ono or two eases of tiimora reecmbling tlieee
homy uroiiiiRtioQfl ; one, on the fneo of an old lady» bolwoen
two and three inches in height, with a baae of nn indi and n
haH or two inchca in diameter, of b. dark brown coJor, and of
come years' ddmllon. Upon ueinj^ elight force, it caino off in
my hand. leaWng at ita base an ulc?crated Burfaco. The excres-
cence wna evidently composed of dried layers of pua, originating
in a chronic ulcer.
The following caae of a true horn of email size I operated
Ml ID 1^63 : —
SE XXXV. — Horn on the FacG. — An Iri^^hman, fiO
old, \vitli rather a Jricdt ehrivelle*.! akin, presented hiLiisolf
nt the Hogpital, June ti, l^l>^, having a homy excrescence
win^' from the skin of the face, on the right eide, ami on a
1 with the edge of ihc lower jaw. The horn itaeJf was rather
more than an inch long, situated on an elevated b.iac or tumor
nbout half the size of tL amall EniiltBh walnut. The whole
growth waa removed by two incieiona, leaving the healthy cellu-
lar membrane below, A j>er|Tendkulur seelion of this tumor
displayed, — first, at tbo taec, fat, forming the mats of this part
of the tumor; eeeond, this was surmounted by thrce-fourths of
an inch of c^rnpnct epidermic tissue, on top of which, waa the
horny structure, disposed in cup-like Uyere.
I have also lately removed from the forehend cf a Female, just
between tho eyebrows, a homy tumor of nbout three-quarters of
ui inch in lenj^'thT and of between one and two ye^rs* growth.
It had at tirst the apj^arance of a wart, this being g«Ldually
BUrtnounted witli a liorny ^>roduciion. It was removed aa in the
former case ; and healetl, hai-dly leaving a scar.
fiS
TilE FACE*
DEVIATION OF TUE SEPTOi oF THE NOeE.
We seldom cbserve in bouka on eur^ry nny reference lo ll
queaLiun of tbe treiituiEiut uE' thia a.1tbi:tJon ; it l^mg piiiinpnlj
notlccfd iti conubCtlon with tlic difTcreDtia] di^gnu^ia of pol^|in9,
niid mucous tlilckenlu^' of the un^^d cnvitice. It i9, 1i(nvcvei-, an
nffectiou of ft£>me iuiportiiiice, iujd oue in cotieefiuencc uf whiuh
patic^nta oflen i^pplj ior trcntuicitt- It would be sujtpuaoi!, llia£
wlmt {[» lutit in frc^duui uf rt^spiration hy the ubaLrucLiun uu udM^H
«!de would be made up on tlte other ; but this is uct tlie ciue^B
Tlie (ibetriicted &ide becomes cougcatcd. and this congestion setati
to be tnuiaiuittcd in pjirt tliroui;rhout the whole extcot of
nnbiil ciLvitle^, caui^iii^ difficulty ia breathiiij^. iuordiuate sec
tloii fruiu the noitriU, more or less congestion about the Lea
nnd A general disturbance of the health* Patients with thia di
eujic often a[il>ly fiJf advice, eupposing it lo be polvpus \ an
flomctiuics, from the grettt buji^^u^^'-down of the ppongj and
ttiickened mucous mcmbriine of the aeptum on oac side, it ivould
Bcem ciiay f^r the mistake to 1^ made. But, on examining t
tumor, it will be found, fir^l, always to belong to the inn
instead of the cuter aide of the na&al pafif^c; Aecondlyt
prcsMiig ou it Willi n. prohe^ or with ihe little finger^ it will
found unyieldjiig ; and, thirdly, by pii&aing a probe ioto
other noalril, it will f:tll into the cavity made by the dcvlfttloit
corresponding to the [irominence on the olher eidc-
Thc method which 1 have adopled for the treatment of theso
caaes will be best illustrated by one or two exiimplcSf which mny
fierce to represent quitQ n number of others wliich have falJen
under luy ohacrvation.
Ca9B XXXVI. — Deviation of the Septum of tit o ^o^e,
A child, 12 years of age. of a scrofiiloLas hahJt, was brought to
me by its parents, having an extreme dcviatiun of the acpCum to
the right side, coni[detcly obatructing the passage, and giving
rise to the train of symptoms already mentioned as belonging
to tlie severe forma of the uili^etion- I commenced, with much
diflicuity and greikt resistance on the piut of the p;itient, b^
%
DEVTATIOy OF SEPTUM OF VOSE.
f;3
•
VII I J
pfieeing a amnU bougie into tlie obstrucLod noBiril, koGpinjj It
upon the iloof ol' the cavity, so aa to prevent il« pcneii-.illng
either in nn upward or lateral dirocTum. After tliis had been
June for several dnjs in suoopssion, a narrow pasange wns
opened. Into this was pmssetl a piece of prepared sponge, well
oiledf about an inch lung, of a cylindvical shape, and pointed at
jt9 cxtremilT- This wos aecured on tbe outride with a string,
whieh witA fiatenffll around the ear. The expansion of the
apcnge at first caiiaed great irritation, whicli wouhl }jave gone
oil to uJcerfltion, had it not been removed after twenty-four
hours, Afier ihe irritation \ind subalded, the sponge was again
introduced; and, by pi-o (deeding with caution, nnd removing it
^oiD time to time, an opening wiis made large enough to allow
tn iVee a passage of air as upon the other eJde.
Cask XXX\1L — Deviation of the Septum of the J^o^e . —
A young genileoi-aa, 18 years of age, with marks of a Btrumous
(lifithe^Uf eoiitulteil me on account of a deviation of the Bepium to
llie rigijt E'ide. lie could breallie frecdy througli the lefl nostril ;
but cu the right side, he could, with great effort ^ force through
only a #mall porfioo of air. The tumor formed by ihy aejitinn
looked much Jike a jMfh-pus, forced duwa to the external opening
of the nostril. I first passed a bougie along tbe lower eido of
tumor; tijen the little finger, well oiled, woe VQvy slowly,
with much dirtieulty, inainnaled into tlie pasesij^eT forcing
the septum over, and guided nt the same time by a finger in the
other nostril- On withdrawing the finger, he breathed freely
tlirough the right aide. He waa now a'lviscd to introduce twice
II diiy a bougie ; and at nij»l]t to wear a little instrument con-
structed witli a spring, so that it could l>e closed by pressing the
blades tugi'thor, imd then allowed to exfiand after introducing it
into th& nostril. After this course had hcen pursued for a short
time, the paaaage seemed to be fully diluted; but, on ita being
neglected for sevenU months, the difficulty recurred in part, ao
&0 to rei^uire a rejietition of tiie treatment.
Casi: XXX\TII, — Det'iitfwn of (ht Septum Nasi, ftith
apparent Ctthnveons Dejxtsit on the extemni end of the
64
THE PACE-
Cartilage. — A boy, aged 12, was brought to me, June 2-i,
18li<j, by hifl phyaidan, i'or wbnt appjiared to be a tumor in tiie
ri;;lit nostril, and which bulged out the eide of the nosG. It
hrtd couie on gradually, fionliy completely obfitructiBg the breaih-
iiig througb that noatrilp
I found it to be the affcclion mentioned aliove, Tbo surfaec
of the tumor hud on it one or two streaks which looked like
uketntion, but wlLich, on being examined with die finger,
proved to be cnlcareous deposit on the end of the cartilage,
where it pressed on the mucous mcuibninen At first, there
eeeuied to be no visible opening iuto the nostril ; and it wa* with
come difficulty and with gi-eat rofietanee from the pntieot, tJut ■
the probe eould be ind[nuaieLl alon^ tlie floor of tlie ni^stril*
This was replaced by ft conical gmn'clastie eathcter, through
whieh he breathed fi-eely, I ai]viscd the O'eainieut pursued in
the former easea.
TIIMOK8 OF THFh JAW-BONK.
In the substance of the superior and inferior ma^Ufle are found
tumors of vnrious character, myeloi*!, cystic, cancerotie, fibroue,
cjirtilfl^inouH, and osseous; more superEeiidly, and springing
from the bone, may occur e}mhtf,
O|xsruttona for the removal of large tumore of the jowa were
formerly very rare, and were eunsidcred highly dangerous. By
the use of improved cut tin rf- forceps of large size, the upper jaw-
bone nmy now be removed with but little trouble or daoger;
being, in faet, a less f'oi^mldable operation than tJie excieion of
the JoAver jaw. The deformity, loo, ia mut?b less than might bo
expectoJ ; ys the cavity ia, in a measure, filled by adveniitioufl
tissue, and may also bo partly closed by artiltcial coiitrivaneca.
Myeloid Triions of the Jaw, — Myeloid tumors in the
ja^v are rai-e, anJ, at a late stage of their exUtenee, are orten
djfitinguished Avith didieulty from that external affection caUed
" epuUs." The following caaea characterize well the history and
appearance of iliis disease.
MYELOID TCHORS OP THE JAW.
65
C\eE XXXIX.' — Mffeloid Tumor of the Loii'ct Jftw. — A
Ilftdy, ^L jcara ofa^e, applied to me In iWVj with u hanl tumor
en the ri^'Lt siJe of tiif lower jnw, in front of the socket ^jf iJto
■c^ortd moUr tooth- wliirh had bi?pn estrooted n couple of yoara
before- Sim^ its cxtmctioii, she haJ had ncurol^i^c pains in that
•ide of the fauo- The tumor hnd aonjet^hat tho fcding of a
cyatic growth. Th«re waa no dieense of the gum. I cut dowTi
Upon it, and remorcd it even off \\\i\\ the jiiw with the bono
forceps. The wound rflpi<l]y henlod ; nnd I did not see her for a
yew, when a elight buJ^'^in^-out of the .jaw was perceptible At.
tJiat spot, but not sufficient to demnnd eurglcal intorfcron^^e.
ijn November, 18*15, she consulted me for a fuu^'oid ;:rrowth
*emhlia^ epulis, occupying moat of tho horizontal portion of
itJie Jaw on tho H^ht side, ^hicli had appeared wifJiln the hn^t
iroe uumtha. The lower ed^^e of ihe bone etill preserved a
^-clenn margin. It wati decided to expose the diy&ise hy a free
extemal indaionf and to be goTeme<I by cin:iimstanees aa to
Texuovin;* tho whole aubetttnco of the jaw, or leaving tho lower
1^^ riiu of b*Dne, Thia wa-s done in tlic maMner related in tJje next
^B<oa«e, and the tumor exposed to view : tho facial nrtcry was tied
^^ before bein;; cut, to avoid the f^it and troublesome flow of
bJood whidi UBUully takce plaee wlten ihat vessel \& divided,
tooth was now removed in froTit of tho diaeaflc, and tlic
tii^dom-tooth behind \ an^I, it hcin^ fbund possible to preeervo
iihe ed^ of the jaw, peqjcndioular incisione were made with a
iidl haudaaw, a honzontal ^^roove underneath the tumor with
[ey'e saw, and the diviflion was complelcd with powerful bone
rrcepe. On romovint^ tlie tumor, a emnU cup-liko depression
[i^midned in the cenfrc of the jilace from which it was tukon;
tdr althou^^h this appeared quite healthy, ae a matter of pre-
miion it was eeoopcd out with a chisel.
On making a scetion of the tunior, the bone wiis found ex-
faiided to a ^hell, and contained a sofl material similar to that
|lo which the name of myeloid has l;een pveu, of a ^otX uniform
appoarnnoe. ami which^ on examination with the microscope,
I proved to be a Rue epccimcii of that ditfeaae. It had broken out
^^^m ita osseous envelope on the outside, and then hiul sproiLd
^^papidJy over the gums in tlic vicinity.
L
6e
THE FACE-
Tbe wo'tntl was brouglit t(>p;cther by quite a number of^
autnres, ami unifed nearly throughout by first mteiition.
patient haxl scarcely any const itutioniil disturbance-
Case XL- — Myeloid Disease cf Loicer Jnw^ — A young
married woman, 19 yeare old, whoBO p;oncral heallt hnd been
very g;ood, oonaullcd me, in June, 1865, for a tumor of die
lowor jaw- It Iind commcnccHl, two years before, with pain m
the first molar tOf>th of the ri^lit lower jaw, which was thoitglit.
nt the time to be due to an "ulonrntion of the t(>oth," A swell-
ing, which made ita appeurtiuce a year imd a lisdf after, gradn*;
ally increased. The looth was then cstrut'ted : in the course i
of six weeks the tumor doubled in size. It was easily felt
extemidly, extending from an inch from the anglo of iht* jaw
to the canine tooth- On the inside of the mouth it bulged
out, and protruded upwiirds through the eavity formerly occupied
by the tooth. Sh:^ hjid little or no pdu. and experienrcil no
incouvcaicnce from it. Her general health was very gixvd,
Op&ration. — An IncUion was made from the zigoma, sweep-
ing around under the ramu;* of iho jaw, atid t<^rminnCod near the
Up iu front uf the angle of the mouth. The fadal artery, wliich
woa now cjLjToeedj was aeiacdj with two piurs of forceps, above
and below, divided between them» and the two ends tied. The
mucous membrane was now cut through into the mouth, and
the tumor esposed. The teoth in front and behind being ex-
trnicted, the juw waa flawed through with a smaU saw, and waaj
theu dissected out.
On examining the tumor, the walls of the jaw were foundj
expanded by the growth from within, and deficient at the uppec
portion, where it protnided. On milking a longitudinal section,
the gross appearauwa were fijunJ to be characteristie of myeloid
disease ; being compact^ uniform iu appearance, with a few of the
characteristic " blotches."
Under the raieroscope^ there were found chmgated and many
nucleated cells.
The wound healed rapidly j but her health remained delicate
for some months afb^warda.
SrVELOID TUMOIie OF THE JAW.
C7
Case XLL — licmovftt of Upptr MaxUhiytf J]one for
^i/el<ftd J}ij*ea^€. Pal/iatcuG Opf^ralion two i/cars ht^J'fn*.
jiriijicial Substitute. — A young man, 10 years ol' ago, en-
tered the HoapitrJ, April 7, 1864. lie was formerly a aolilit-r*
A ytoT and a hidi' beftrre, » small swelliiir^ wits iiDticciI ii[ioutlie
outside of the guiu of the upper jaw, neat the Grat uiolar t€oth,
foflowing loo earlj exposure after an attack of ti-pboid lever.
Thinking a cartons tooth was the cause of the awelling, it was
removed; hut tlii^ hail co eflect ou the tumor. Nine moulliD
nhcTt tt begAu to increase in ^Isk : on adniia^ion to Uie Iloapi-
tult it inejisurcd one and a \iaI£ inches in diiinieter ; was ovoid*
hard, not tender upon prcL^riure; pmnful at timea, pain ^' stream-
ing np" the side of the iace, and at such times the eje was
jUentJy hlood^hot,
'April lilh, he waa etherized; the lip wns drawn up, expoaing
djc tumor. An incision wud then made in the protruding wall.
Through this opening, the linger waa parsed into a csLvity con-
taining a pulpy fiibftancc, which partly fiUed the anb'um, and
which waa ecooped out.
A fraginent was examined under the microscope, and Touud
to contain the many nucleated plntee of myeloid growth, and
ditftinol, isolated nucleated ceJla, euch as are usually found In tlio
connection .
Sixteen days after, he ww dir^charged, relieved.
Nov. 21*, ltf05, he returned again for the removal of the
upi^cr maxillary ; the disease having rceurrcd, and made consid-
crahZe progresa. The right side oi' the cheek waa occujiied by
SL liard (uuior, expanding the anterior wait of the antrum, and
ini|jin^ng un HxQ maliir hone. The apciturc previously men-
tioned was Gllcd with a dark^colorcd* fungoid masa, of the «izc
of a cheetnut. It was deeidcd to remove the whole bone, as
afl'ordin;,' the only hope of cure. It waa done in the fullumng
manner, which 1 shall describe in detail, aa being the mctliod
which ! have unlinarily pursued fur ihc removal of the upper
aiaxillury hime, and which IcjIhVcs ua little deformity ns any of
the methods proposed, where llie diaeaao is extensive. Ucing
trlheri/^l sufficiently to carry him throu^di the preliuiinary in-
cifiioiuj, a puiuted bistoury was plunged through tljc skin just
THE FACE.
above tlie lygfjTiijiiic process of the makr bone. A curved
fncL^ion WHS then mndc througti the s\dii unil miiiiclea tct tbe
Hn<rle cif the month, A bit tif sponjje hsul liccn previously Muffed J
itifo (bjLt clicek to prevent the blotwl fnim fluwing into tlie Tmijc^. ™
WJiiin ihe skin of the face i^ more fJiicci^l, us in oU] |>craoiis,
thid inclnion mnj be {nrnmenceit Tower dovniT thereby iiivi(lin£^|
fewer filiurjonta of the fticinl iieTv<** leaving lesa pnralysis, A
t(Ju Ii:iii[f<] iiicisiari, however, embarriLSPes the sectioa of the
bones- The flap waa dieeectei] rapidly up, the right
the nciHG cut nw:ij, anil the contc?mj' of tfie soctet rliflsectral pa
tiidly iroiu the floor of the orbit. The bones being well d
the vcs^icIh iu the flupj) were tied, the blood wnii cleAreil awit
from the wt^iiul, and ether wiia again given. With a amall hand-'
Haw, a groove was made In the frontal process of the tnalnr bono
and through the zygi>matic prfH^ess^ 'i"'^ *^'*^ Boction eompleled
by the cutting foreepa, the former incision eitending into the
Hphf?no-m!»xillary fiesiire, Tfie nitsal |H-ocesfl of the 8Uperi
maiilliuy hone waa now ent through in the direction nf the *ani
fiasTire. The month being held wide open, a vertical inci^iio'
was made with a f*trimg p(Mnred Icnffc, rhnmgh the r^iveritigs
the hard pahite aa far biLek aa the palate hone, iind a lateral onff
fruni tlie termiiiation of this behind to the rotJt of the hu^t ciiolar
tooth. Listen's large cutting forfepa were now iiseil to flivld
the bone, whiijh tliey cleanly and efliciently did ; the first incis
tooth hjiving been prcvijuely removed. The whole mass w
now seized witJi powerful bookci] fijrcepa, and iiii attempt made
to depress it ; hut it field faat at iu junction witli th(i pterygoid
process of the wphenoid. A diiael was therefore driven in Iw-
hijid the bone, and nn iittempL made to brejik its nttri^^h in enta,
but withoot fliKTtsw, A blunt chisel was then inscrleil between
the two maxillary bonca ; and* by a prying motion, the lulhesion
to the bone behind w&s broken. The remainintjr sofl attaeh
mentfl weri; divMisI by hhint curved scissors. The maxillary
artery, which lileU freely, iva* tieil. Wien all hcmnrrfia^'e luid
ceafeeil^ the e*Iges t>f llie skin were ai^curatcly broiigixt together
by Kutures, ciire bein^ tukcn to nicely adjiiat the Itp ; and one op
two sutures were insertrtl inside the moictli.
The patient waa gieatly depreooeJ, and stinmlauls were freely
KYELOtD TUMORB OP THE JAW-
6d
ImifiistcrcJ* Tbcrc waa an oo7.in^ from Lho wound rlurin^ the
titmc <|jiy. For goiuo days the piUi^C rcniuinod fcelrk and the
^trcii^L inut-li dcprosecd- In two wocks tfiL^ powere of Jife ro-
i^ved, and ho then recovered with ^eat rnpidity. The imrnlyaia
waa Icec ttinn usual, nnd ivith a alt^dit cHbrt the cvelida could
l>o nearly dosod. .Sight was not impnircd. The union of the
wound WAS j>erfeet, except at one Bmitll spot, where a Bolivary
aeemed to ihreiLten.
On inepcetion of the diaonflcd part, the cavity of the antnim
wiu foiuid filled with a sutt, dui-k-oolored^ apon^ mace, which,
iindc'r the mioroecope, pref^cnte^l the Avell-markcil choriictcrs of
Iniyeloid grcwtli. The disease waa entirely removed hy the
opcTBfjon.
Jievifirka. — The inciaionfl in tlie soft part^ in tliia ea,*e leave
M little deformity as any of llioae putr^^eeted for the exoiaion of
tlu^ hone- Gensoul rocomniend^ int^iBion of the upjit^ lipf a
^roea cut through the eh<^ek, and n perpendicular one at the end
of tiiie, leaving three very disajcreeable ecarw. Fer<xiieson, a,
iimple cut throupli the upper lip into the nostrilj or, ]x)saihly,
% eontinuation of thi« incision around the mar^^ of the ala^ up
the rtiiie of the ni>eG, and alon^ the ed^e of the orbit, if necee-
»Aary. In regard to the boaea, it has been advised to make one
cut Lhrou|:!h the maxillary proee^ of the malar bone into the
»pheno^mnxillary figaitrc, instond of riividinj; the zyp^oma and
the frontal process of ihe malar bone. The objeetion ih, that the
M tumor rpenerally oceLj[kieft the whole cheek, and prevents* the exes
^■cution of the plan propo^cfl- The trying point U the iidheslun
^Hof tJic iimKillary t)one to the ptLTv;;*>iili made more firm by
^Birtflommatitry aotion, Eo that in malignant; diai^atiGB, in attcmpt-
^■in^ depreiffiiou of tlie hone, the front pan of the nntrum is apt
1^^ to break a^vay from the posterior portion^ retiinring tlie back
|^_ port to be flubBeqnently removed.
^B The ellght deformity Ict^ tiMm so extensivo an operation ia
remarkable. There la n flight parulyjtie in the cheek, and at
firpt a confuftion in tl^e speech and aome difliCiUty in dep;lutilion,
'Vhich COD he almost (Completely remedied hy artJfieiaJ appllaneea
,ofpold, i^itta pereha, or hard India-rnhber,
With a little mnn^>nient, a mneh luri^^er portion of the £oft
70
THE FACE,
[inrlA Govermg the piilitLt; mi^'bl be 8&veil, as iiwy peel ofT cfteily
when the buiii; is ciepreased-
Tliis patient rec(»vereJ ppTfi^ftly. Tin- salivary fie^tula, whidt,
it WHS feareil, woijUl be pcrniaijent, dospil iiftor two or three
jiljpliuiitionrt of caustic- The voice and deglulition were, of
course, veiy much iin^mireil by the gre&t cuvlty lefl nilcr the
removal oPtlje bone* These, however, were completely i-cdtored
by tlic iiigeiiiimF^ ron^lnictioD of u ha.nl nibl>cr ohtiirnior uuil
^lahitt*, Dijule by Dr. Rufria !C Dieki^oD, ilentiat. lie now
r4[ieaks well, aud IjcjujcIm nu luogfir regurgitate throu^di tbe
DUfiLrlle.
Kpclis, — It IH TH^cpsaary to iliHtinguisb epulis from niyiJold
Jiaease uf tlic jaw. The hitler iH UBuidly a. disease uf the alie-
nor tif the hniie, which, exleudlug Diitwards, after a while pre-
aents an a[>pertninee similar to the former. Myeloid dLscaac,
involving the Muh.sUinee t'( the bone, and changing entirely the
rttnictiire of tlic p:trt. as lei well deHeril>?d by P^gel, itjipiirts
the cicie-ion i>f tliat portJou of the jaw whii-li ia attach«l»
Epnltti ifl comparatively siipcrfii^ial. Ii arises from the peri-
ofttLrunj aiid ^^rows outward ; is more coiiimoTt in young persooe,
ihongh it fre^jucntly oecwrs in advanci^l HfeK If the gum is
reiuoverl with ihe woeke^s of the teech from wliieh it sprin^fs, die
diaraae in c.m-eil ; tiut care should he taken to cut deeply enuiigh
iiitii tlie boae to remove the whole, us otl]erwi?*e it will be likely
to return.
In ihe case to Ihj adduced, the disease \\m\ lieconie so dee[dy
BeJited, and attacked to such an extent the neighboring parlj>,
tliLit removal of the wJuile Ujne, which wa« very small iind ileli-
eate, was £nully required.
Case XLII. — Removal, throurfh a Sinnll Qpenhuj, of
IJtilf of the Lorrer rJafr^-httn^. EpuU-^. — A married lady, 30
years of age, considteil mo, in June, lyGO, for a fungous ex-
creseenoe occupying the alveokir processea, aud aockeLs of the
three \i\i^i molar leeth. Tlie disejiae rjo up a little on the ramus
of die jaw* and lapfted over on each side. A yc.ir previous, whe
laid buhmitted Lu the removal uf a uiolar tooLhi and tlio jaw had
EPCLB.
71
'Dot nncQ been in a flound etnto. A phort time aftenvnrdj?, a
fungoua growth from the di&eJiscMl aoclitl wjie retnured. It
gflvc h«r \ery littlo pnin, but wag iccrcitj^ing, hnd tnken in the
muooua membrane on the ouUlcle of tbe jatv-bnuCf luid was
^m creeping up on tho as^enilinjf pnrt of it. She was Uesiroua te
^K huvc nn ojierntiou dono at uncr?, so tiiat sha miglit ii^turn home
^Bthut day. Tliia I did, as thoroughly us pog^ible, in the ordinfiry
^B^n, with the cutting forct^pfi, going dceji into llie jaw, and
^^HBiov'ing the disease ^o far ns it 4!oijld Ix' JpU.-ctGd. Tlic blood"
ing for the moment wiifl profuse, obsf^iiriug the after stepa of
t}io operation, a^ ir always dooH when an nitciTi|]t is made to out
away pleees of the jaw, without making an oj>eniiig iJiiough the
clieek ; and on thi^ account the subaequcut safety of the patient
^Aften sacrificed to tlie natural desire of avoiding si deformity,
le liemorrhago wjis eliecked by tlie local u^e of porcbloride of
imQ« In a fortuiglit I saw her again, every thini; apparently
bavitig done well'
On a very careful extuoination at lius time, I detected, deep
in the jaw, rennuns of tlie diseased tissue, and, knowing tlint any
ilelay would be fital, proposed to the patient an opemtioa for
the exposure of the bone by an exlcnial incision \ and, if it was
I then found nDceaaary, ihe removnl tti' the whole bone. Being a
person of great courage and decision, she at once consented
without hesitalion to submit to any operation that was thought
tiucessttry.
On the 20th of June the jaw was exposed. What was left
cf it was found to be very narrow^ and icTaJed by disease, which
nm up on the ascending ramus. It was at oncfe decided to di«ar-
ticulutc iIjc bone, which was done in tiie uaiiid manner.
Tlie wound united by the firjft intention. The constitutional
Irritniiim was sli-^ht. On the fourth <]ay &he eat up^ nnd on the
i^^ ilxlh waa out <if doors ; on the eighth eIio returned home, a dis-
^BtftDce of eighty mileH. A daguerrotype likeness taken at thifi
'"^' time scarcely shows the marks of the operation.
November, 18ti.^, being in town, she called on me. She wns
in fiill hcaldi, and was free from disease. She talked plainly ;
»nd used the remaining portion of the jaw well in mastication.
The gap caused by the removal of bone was filled up witli
71
Tin: FAOE.
dense fibroue tJesiies, which accmed to ana\7cr oU the purpose of
bone for atcatlying it. The ladaor Iccth above and bclf>w wero
in Eippoeitian. Thctc vraa no pamlyai:^; and the murkd of tlie
operation wore ^^carcdy vbiblc.
Cystic Toiojis of the Jaw. —The appearance of tL(
tumors ia pcncroJly very iorraidalile ; and tijc practitt,
tJic most part» when the wliolc subetanco of tbe l>onc b
dilated into a mere aao, almoet entirely deprived of oe^fiuu^ eub-
etancc, hns been, until very recently, to remove the portion of
tlie Jaw involved by tlie tumor. Wlieo the tumor hiw ^towh
simply at ttic expeoac of the outer table of the bono, cither of
the upper oi- lowor jaw, without iuv<jlvinR; Jte whole Bubelnnry,
it liofl been eu3toiuiiry ti> es|jlore tlie cyi^t and remove a portion
of it, causiug ioHammution and oblitei^ation oF the cavity, oa in
tlie cafio of cyata oceurrin^ir in eoft purt^. Diij>uytrcn. in hia
cullectcd artielofl on Diaeaaes of the Hones, has attnoheJ mure
importance to tUie question than any odicr writer; aud illus-
trates, by cafica, the effect of caposin^ the tumor by cxtcroal
disaection, removing a portion oF the sac, ami by applicntioua
cfFccting lU (»U iteration. I'roleasor Marclii of AlUmiy, hn*
written p. volua^ilc paper on thia subject in the " Tranaaetions
of tlic Jlcdical .Society of the State of New York,*' Profet^eur
Groea and otlicrd have au^^eated the idea, tUat, iu the birgG
CTBts wlucli involve the whole bonoi and wliicli formerly were
known uniler the name of " apina ventojea," the treatment ahoulil
be the same, Iu one of the eaaca cited by the former gentle-
man, the extirpation of the bone wua finally found ncccaaory
after this plan had been tried.
Afi to the enuscti of these diseaacs, they are vnriou£. In tlic
jaw, they probably ariae, in moat inatancea, from irritation at
the roots oF the teeth ; in the long boues, the head of the tibia
for inatance, fwntx blows,
In ltiG2, I published, iu the ''lioston Modical and Surreal
Journal,^ a case occurring in an elderly woman, of a eyat whieh
involved the aacending portion and condyles of the jasv, and
wliich I removed; not tliinkln^ it eafc, in a person of her agc^
wlica tlic didorgiuiizatioa of the jaw seemed to be so complete.
CYSTIC TUMOIIS OF THE JAW.
73
run
tlie risk i>f
expoi-imentnl moile of trofltmonf. Since
that lirnt?, I h.ive hat] tin Of>[)ortunky of trying the eon acr rati ve
^an (jf treatment irk two lii^tanccst which I pro[iu«L' sliortly to
relate,
Nuhdthi^tamling llic principle wluob Las been su^^esied or
[luntcJ at for the treatment of large cyalic tuniora of the jaw,
me of llie wi'ittra on tlie aiihject have pi-esenied enaee, — where
Jete destnnrtion of the hana hns taki?n phice, le:mnfr nothing
delicate cyu, — as having been s^neeessfully treated by the
icuifxl adverted to. Dnpuytren, in hia work t>n DisenHea cf
B[>nes, g-ives several cases treated witliout excMunj some
uf them. ln»vevfTt nnsiiccessfully. M. Nthiton hns nU\i written
the Hithject, referring for caacB to ihe work of Dupnytren, and
vlvHin^ the pnnoture of the cyst, aud the ^tuflintf of its csivity
^with Jim. Mr- Krichsen wiya. that, " when the cysts arc ao largo
Lat they have destroyeil the integrity of the Lone, nr when
ley are iLS^ueiiiteil with a hirge rjuantity of fihnms tissue, eo us
iMnslLiute True fibro-cyslie tumors, eTcision of the di^caswl
jnc ini]>it be practise<l." Mr. .Stanley, hi his " Tn?iitise on the
tiecHitea of the Bones," deacrilrtjs perfectly the affei'lioii, hut
JiM?« nut allude m any other op(*ralJon than the "removal of the
^Luinor, aiid of the portion of the horn; from which it. has
isen."
Ill the rollowing cjwea, the treatment consisted in the piin(v
ire of the ^ae withbi the month; cvneua(i:ig il8 coiitcnta,
d, at the same time, obliterating the cavity by t^rui^hing in itfl
wnWa ; and, liwtly, in keeping up, by injections, &c. , a anfficitnt
Ilegree of irritation to f;ivor the deposition of new bone- The
ompamtiTe mildness of this moi^e of treatment^ and the excel-
eni ehanuTter of the reaulla, combine to award tJie pnifercnce
or this operation over eseision, or even tlie large external
ipctson adopted by Dupuytreu.
XLIIL — Ut/iflic Tumor nf the Lowgt Jaw^^A
woman, aged ^5. with light hair, blje eyes, and delicate
^n, applied to me in the opriug of 1863, on account of a largo
tumor invoKingtlic whole ri;,^ht aide of the Jaw ahnvc its anjj^lc.
lie tumor was of a globulur dhapc> extended boAik under the lobe
10
Lun
u
TITF. FArE.
IC
of thp our, Torwimls en an t.> cncmacli ii[mn tho iruvity of tl
nioiali, ami upwirdit 8u tn Ut pru*< ii[»o»i, ninl soniewlint to over-
lft[], the Kj'^fniia. Tlie eil^mnl surface of Uie tiinifjr was
Brnrjcilh nml «Lin!n;j;, slightly mlpnitttoua; u.iti1 slie *iuifti\il fmiii
its pre88urti i]|)oii the surntuudiiig organs. It tiud ciimmcuL;^^,
floine jeara Iiefore, by a swelling nt tlie root of tlie wisdom-
tOiilTi of ill e right side; nnd the i neon v tin iencc naij*je*l liy iU
|ir(*ssurc hatl l)eci>ine eo great us to leiul her to take niea^urea
f(ir Its rnnKtvjd-
Upon coi^flultatioD, tt was Jui^iJl'J tluit a portion of tljc jiLW
would probably rtquirc removal ; tljc tumor having been first
exposed by an incitiion mitde inside of the mouth, to vtrJfy ita
character .
TKi; fulluwijig operation wu» pe:'fonncd under tho influence
of ether. An iuijifiloii wils ui^dc in the umsi prommcnt part oi
tbc tumor in the mouthi upon wbich a hirg^e quiiDtlty of gluiiy
Huid escnped- Upon pulsing iJio fitiger into the opening, it was
foi^nd that the whole Jaw at tWt* point, with (be artluulatmg and
coronoid proee^^aes, wa.s ozpacidtid into a mcru bhell, at some
parts us tijiQ aa parchment, and destitute of osseoiiii aubatance.
It watf witliont aolld i.'oiLtents. Under Llic^e eircumstanceri, and
cou»!derhjg^ tlie good bejiltb and youtli of the patitrut, it wau
determined ti make the attempt to aave the jaw. A portion
was thi^refore removed from the aric; and, with tlie fingura, the
aided of the cavity were made to tolln[ifle, au an to eume in eon-
tELct with eiich otber. In order to excite »till fuilber irril.ition,
a bit of cotton cloth waa fojv^ iuto the interior, and tl^e end
left pi-ojeeling intL> the uiuuth. A moderate dogioe of irritation
followed; and, at the end of a day or two, Uie pledget was re-
moved, suppuration baviug; commenced in the sac> The aper-
ture was dilated, from time to time, by the introduction eitlier
of the finger or of a bougie, and the sac iiijectcd witli tincture
of iodine. At the eud of two or three wcckd, she left the
Ilospllal, with the tumor reduced to about otio-hnlf lU origind
size. From that time until tlie prescul, f\iG has occasionally
visited me at my liouae ^ and, by keeping the extcrual opening
free, and occasionally irritfiting the interior of the sac, a ao!id
ma^3 of bone has been deposited anew, aad the Jaw hue resomcd
CYSTEC TUMORS OF THK JAW-
75
Brnncirniit of it* orip;innl shape. Tho sac ia in the way of becom-
ing; entirely oblitoraled.
In November, 1863, I ofrain saw the palient, who camo to
coDfiuit me, not about herself, but about a frienJ. All bi^s
of the tumor had dianjipcaretl, anJ the jaw had rogained almost
iU nntunU »hape ; but n small apcrlure siill cxUted at the dite
of the tbrmcr opening into tlic mouth, and A filairy fluid wae
fifeft*iiornlIy difieharj^Dd from it. She wriB i^nilo well, and all the
iunctic^n^ of the jaw were perfectly performed,
SuhFcpicntly, abu ajiplieJ to me with a tumor of a smaller
I, whiuli liad ftppcarc<l in the jaw anterior to tho ftilo of the
^nt one. It wa^ treated in a. eimilar mB.nncr, with a aimllar
result.
Case XLIV. — Cj/slic Tumor of the Lov^cr Jaw. — May
23, 1863, Dr. Bennett of Uxbridfje, Maaa., brought me, as a
patient, a ^jemlleman 56 years of age, with a large tumor on the
ri^'ht Bide of the iaee, oeenpyin^ the parotid region. He was
pale und Ballow, mudi cinauiatcd ; and hia aspect at first etruck
inc 9a that of a pereon entering from maUgiinnt dlBcaae. He
Btud thai, five yeare tn;forc, while earing* he bad the fieneation
of fiomething giving; wj*y in the neighborhood of tho ascending
nittiUB of the lower jaw, Sh*>rtlT after, a tumor appeared in that
region, which had flowly incrcn^oil to ita present size. Before
making an cxaminationi it wa* not easy to say wheOier the In-
Ki<iT was connected with the parotid gland or with tlie jaw.
From the commencement of the diflcaac to the prcecnl time, maa-
tication, and. for a good part of the time, deglutition, liad been
much interfered with. The tumor hajl been examined by many
pliyei^'ians of experience, and by moat of them coneidercd as a
parorid lumur, and aa the patient infcrrcii, althtiu::h he was not
direetly told eo, of a malignuut character. It CKleitded baok-
wtirdd into the parotid region, upwards upon tho faec, and
iDwarda so aa to occu|*y the ri;^ht hulf of tlie palate ; and was
covered with a highly irritable mucous membrane, somewhat
fi^lcmatous, and similar to tvJiat we olVon see inve^tiTig malig-
nant tumors in tltc moulh, whieh have mode their way throu^^h
irom tlic neek. Duiing un exanunation, the patient said there
76
TUG FACE,
liad been of late a sli^lit di«clt;ir<,'t; of fluid into tlie mouth;
iuhI, on making a Careful inapct^tioo, a minute aperture wm
detected nt the point wlierc tlic- la^^t tituW tuoth iirul ^jtxa
removed.
t)n introducing a probe nt Ihia point, a jet of eenim, miKcd
with tiakea of Innph, was projci'tcd to Q, considerable dis-
tam-e, I immediately enlar^'cd the opening with the knife,
80 llittt I could intruduce the fin^'er. Thid wua a ninlter of
aorao ditficultj, however, oa Uie patienl*s jflwa had been for
a long time nearly closed in consefjuencc of the liiseaeei The
finder pcnctnilcil into a lar;;c aac, extending far out of reach :
and, on investigatLon, it aoozi bccnmc evident that the whole
tumor wna fitrmcd by the cipnnsion of the jaw, irom the de-
velopment within it of an ininicndc cyet. On withdrawinp: the
finger, a harrier of bone was felt, citcnding iicroaa the jaw;
and behind it, under the first molar tooth, another amnllei' sac
waa discovered.
I now decided to treat thia case in a mmiiar monner to
the preceding one- An obl^^ng piece of about aa inch in
length and half nn inoh in width wuh removed* by eciaaora, from
tlic wall of tlio cjfit ; and with a fiogcr of one hand in the
mouth, and a finger of tho other on the outside of the face,
the pidea of the cji^t were bn>ken down, giving way under the
preeaure like i>arehrncnt, witli a crepitating noiac- The pro-
jection of the tumor on ^ic face, oa well bb within the mouth,
became in i\ great measure cfJiiced. There was a alight but un-
important clfupion of blood. The patient returned home, under
ihc eliargc of hid physician, with the intention of pursuing
pretty much the same eourec aa wafl adopted in the former in-
atan'.'c. On account t»f hia age, and the debility aiiised by the
want of proper nouriahiuL-nt. owing to tiie diHieidty of ma^tica-
laon, he was ordered tonics and a nutritious diet.
About four weeks hitcr, I saw him npnin, K very thing had
irone on well : the tumor was not more tiian a fourth iis larcrc
as formerly, and oeaitication had commenced In the wnlU of the
eac. His health was witaderfully inipr*)Vedt and hia complexion
bad tiaf^umed a iiealthy hue.
Dec. ^, l^G3, 1 caw him foi' the third timci ao altered for
cirsTic TUMOns of the jaw.
77
the hotter its scari-cly to be rcco;;ri>JZ^ ae tho Pfiinc peraon-
The jnw cxtcvnsilly hiwi resuiue^l iis nitural *Lape ; antl, cii ex-
muinatioii with tliQ fiDi^er, its Jislini^tive anatomiciJ markg and
pi"o<:csses ccmld be felt. On llic iosidc of the jaw, wliore
the incieiop hiid been ni(ule, n. deej> eulcua w;w3 obeervcd, lim:d
mitli mueoiis uieiubrano. Into which a probe could be paseod
into the asccndinj^ emiulw. There was no diechargo to he de-
tf^eted, nml tlie jiowf?r of mai^ticalian wns as ^od as ever. The
only troubJo he experiecced. was from the lody;iotnt of fooil m
thli cavity.
Three months Inter, ho wna spoti with the ja\v til a porferfly
healtliy condili^'D, performinif nil ila fuiit'tiona ; and ihi? only
cbunge frum tho nornjal «tate Mviu^ {icthnpr^t u tiu^tre soVid and
somewhat tiiickened condition than natunil, witli tho aulcue
oxUlio^ at tho har.'k part, whcro tho liimor had ou^nnatod.
In I8CII>, he modo me a rii^itf ^ he s^ud, to show tlie com-
plete auccess of the operation.
Cash XLV. — Cyeiu: Tumor of the Upper Jam. — A young
lady* 16 years of age, of EngUeh parcnUi™c, wne brought to mo,
in May, 1805, on account uf n. innior which Imd been develop-
ing for the liLtit tlircc yenra in tiic alvcohia of the right u[j|ier
jaw, jtlBt alx>vc the cnnlnc and bicuapid leclh. Three years
)re, the nerve of the canine tooth had been dcetroyod by
lie, and tlic eorious cavity tilled with i^ohl ; the tir^t bieue-
pid being aho filloil at the same time. Jrrimtinn soon coni-
mtmecd at the roots of theae teeth ; aod grv-diiidiv, and aliuoat
imporcoptibly, il flwcllin;; appeared there, A month before slie
came to me, this lamor opeo'rd at it« moat dependent part,
di^chnrging a glairy fluid, which eontinucd to oKudo until I &aw
the COM.
Tho aperture admitted ft small probe, which penctnitod into
u deep, eniootL tavity. With the fin^'cr, the tumor from below
appoarL?d linn; but, when prce^s^d upon under the gum, a de-
gree of elasticity wtus distin^uii^hcd.
1 infornic"! the piirent^ of the young lady, that tho rliseaee was
A ey^tie tuinor of tlto bone, and advised on o|>nrntion. This
wad utiflcntod to. Th^ [kutiont waa ethcriEodj and a cut made
78
TMK FACE,
iotu tlie tumor. The mucuus niembruTie wan ihen ilUsectin)
up from ite Harfoce, so aa to expii^e so niiicli of tlie houy
sm jLrt w*)i(M iwlmit nf n free opcmii<; bein^ matle mtci it ; and
a portion of tbe l»onc waB romovetl with Hciissora. Tbc finger
ciHild now lie passed frwly into tlie cnvity, which was rpjilc
smoritlj^ancl (entirely lined wi(h tnenibnine: itwriw not ponctiatod
by the roots of any of the mljicent te*^tlu The cjivity ^M^a
8tiifti:Hl with lintj iq order t^ excite i]kf1:LUiiMutory action, lor
the piirpoae of oM[teratirg the sae.
The operation haul all the eflecT thjit ciiulil have been iWireil.
In the caurw of u. eou[>le of i[ionlhf*, g^nulations filled up the
the cavityT entirely oblilerating it.
k^he was complcltly relieved of the dij^^yisc.
One or two oilier canes of cysts in tlic upper jaw, I have
ite*\ in tlie same way, with a similar result.
Case XL VI. — U^tnoval of ih*'. Lower Jaw far a Cf/stic
T^nior* Snlist'fpti^vl Lii/'ttuff of f/n' Oiimtid AHen/. —
Mra. W., a widow, 49 years old, had had the wifulom tooth of
tlie riLilit flide of the lower Jaw eslraeted aljimt twelve yeara
l)efiire I ^nw her: the soel^et remained ijuite gore fur some tiiae
afler the reinovnl of tlie tooth. 813 years after, the angle of
thn jiiw iwgan to enlttrge ; stud the bone jjnwiuilly expandeil
80 aa to form a tumoi' the size <if a hen'» i^^^, which eneroacLed
upon the cavity of the mouth, and displaced tiie tongue and
other orgjine. The tumor was slightly elastic to tlic toueh, and
had t)ecome a little t<^ndpr on pressure; with this cxcepdim,
there was no pain* and no ineoovenienee in niiLstiealiou. Tlie
disease involved the an^Ie and azricending ramus of the jaw, and
extended forwimls as far as llic second bicuspid tooth.
March 30, 18GI, the portion of the lower jaw beliiiid tlie
second bicuf^pid was removed in the nenal maoner, though when
the bone waa seized with ^t^oug forceps, in onlcr to raise It from
iltt itdltcsions to the surrounding [jnrtH, uu tl^e application of u
very slight degree of force it gave way, imd disclosed the fact,
that the whole angle, the u^cendiog ramus, and the proeesses of
ihc jaw, bnd become rediiccil to a sac or cyst conlniuing a thick
yellu^v tluid> The opcratli^u waa liEUalicd, lor the mott part, by
CYSTIC TUMOnS OF THE JAW.
79
tlio finn:er? ; nn<l t>n? lintrual nerve, which lay close upon the inner
surface of the tumiir^ wna iliaaeeted out lind saved. Seventl vea-
eela were tied ; and the ed^^ of the wound were brought to-
gether by siituresi, three of which were plueoiJ inside the iiiniKh.
No aeverc eonsfitutiond disturbuncc followed the operation ;
and oil the third dny tJie wound wiie nenHy united. Two dnya
Int^r, the fnce Bwcllcd. and the wound bc*^an te discharge jura.
In the coiirse of anoihcr fintnight, the w^oiind hiid healpil, with
the exeeptioTi of n jtmnll opening at its lower an<rle. On tlio
17ih of April, fl alight hemorrhage, of jwrhsipa two ounces,
look phiCf from thiti opening; ?md on the niijhl of the !^7ih,
^^IkcJi iIkt palionl ha<l ho fiir rei!o\cre(J fniiEi die operation as to
think of ^Diny home, profuHe bleeding ocfiurred, which was
widi difticaltj c<in[ro]li?il by a pponge and conipreAses. Ou the
2nt}if il becjinie evident ibat the hemorrbagc could not be con-
trolled, by even the muBt careful phigging of tUe wonnd ; and
the ligature of tin? cwrolid artery hcemcil to offer the only
chance of saving life. The paiierl was therefiire etherised, ntid
iJie ^pongCH removed frum tlie wound. The finger pnsseil
ri'adily from the external aperture, corres|>ontling in poaitii^n to
ihc iingle ijf rhe emutd jaw, H8 far iv\ the <rlenijid cavity of the
teiiUHira] lir>ne, which iVIt nmgli and cjiriou^. Pressure upon
tlie carotid urtery of the ntTccied side diminished the bleeding,
but did not entirely check i[ ; and no <^eater clfnet fallowed
llie com|»re6»iion of botli cariitids, Tlie arteiy wiis tied nl the
middle of the neck, after a Homcwhat tcdioua dj8scctiunf owing
to the atleuiatoua atale of the tissues- A slight oozing of
hloiKl cimtinucd ; but it wn^ ejwily nrresled by forcing a picre
of sponge deep Juttt the wound i[i the direcLion of the blceiliiig
TPs^elti, On reruovin^' the patient to her bed, it was notit*ed
that the side of the body opposite to that upon which the Jirtery
had been tieil haul become completely paralyzed. The pitndy-
ais gradu&Uy diimuidied us tho strength of the patient im-
proved; nnd, on the Htb of May, the ligiilure of the carotid
come uway. The sjjongea bad been pi-evioualy renn^ved fnim
th& wotind, which bcnied ni.pidiy. An dweesa, ivhicb fornml
behind the ear, did not dehiy ihe ciii'e ; and, oti dte 24tb of
May, the piitjciit w.m dirti^hurgod, cured, hut «till F^omewhat
focblc.
ft) THE FACE.
It Jihoulfl have been remarked, that, pnor lo commencing tltc
opcrati^m on the jaw, it had l;ccn dcci<lo<l to unci>ver tfic tumor,
and, if the cvnt was found hut partially to occu|>y the }>onc, to
remove a portion of it without rcnioilng ilie whole bone. It
wai4 evident, however, as eoon a^ the tumor was expo,«ed, thnt
all the bony tisHue had dli^appeared ; and it^ place had lxtci»iJic
occupied hy a thin and almost tranq>arent oy^t, of the con^int-
cney of jiarchment, the eoronoid and condyloid processes milk-
ing a part of it. The removal of the whole bone was lliorefiirc
|«rfonned.
The effects of the lipiture of the carotid were quite rcmark-
ahle' The current of blood was suflioienlly chcckeil lo nlhtw
of effectual plugging, which lM.'fore would not stem the cur-
rent of hloor]. The effect on the bmin was certainly very
itin^lari A hemiple^^ic affection, three or four days afjer the
nature of the carotid, is not uncommon ; arisiniTt probiihly,
from an inflammatory action taking place in the ^^ubstance of
the brain. In the prewnt ini^tancc, the [>am[y«is was imruL'di-
atc, and musl have ariaeo from the sudden dimimilion at' the
supply of blood to the brain, following upon the great drain to
which the system had been subjected a few days before.
The patient has been heard from lately, having perfectly re-
cjjvered her healthp
Can<"EUol's Tumor-s- — Cancerous tumors of the jaw pre-
nent all the ehiiracteristicB of that growth as seen el^^euhcrc ;
nor are they very rare. They arc more fiequently foinid in
connection with the upjier than tlie lower jaw, and generally
commence in the antrum. Being concealed within the bime,
th<^y otlt^n make tlicJr way into the nnsal passages, nnd iucrensu
to a eonniilerablc size before they nppear through the bone ex-
ternally; and for this reason it is difhcult in the earlier sta;^C3
to decide whether the disease i* malignant : when, however, the
tumor has protruded l)eyond the wfilla of the antrum, and when
it is nituiitcd in the lower jaw, the diagnosis U less difficiilt,
Tvfi> or three cjibos are jrivcn in illuatration : —
CAKCEItOUS TDMORS.
81
Case XLVII. — Ttemoiud of the Upps^r MtimUary 3one^
— Mrs, G., aged 41^ years, njiplioJ to me in Septombor, 1857,
for ft tumor of the left upper jaw-bone. She was a einull,
tliin woman, of a <Ielicatc conBtitutioTi, and eoraewliat salUw
primplejcion. She knew of no hcveditiuy dUpoaitiou to cnncer.
She w."V8 the mother «f severfJ ehildrcn.
For Uireo yeora ahe had perceived a AUncee of the cheek-
bone, anj there was nt tlie sftnie time a elicit nnd conatant
dfschnrgt" t'fum th*- noiitrU of ihul side. TliL^ continued, and
the f^welling inci'ensed, until July, 1857, when eho Buffered so
nnieii from it, tliac her physician jiuneturoj ihe antrum, after
hiiving extrflotod a tooth. At the time tliete was a elight hem-
orrhage \ but diree ^f^y^ afterwanla a copious diftcharge of pua
tDiik pluec, which continued in varying qunntitles. Wlien tlie
discharge wag etiudJ, there wna much fulness nnci pressure about
the antrum, which wa* reliovoiJ hy an increweed flow.
Thtf whulo upper jaw-bone si^Qtnt'd to be enlarged. The
tumor bad not made its way into the mouth, but seemed dis-
poned to do so into the cheek, die integuments of wbiili were
reddened and a Httlo d.-dematous, I aJvised an operation as
iiffonling the only ehance for relief from auffering, thou^rh iia
ultimate siicc&^ was doubtful ; letting her nnd her friends
understand fully its advantages and dJead vantages. It was
that the operation ahoulJ be drme.
"waa performed in the usual mauoer, aa has been before
related, the palatine bono and soft palate being preaerved. In
depressing the botie after ili^ attachment hai] been divided, a
|)orlion at its posterior part was found adherenij and wna left
attjiciied to tlie pterygoid pn.icess so jis Lo recjuire removal by
the chiGel. This circumstance I have, once or twice, seen
happen in removijl of the superior maxillary hone ; the natiiifil
fidhesion of tlic part being almost increased tn anchylusis hy the
inflammatory action, which had been g<"Ug on lu its neiylibor-
hood. It la of so frequent occurence, that it might be well in
every ease, as recommendeil by Dr. J. C Warren, to pass a
chisel beliind the bone, and loosen it hy two or three blows ef
the mallet.
She had a very good recovery, and returned home about three
11
82
THE FACE.
weeks after the £>|icrution in i^ocd. health anJ spirita- 8hc con-
tinued well tor 0, time, but La6, 1 believe, aincc had a return q£
the didcitaop
Case XL VIII, - — Mafignnni Discosg of the Upper Jaw,
Hcn/ovaL — In April, 1S5£!, Mrs. N. M. applicJ to me for a
tumor wUicli hnd csi^tctl uboitt five months. It coninicnced
a few wet'kfl before the hirth of a diiM. The tumor occupied
nearly the whole of the upper masiUarv, prcsaing tlown the
pnlatc, cxtciifhng from the root of the cnninc Imek to (Lc lost
molar. Extcrnolij, the swelling otcnflcJ quite back to the
car. The whole bony margin of the erbit waa lo^t, ami its plaee
supplied by an irrc^Iur BwcUing. The pupil was turned up-
wards. No tumor couhl be perceived in the nostril. The skin
(jver the tumor was movable, but tcnae and gloiS^y* Tkcro
\xang DO doubt in re^'ard to the D]aUp:iant nature of tlia disease,
an operation waa decidod upon.
Tiie incisions were maclc & little differently from thoi^c I Imvo
ueuuUy pi-actiscdf on aeeoimt of tlic e:^tcnsion of the disease so
far bjtekwarda. The first iticiaion coninKiOced midway be-
tween the orbit and auditory paaaagc, nnd cstcndcd in a Keuii-
circular form lo tlic angle of the mouthy with fi \cry bri>a<l,
backward awcep \ iont^yid of commencing' juet back of the oriji-
tar pro<7fes i»f tlic superior nmsilhuy. In dei>rc9fliiig the bone^
aitar the u^ual divisions, the hngcrs were useJ, as it was so
dGgoaaratcd by tlio disease as not to nllow a firm hold with for-
cope- After removol> it was found that tbe concer had pene-
trated into the pterygoid fossa. Tlua waa scooped out Willi the
fingers^ end a hot iron applied.
The eye regained its nutural position, and the wound healed
without unpleasant symptorasp In a fortnight she left the Hos-
pital, and returned homo,
Case XLIX. — Ilemovtd of half of Lower Ja^e for Cflrt-
cer.— Ja.mes W,, 50 years of age, apph'cd to me in the early
part of September, lSo9, for a tumor about tlio size of a hen^a
eg*r» oecupying the angle and horizontnl [tait of the right j?idG
of^ the lower jaw. The disease had commeneed twelve years
c-ucrcRors ttmoe*. >o
[tvriooslT, with % umahoes^ in the jaw* fi>11oweil hj sirellm^.
Three vcftn brioK, the pAm in Lt became oxce7^ivi\ when an
upenmg irmc made viih a lanoet. and a di^^han;e ot' duid ii>ok
place, anendcd with relief.
H hen 1 saw him, the outlines of i)ie jaw had dUuppeared :
and the place wa* occnpied bv a $niiX>th. n^und, slicU-liko luiuvir-
whkh extended from the canine toc-th backwards. Hfini; a Utile
upon the ramus of the jaw. The tumor projooccil inwanl?:. prv^s-
in^ upon the tongue, lUiing up ihe palate, nud iib^inioiiriL: aUhie
ooe-dilrd of the apertare of the tauee?. Hi* health w;i^ ptvttv
good- He auflbreil princi[tallv from the ob^iruotion to do^lti^
tition, and the affection of the \oice. The di^'a^e thu^ far did
not KCm to hare invaded the ^^1^ parti.
There appearetif thcrefure. to bo no quc^tii^n a^ to the prik-
prie^ of its removal: the onlv di.»iiht wa^, whethL*r to rvmi»vc
the jaw at the articulalion. or .*aw off the b^^ne just WIow. The
prine-ipal objection to di^nrlii^ulatiim, where the tumor is lar^e.
b the division of more or ]e^^ of the lihiun^it^i of the fai-iol
nerve. The objections to sawing off tlie Kmc in ii:^ a^oendinj;
ramiu, given bv some surgeim;?, is, that the rouiaiiiin^ fra^iu-iit
is dnkwn forward bv the pten'*j'i*id muscles, and aftovwanls pni-
duces irritation. This I have not found to lii>ld gitM in praciii'e.
In this case it was decided to disarticulate, the opcnitiitn boin^r
performed as in previous eases- While continuing the dissceiiim,
however, after the facinl arterv had been cut ancl ti*-*!. it wa* cut
a second time, although the inei->iiuis were not canieil any fur-
ther below than before. The tutnor luul lifteil it out of place.
1 ruention this fact to show Imw the best concerteil phui may
be frustrated by the anatuuiieal di?iphieenient of the [kuIs, in-
duced by the growth of tumors in tlicir ni"ijrhboHn»od. The
flow of blood wa^ arrcste<l at unee : tlie patient lieenmc quite
faint, and was obliged to Ijo phireil in the horixoutal position tor
a few moments. This is worth mentioning, as it so ran'Iy
oocurs in tlic course of r-urgical O|)0rations whci-o the patient
iff kept up by the stimulus of the ether; ami, preWous to the
introduction of that agcjit, it pnibahly occiiriXHl Jis otieu fnmi
the exhaustion of the system by jmiu, as from the loss ot bloinL
Tlic [*cparatiou and di^arlieulation of the diseased portion waa
completed as usual.
84
THH FACE-
He hnr^ w^arcely a htid Bjmpttun ; ami tin? wound vtis nlmost
entirclj^ ii«iled ut tlie eiiJ of two wunkrt, wln^n he kft Uiwti.
On makiuir a gectlon of the tumor, with tlie saw, the jnw
wjis fotJTHi expanded into a shell, the Ciontent^ Iwlng a soft gray
ni*».iter-
It mny lie worth mentioning, that, in dejir&saing the jhw for
difiarticulation* fllthcu^h dune with great care, the ramus jijutly
gave way in the timior; at^ainst whit^h oixurrence a mution ]&
given in rtome works on siirgerj. TJie faciiil nervu, und, m*
fiir IIS could he siAt^ertsined, the pjinitid duct, eeeinetl ti> have
e?iea[)t^d thi^ Iririrtions; llic drssectlor for thtr di?i3utM^ulHtii>n of
the Inmc b^ing^ itiadu aa fur ji^ pos.^ihJi: i'mm the iaaidt, uJler the
tnmor wtu sufHelcritlj freed frum the aoR: p&rta.
FiBRODS TcMOttS. — Fihroas toiiiora on the jaw are rare,
thoLigh they occur here more frequently t}ian on other honen.
As dcBcnbed by Paget, tliey are round orovul, lohidateil, dcnae,
ami heavy. Tliey are almost uniformly while, and oecaaionidly
contain minute spiculre of bone.
Cask Jj. —~ Hemoml ixf iht*. Upper Maxilhtrij liitint /tir
J^tliious Turi/'fi\ — In the eujruoer uf I8o7, 1 wiia re<[ue«lt'd
by Dr. Edward Reynolds to visit with him, in consfultation, &
patient '^ho w;La Budevin^' fmni an afTeetion of tlie left upper
jawbom;. Some months befure, the disease liad commenced by
an irritation in the ueighborhood of the left laehryuiji] pitft^age,
which priKluceil an oljstruction ami an overflow of tears. Tfiia
VfKs fuDowtfd hy au mcreaae in size of the upjier maKillary bone :
doaUy, an apeiture ap^ieared in the alveolar proeesH of one of
the molar teeth, through whii^h there waa r discharge of blood.
In the lefV noaCiil. there wil^ a polyploid luuujr ; cuid fliere had
been one or two bleedings from this puiuL A probe vMm passed
into the opening In the mouth, whioh penetrated deep into the
niaxllUry sinua, and waa followed by a free diachurge iff blood,
The patient being rather low in health, imd propuain^ to make
a visit to her trieudf^ in Muiue* I provided her with iuBtnictioue ;
and ahe agreed to sec uc u^iu Li ttic courae ui' tlm^ or four
wcek&.
FlBROUe TUMOIiS.
85
At tho oxpirnlion of the time n|>p3iTit*?d, she returned to Hos-
lOD, improved in hcilth. The tuinor in tbo noslril, however,
had increusod, aa well as ihe diateutlon of tliD maxilliirj ebufe ;
sutd Hte haul Budbjvd From one or two aeverG hcmoiThagea>
thiriog lliG following week, a bleeding of ho Hcvere a nnlura
took place, aa to render it necessary to bavc some iictive sur-
gical procedure nt onee ndopted.
Befurc Tiiiiking my decidon, 1 pnssf^rl a finger into the nostril,
whi(?h dist'losed ii Isir^ro opening into the nuisilliiry sjnns, from
which the tumnr in tbo nose fiecmwl to have projctled. Tlie
Jaw, in tho neighbf>rhood of tho upnTturc in tlie mouih, hiid,
avice the laj*t esnnuuation, three weeks befurc, been more or
Itaa forced downwards into a rounded elnattc tumor. These cir-
cumstances left little doubt tliJil the maxilUiry sinus was occu-
pied by a tumor which wag gradua-Uy forcing Uself out from the
bonv cnvity in which it had originated. 1 advised, tlierefore,
fm immediute o[>crfttion.
The operative procedure was ns ti^unl, and occupieil nbont ten
Tninutes, The hemorrhage wus not exceeaive, and the veaaela
were easily secured. The edges of the wound were aj ore« ap-
proxiniAted by sutures; and a bit of lint, moistened with cold
water, hiiil over the surfaee-
No linl, bits of epongc, Dr other substances^ as recommended
by some of the French surgeon*, for filling up the cavity made
by the rernovrd of ihe jaw, were used in this, or the other ca*ea
in which 1 have done the o]>eratiou. Wlieuever I have seen
tbcm u*«I, they have been the source of much urrtntion, have
been with difficulty removed, and liavD enused a mo&t otfenalvG
odor, from the retention of fold secretions in the mouth.
She recovered fully and entirely ^ and now, at tbe end E)F
nearly nine ycars^ T have hcaifl of her In tJ»e enjoyment of goml
be^ilth- The eye siLffcred no injury from the operaliun-
The tumor was of a fibrona character, and wiw completely
bounded by its c^ip.*ule. In its expansion, it had at first nearly
oljlilcratral the lachrymal passage ; next, it had proilurtid an.
abnorptLon of the hone, in thi^ vicinity of the noittril, iorcijkg ita
way thningh into timt cavity; and, (inally, it was making
Ita way dowawank through the bone into the back jiart o\* the
inou
di.
86
THE FACE.
The oj'ienition was aa effectual anil auLiafaiitt^ry ia its result iia
g.uy one of this dcacriplioiJ that I have ever dune or witnesaud,
Apparent TrMons of tfie Lower Jaw^ recottdart to
THE ItESrOVAL OF Ca^'CER OF THE LlT. — It ifl aumetiiiiCH
neceasar/ to remove a part of iJie jaw for oilier Jiseases tliau
ttLDiora oF the bone. Tumprs which take tlieir origin in tlie
Yicinity of the bone Homctiines gi'ow around and envelop it so
as lo necefi^jt;ite kd rcuioviJ.
AlWr Laving exaiuiaed a firm and a[ip^irt^nllj ojsseous tumor.
of the lower jaw, anJ after Laving fiillj decided on an opcvatiim
foi its removal, I linvc often htcn surprised to Icam thiit tlie
pjiiicut hud, A year or two before, heen operated on for cancer
of the lip. On rritically queatioiiiug luLUf I have discovered
time tlie tuiuur had origiuat<;d, not hi tJie jaw lleclf but under
lU in the position of the aubniaxillarj gland, and increased,
tmlil Hnidly, embracing the bone Jind becoming adherent, it
coLtld not be d let! ngiue lied from the bone iLscir.
Caag LL — Ti^mor ^imiltting Canccroue Diseaee of the
Pttrviid, itccomjMtiiitil imfh Famfi/^is. — 1 hiivc ^jcen lately
conaulted by a ■j;enl]cijian wlio had a liatd tumor growing ju^t
helilud hia ear, of a year's atanding. It citenJeJ under the
jiiw ; was very firm, almost like bone; aud appeared to bo
tlic parotid in a Atate of Qiali;^'nant didciiae. The eide of hie
foc'e was paralysed; and aUo, curioLis to relate, there waa a
Blight |i:indyais of tlie left arm, the tumor being on tlic right
side of the body. 1 found, on investigation, that a few months
belore tlie commencement of the preeeut tumor, a cancer of the
lip, of some yeurfl' duration, had been removed from the left
fiide-
Case LH. — T^pwr, involving iht Jaw, oacurritrj njltr
Htnwval of Ca/tcer of the hip. — ^A gentleman it8 years of
age was politely referred to nic for odricc, by Dr. Gilinnn,
of Portland, for a tuuior abL>ut as large as a email orange, grow-
ing from the lower and outer cdi^e of the jjiw, on the left aide,
concealing Ujc auglc^ and extending backwards so au to pres;^
TUHOES SECOXDART TO CASCER OF LIP. SI
Upon the gnat \es^h of the neck, and partially lo inteHorc with
the tiacheft. The inner aspect of the jaw wa.< qiiiic nonnal, lliuI
rhc teeth were eviJcTnIv not involvcJ. It feh like an cxost^^^-ij?.
and had the regidor form characrori^tio of a cystic tumor of
the bone : it was, however, pertoctly tirm, ami had nono i^i' tho
ela^ticitv of the latter kind of ^ruwih. I had ^oillotL in my
own mind, that ii was of a bt^uy natiiro. whun tlio |>;uiciu ti^d
me that it had be^un, about a year l>efoi'e, tis a small. iu<n-ul»]c
tumor in the situation of tlio ^ubm:L\iltary gland \ and that it
hxul not become fixed until after cighi months* and had then
taken on a rapid growth. He also ^idil, that, four yeari^
before, he had submitted to a jiniluEiLred operation, by meatus <»f
eancer jdasters applied dally for i^evend weeks, fur a ^-Jiru-er
of the lip, of whieh a scar 5till rcmainM rather to the riirlit of
the median line. On a^eertainiu^ this faet, the Inmur was a^ain
examined; and it was found, that. \iy exerting niueh foive. a
flight movement upon the jaw coiihl bo prinhieeib The patient
Tvas therefore informed, in iw ilclieate a manner as iHi>filile, i>f
the nature of the disease, and that an operation miirht K* per-
formed for the removal of the tuinor, either alone, or w:lh a
portion of the jaw, whieh would Ik? a nmeh less ditfirnlt ami
bloody affair : the danger of reciiri'enee would of course n-maiu.
lie widely coneludcii, however, on aeeonnt of his a^^e and Ins
entire immunity from jiain, as well as troni the danger of recur-
rence, not to have It Jntertcred ivhh.
Case LITI. — An old gentleman, 7*> years of a<fc. wa*i
brought to the Mu^saohu^eIts General Ihispital, with a tumor
of the right side of the horizontal part of tlie lower jaw, oi'
about the size of a pigci>n'g e^^^'. It was 6rm]y attached, atul
Gccmed to fonn a part of the iHiiie, and so far painful as to iu^
duce him to rccpjest its removal. It had eonnneneed at ifie
lower and inner edge. Upon inf[uiry, 1 touncl that he had bi.'eii
operated on for cancer of the li[) a few months befoi-e the
growth had appeai'cd. I informed him of tho probable nnluru
of the disease, and of the Jan^^er of recurrence after n'moval.
He decided to have an operation pcrfornicib Aeeoriliji^irly,
the portion of jaw involved in the tumor wud removed. The
ss
THE FACE.
diflcaae, on examinatiou, vras Found to be cancerous, and firmij
embraced the bone, although by c^rctul diaact-tiun it tould be
cntin^lj aoparatix] Erom it, inclLiding, howcror, the pcrioatoum*
The Icrminolion of this case was intcrcstrng. After the |>a-
tient hw\ ivcovereU ft'om tbc ether, he got up and insisted on
walking downtitairaf which he did with the aid. at' two persona,
one on c^icb ttidc of him* Just ne he arrived at hia hedside* he
beeamc suddenly tiuntn Tho nttcndnnts come running upiatairai
and inforujed me that the patient waa in a dying state; and, on
going instantly to him, I t\mnd tUal respiration had ceased, and
that tbc pulaatiuna of the heart were scarcely pcrecptihJc. The
mouth wue imnicdJatcly opened, and the finder parsed down the
throat, in order to allow tbc entrance of air into the larynx:
it was then found that the tongue had heeomc retrovcrted from
the xiarlial dL-tjiehrnont ol" tioiiie of itd muselcti, and bad retracted
down the throat* It was at once seized with forceps, and dra^vn
out of the mouth, and means taken to produce arlifieial reapi-
ration, as in ca^ea of drowning ; an<i cventuJilly respiration and
the circidiition were restored. The patient did well for a time }
but, at the end of about a week, he was seized with thoracic
ayniptoiDS of wliich he died.
NECiioaia of tub Jaw. — Necrowa of the jaw-hone is
eomctinies caused by arBcnious acid, uaed to destroy the ncrro
of a tooth i at others, hy phosphorus; bIho by the depre^eing
effects of cold; and now and then we bcc it occur without any
«peciHc euusc.
The use of oi'scnic, introdueed into the cuvity of a, carioua
tooth, Jiaa hccn very estcueivcly Allowed, for the purpose of
prodiiein;^ a aluu^'h of tlie pulp, and thua admitting of tlic
flubaequcut preatrvation of die tooth hy filling. Unlesa care-
flilJy protceted by uii:tture witli uiorpliia, to dull scudibility,
tbc pain is otlcn of the ujodt excrueiatLjig eliuructcr ; but, with
the btuuiuhin;^ cflect of tliia agent, tlic cselinnjtic action g'Ji^
on, in many easca* uaheLded. in one or two instances in
whieh this agent boa been lucd, and allowed to remtun
for too great a length of time, or el^e from eouic peculiarity
of eonalitutioii, principally in persons of scrofulous diathesis
NBCROdlS or THE JAW.
89
imd of JowTitolity, 1 have acen very ocverc effects prodnccd;
iho cauterizing action not only destroying tlic vitality of tho
tooth, but going liirtLcr, pofgiUy by ub^urptioiiT Qi^^ produQing
catteneivo necrosis of Ujo alveolar procceBcs, ulraoat oa great in
llie upper jnw as we ace in the lower from tlie effects of
iJiospliorutJ. In one ease, a Jciicato young \adjj whom I enw
in conedEAtion with Dr. N. C> Koop, of Boeton, to whom she
|»pJic<l for Julvicc. li/uJ eufierc<l extensive Jestraction of the
processes of one side of tlie upper jaw, cnu^edf fta was
(Htppoacdr by arsenic applied by a donti^t and left too long in tho
cavity- The foUovrin;; case I aaw la consultation with Dr. £.
T- Wilson, Jnn. 3, ia65.
Case LIV. — JVecroAis of Upper JitttJ arisinf/ from the
ZTfC <'J^ Arsrnioifs Acid*^A young married lody^ of scrofuloua
habit, lind arsenic introduced Into the right bieti^pid tooth of
the upper jaw, whore it wad left over niglit, cnusing great auf-
fcnnx- Tho tooth had been aRcrwoi'dt^ hJedi but was olwaja
the touree of more or leati imtroginoae* Aloul three years after,
elie hftil a long and debilitating illness, at the end of which fihe
fotmO ihot tJjie toothy together with one or two of Its noigh-
bora, waa<|uttc loose, — ao loose, in fact, that she removed them
with her fingers. On applying to Dr. Wilson, ho foutul that
the alveolar proocesee were in a stato of ticerosis, and re<|ucstGd
loy advice witli regard to an operatioa. The guxos had receded
quite exteuaively, leaving a largo piece of jaw dead, and in a
svo^t oflbneive condition. On seizing the bone, I found it so
iinnly fixed tliat 1 a^Iviacd againet any immediate o]>eration.
Dr. W, agreed to give her a detergent wash of tnnuin ond
veofloie, aad tct await tho farther loosening of the bone- I
aftcrwarib loaiiicd that it eoparated piccofncol.
Dr. Wilson itiforms me, that, whenever bo usee the oraenie, he
alwaye applies it in the niorniog, so as to watch ita action, and
removoii it before night; most of the aecidenta having been
mu^ed by npplviiig it one day, and allowing it to remain until
the next before removal.
In another case, a young Imly liiid a bicuspid tooth filled by
a dentist, the nervo having been first destroyed by arsenic left
12
90
THE FACE.
in over night. Six tnonths after, Iicr face swelled, iind nii ab-
Hcess formed at the root of the tooth which was estraeteil,
the alveolar proceas ooming out witli it in a state of necrosis.
Aftcrwanis othex pieces oF bone came away from the jaw in
the vi[?imty.
Her face looked puffy ; and she had conaiitutional symptoms,
such BJi HWelling of the alxloraen, and great losa of strength.
Many of the teeth in the npppr jaw hccajne bo loose that tbey
might have beeo extracted with the fingers. She was a very
handsome person, of fine physieal development, and had ft
licjuitilal set of teeth ^ and, before the use of the araenle, bad
alwuyK hjid good health-
1 have Heen other similar easea; but those given above will
eerve to ifhistrate the alfcctioQ.
Cahe LV. — ^^ecrnsis of half of Tjower Jav^ from Phospho-
TUft. — A young woman, 19 yeara old, entered the Hotipital on
the 91)th Februaty, 1800, for necrosis of the jaw of five mooths'
Btflinling. She ha^l lieen an operative in a matr,'h facUiry fijr two
yeaJs, and her employment waa to pack the matches in paper.
Five months before, an abscess formed under the posterior part
yt? the jaw, bebind the angle ; and, from this spot, there wns Jt
discharge of offensive pus. Denuded bone was detected in this
situation- On the 7ih of Mnrch, she was etheri^ied \ and a hit
of bone an inch long, and two amnller pieces, were removed-
On tlie 25th of April, she was ii^ain eiheiizeJ, and the cheek
kid freely opeo, exposing most of the jaw, which was found
("ornplclely dead but finn. (^n the I'ifltli of Afay, a finid opera-
tion was pertbriue*!. The bone wjia finuly seized by a pjwerful
pair of forceps, worked gently, for some time, to and fro ; and,
finally, a portion of the body and the whole of the ramus were
removed. On the I'lh of June, the wound was closing rapid-
ly; and new buiic was foniKl to bo forming in the phice of that
which had Ijcen lost, tlii^ processes being well maikeih This
pjitient remained some time aftemArdA in the Ilospit:d, acting
VLA nurse. The woun*! graibially healed, aurl she waa left with
(jLite a well-formed jaw, serviceahlc for all purposes. T «ab-
Beijuently saw her, Bonie years ailerwards, m the lull enjoyment
of health.
NECEOSIS OF THE JAW,
91
C-SSE LVI. — Necrosis of the Loii^r Jan\ from tJiP^ EffscU of
Cold. — A joung lady 25 years of nge, in moderjitoly good
lii^aldi, nbout tlic middle of September, 1859, waltod over
SomJi-Bo^ton Bridge with her fnce eicpused to a very bipfh wind-
Almost imraeclintoly, she began to feel an uneaeinosa in the
right tide of the lower jaw. This increased, accompsnied with
fiwelling of the ja;uin. After some weeks, the aecond mi>]iu-
tooth was removed, being completely lr>03eaed and detnched
from lis fiock(>t. The disease extended fnrward. At the same
lime, the leil knee hcgan to swell, and r ooplona ofi^aion of
seriiTik took place into the joint.
At the lime of my visit, I found her confined to the soft hy
the trouble in the knee, and in a very nervouB and highly ap-
j>rehensive condition. On oiamination of the jaw, the canine
tooth and those behind it» with The e^treption of the hwt molar,
were looi^e. Passing a proh^i into one of the numonjiia openings
whit'h exirttEi.1 in front, the alveolar portion uf the jnw was
found denuded ; and the prohe, at one point, passtHl ijuite
tliruiigh it- A alight swelling appeared below the jnw.
As she was auffering no pain, and the bone wad atill rjinte
firm, T did mit advise any immcnliate o[M:Tatioii. She wjia n^L-om-
m<"ii[lwl to take wine, and as mnoh nonrishniont aA the Htnniiii'h
could well bear, consistently with her confinement, and to have
All attempt mailc to remove tfie (lead bone as soon ha it seemed
luuKcned from its attachments.
Thia Wits al^rwardd done hy her physiciaji, and she completely
re<y)vered, •
Case L\TI» — Necmslt of Lovrcr Jaw, fnmh Ejjyosmx to
Cold, while, under great Menial Dcifrcssion. — A man 49 yeai^
of age entered the lloapitid, March 10, I3^fi, with a necroais
of tlie rigljt eide of lower jaw, extending from beyond the
symphjBifl to the aoglc-
Inflummation and awellin^ had commenced in the jaw, after
cxpofinre at a fimeraJ, while autlcrmg from want of foed, and
under great mental depression. Moat of the teeth hail dropped
ouU tliL^re was a very otfeneive dUchargc, and lua health waa
much aJlccted.
92
Tilt FACE.
I removefl the whtUe of the jnw in n necrosod NUite, Iravmg
the pprkiBteum at tliis fliUea, Biul a thin riui oi' iiew-tViniiwi hime
on tte lijwer eJg^.
The iucisor tecLh rcmaiitcf] Ioopc in tliR ;^ima, tKelr nwte pro-
jecting inti* tlie cavity left l»y ihc reinuvel bone-
I saw Uiid iBflu t»n the last of May, eiitii-ely recovered. Kcw
bone was deposited in iLc place of tlie olil, whidi lie (.-ould Lee
in tlic mELstiealion of mtxlerately hard J^ubt^tanees. TLu iuciaor
teeth huJ bei^ome pretty firmly CxL-d lu tJieir pliicoa.
TRE TONQUH.
Ca^e LVIII. — En^ijsttd Ttimor under the Towgur., re-
Ecmhiiiitf Itmiula. — Tlip tumor iirdcr the tongue CidW rnitii-
la, whether it be a dilatation of the salivary duct or a distinct
tumor, Is alw&ya troublec^ome in treatment. I tried, ibr a
number of jeare, DupuyLreu'fl method of a pcrmiineut button,
wLich, though eflect*jal, has the iIismtI vantage af requiring to
be pcruianent. Pt^riiitps exeieion of a |)ortion of the ^ae, and
the free a]i]i]iciLt]on of the tincture of io^line to the interior,
if this be found neoei^ary, is aa good as any prsA^tiee. Tlio
fbJlovfing ca^ of lumor urder the ton<rue U interesting, as
resembling this difiea^i whicli I huve fri^qucnUy seen of great
size, and fonuinj^ a tuuior on tlie side of the reek. It ivas, how-
ever, in thia ci^cc, [ilai;i;d in the ujediau Une, and, a.s suun as tlin
operation was commenced, was found to be a dilTerenL afftelion.
When I first mlw this patient, *od opening bin moulli, it
**emcii tu Le entirely iilltd with a. greatly enlarged lougue,
Ou iarllier inspection, the ttjugiie was found cro;vdtd Into tlie
back ^mrt of tlic faucee. An daatic tumor occupied the mouth,
and eileiided beneatii the jaw, njipeai^ing in the neek. The
patient was 25 years of age, a [jaiiitei' by trude ; and tlie tumor
hud been of eeven yeara^ growth.
Tliie large sac was completely dissected out, with alight
hemorrhage. Its contents were aeid, while colored, and of ihn
^onsifitenee of cream. An Indannnatory action followed, pro^
dueing hoarseness and difficult deglutition; tlud lasted a week
Qt too daysi and he viiXA entirety ^vcll at the end of a fortnight.
J
Tira TONOUB-
03
Cape LtX, — Cancer of TontfUG, MemGVftl. Bccurrence.
JJctUhw — A ^'Cntlcman, 30 years of n*je, cnllcd on mo about
the year 1850, on tn^count of a Avhito film under ihc Iwick part
of hifl toD^e, on the n^ht eide. It Imd tbt^ rippcaronce of
mucous membrane wfiich liad been touclicii by nitrato of eilver,
ujv} turned wliitc; but the ed^ce wcro moro perfectly dc6no<l.
He was nervous nbout it and wi^liM its removal, feiirin^ that it
mi^bt become cancei-oua, I disflectc*! it Harmfully off from the
loDgUQ ; and ho IniJ no trouble for q nunxbor of yciira* In L8i>5,
on my return &om abroad, I found a smoJl ulcer at the spot
from whicli the dLfioaee had been removed. He did not acnil for
m« till about eix mcnthg aflerwiLrds, when the ton^c was ^oLdly
tixcdt and pervaded by a cancerous inftltruljon. Ho wos in a
tnoet deplorable condition : the saliva was eonstaatly running
out of bia mouth, duglutitlon ^va» ditticultf and the pcun at times
jfory severe. The disease gradually extended down \\i& throrit,
finally opened a large-sized vessel, when n jiroftiae hemor-
iOOOurrt?d, which was checked by a gflffile of a strong solu-
perchloride of iron. He was pfradually exhausted by
lose of blood, and finally died in an anaamic condition.
Tins ca^e is curious from the manner in whicli it commenced,
nithcut ulceration and as a riimjilo wliite deposit. I have lately
4&ccn another ca^g with white dcpoait on one eide of the moutli,
and extensive cancer of the gums on the other, brou^^ht on hj
cxccssjTG use of tobacco. In regard to operations Rir cancer
of the ton^e, I can simply say, they are genernlly unsiicccpe-
fiil. As to the method of operating, I formerly need hgatui-cfi,
rarely the knife ; but of late years the iScraseur.
Case LX. — Solid Encysted Tumor of the Tonrjite^ He-
fnttvnl. — Oct. 12, 18-17, a pliysician of Worccater brought
to my house a patient ^\'ith a tumor on the end of hia tongue*
It was about as largo as a filbert ; on the tip was an ulcer the
eize of a poa. The timior wa* first noticed seven wooke before,
ttnd die ulceration two weeke. There was no pain nor tonJer-
nesE.
Passing a |iotntod knife behind tlic tumor, I made an incision
around the left side, whoD the pressure of the knife caused tho
u
TIEE FACE,
eecnpc, through the ulcerated apcrtiu'e. of a solid red eubataace,
like a fiiuJI cherry. The ujjcration wa^ ccmplfteJ by an iu-
ciaion on tho right side, by winch a. cyst ivaa removed, wltli a
eicinll portion of the tongue.
The cy^t resembled those ao frequeatly met nith in the sub-
Btance of this organ . The aolid tumor appeared to be organized,
nad not nudignant ; yet its connection with the cndoaiug cyst
niuet have been very slight, cs a moderate preeaurc cspcllcd it.
A etitch was employed, aail the pntjcnt went home the eume
day. He had been in the habit of chewing tobacco.
In another instance of a solid tumor aitiiiitcil in the centre of
the tongue, a ?*implc incu^ion wsib made over the top of it, when
a BmolJ, hard, iibroua tuinor waa ehot out, having, apparently,
acnrccly any connection with ita envelopes,
I haye alao eeen a tumor, in thla situation, apparently of a
ffttty nature.
SALITART CALCUTiDS*
Case LXI. — Ldercntui.^ Cane of Salivaty Cahxiius, —
An Euglish gentleman, 40 yeara of age, applied to inc. in
Angur*t, 18h")D, on account of a very painful enliu-gement and
jiillaunuation of the lell submaxillary gland, attended with on
ubticesa behind it, wliicli discliarged through the duct under tlie
tongue; a &midl quantity of pna alao eacaplng tliroiigli tlie
gInnJ and integument. The inflammation of the gland came on
two years before^ after eipoaure to cold. Subec<]uently, and
alter much autfering, two email caJeuh were extracted from the
duct in tlie mouth. This gave temporary relief. The pain
however, in the gland and whole of the neck, continued, some-
times of the most agomaiag description ; aflecCing the eyatem,
and keeping him from hia employment. AppUcatLons of iodine
and other rcmcdica had afforded no relief.
It wrta with great difficulty, that the aperture iri the mouth,
through which the pua wna discharged, could he brougiit into
vicwf aa it lay far back, and was obscured by the tongue ; but
by [ihicing him in a atrong light, holding the tongue to one
sidci and rcqucaling him to preaa ihc glaud up, pufi was accn to
&ALTVAKT OALODLU!
95
le from it. A probe waa lasmuated into tliia opening ; but it
□nt of Hut^cient siy.G to eervc rs a. guide to tlje knlte. An
utrUioQ jL>vvnw^aiila wns tbcref'ure miwle clone to the jitw, until
the pua flowed ixccly. This opening abortl/ closed np, and the
operation rcrjuired to be repealed. In the meiin time, it wns
inijxjs^ible lo iiiiikc the etliglite^t examinntiL>n of the gland exter-
nally, the touch ofthe probe gave such ejtqalfiite pain.
UnHcr the influence of ether, a semilunar iuciaion waa made
over itti surface, exposing the indurated aud hlghlj inflamed
glnadp The blood gushed out at once trota the wbole eurfueei
iring it, and requiring some delay in the diesectlon, A
I aperture svos l<>und at some distance from the opening in
, which would admit a line probe into an almost callous
ranftl bcncnth iho gland. With much care aud great difliculty
the ehc of the probea waa graduidlv increased, until a director
could be introduced. Thia being a little curved, and turned
in an upward direction, encountered ft resistance which at first
appeared lo be bone, but was fin;dly aaecrtaiued to be a cakuJue.
A finger was introduced into the throat and under tlie tongue,
nnil preaBure mode on the outside ; but no hard eubat4inee could
anywhere be distinguished » The only means left, therefore,
Bccucd to be by penetrating to It throoirb the hard deposit. By
caretijl touehcs of the knife, and dilatation with the sci^^eors,
an aperture waa finally made hirgc enough to admit of the intro-
duclion of a email pair of ]>ulyj ma-forceps, hr which the atone
was broken up, und withdrawn pieeeiucid. TJie enlargement of
the aperture by the scieaora, by intrudueing thorn shut anil with-
drawing llicm ^>artly open, was followed by a guah of blood,
which continued to flow for aome tijuc, as if from the Avouud
of a larjro vGs^l ; and, it being impoflsjblc to reach the deep
origin of the bleeding, a bit of sponge waa crowded down into
the cavity, as soon as the calculus wad removed, aud arre^itcd the
flow of bloodi This being removed, after a few minutea
tile bleeding' recurretl, but suddenly stopped. Aa a matter t>f
precaution, and in order to keep the wound open to permit a
free discharge, tbc d^iungc was replnceJ.
From tliia time ho ^ulually recovered ; and now, at the cud
of aeven yoore, remains veil.
CnArTER UL
THE NECK-
FORElO]ir BODIES IN THE Aia-PASaADElS.
De» Qross, die (Jislin^iahml Profeaaor of Surgery in tbe
Univemty of PenupjUanlii, :tu{\ surj^uon at tlie Pennaylvania
Hu^plLilt has dtyijG nHire thnn any other pL'raon, in hia work
with the djOYC title, La illuHtrate tLif^ ^lubject, as he haa all
otiier Bubjecte in fiurgery.
It 18 well known, that operations on the trachea ar« always of
ti Btiirtliiig ch:ir:ir(tr, iind re<|uire gre^t pkilJ and |)]'oiii[Jt action
on llie part of a surgeon, to save life ; whether it J* for the re-
moval of a forifigu body, for craup, or for the other inflam-
matory al1k.iioas of t)ilt4 organ.
In tlie tatter instances, the surgeon is ol\en called upon,
without any previous preparation, jutssiUy in the midille of
lite niglit, witliout asslstanee, and with a bad iitrht, to perform
one of llic most critiLiid O]ierntion8 in sor^p^ry ; tlie paiienL gasp-
ing for breatli, and dependent on the exertion of the utmost
skill for life.
Froio the great difficulty in respiration, die nock is generally
crowded with \enoua hlood, the free flow of wliich uheciirea the
inciftione i and, on the Um^liea being opeueil, it \a apt to ^n^h
into the ali^pitBt-nges, and eurtooate the [Kitient, If tiie surgeon
hesitates, on die other liand, &nd waits to secure the vessels,
death may oa:ur before tl«e traofiea is rcat'lifd. Fortunately,
in must ini*tjini:efi, iis suou as tlie lur cnlcra freply info tho
Imi^i^a, tho con<;i^Rtion in the veiua id rchevtid, and tht bleeding
Tbe dingnoHis of the existence of a foreign body in the traeltea
or iu tlie Ijronchua, altbougb at iirvt it would seein not to be
FOItEION BODIES IN THE AIR-P.4SftAnEB» ^1
tttteodcKl wilh muoli difficulty, ia often very obftyure. Tliid is
particularly tlie ca?e in youti^ iufjiuta, and in cliildren of
four or £ve ycnre of a^e. On ita fir^t introducLion, there is
usually groat ohokin^^ and violent in'itntion of the air-piLBsoj^.
After a time, Lowevor, if the aubstance sink d'^wn into the
lungs, these symptoms dieiipjiear ; and it tfi then necessary
to look tor niiftlher cla^s of phenomena upon wluch to burie
an opinion. These tonaiet, in the first plricc, of didnoss on
percuJiiaion of the nifuoced side; eecondt ^f more or lees dim^
inutifm of tho rc^spiralory murmur, according; ns a larger or
ftmaller hi-onobiid tubo i^ ohetnictod; thW, of more or less
biMDchi^l and suhcropiLunt r^ea ; bat these niny be observed
equjilly on tlie sound side of the ehe^t, bein^ provoked by the
general irritiUion of those organa. The diiignoaia ■beeoines
iu<*re diHieult uhere the palient has had a prevltins broucfiial
didturbiuicc, or has been exposed to the whooping-cough c>r
mcjules, nil of whic^h compl lent ion** I biive hnd orrasion to wit-
ness. The importance of a correct diaguosia is verygreiit; for,
if an 0[>erMtion be deferreJ, the aubaciinee may suddenly be
atHrt«d from its hidin^f-phtce. and di-iven up into ilie glottw^
caualng death hefcic any help can he ohtninpd.
Tho following page* contain the euh^caiice of reraarka on this
subject, in a condeQfied form, publfahcd in the *' Host on ^loili-
eal and Surgical Journal" for 1«47, and referred to in I)r.
Grossed valuable work, with adJilional caee^ ! —
Oa8K LXTI. — Bf'/iti. in the LeJY liroiw/mii. — On Tue.'*-
day evening, Oct. 13, 1347, I wiia called to aee a little y^i'l,
eight years old. The same moming^ while laiighhig, a common
giirdcn hesm waa dra^vn into the trachea. At first she was
tuKU'ly sutlopatetK Oradnnlly the cciigh and atrngglcs l>ei"ame
less violent ; nnd during a ride of four or five miles nlmrmt
entire tranJioillity in the respiration wart reatorwl. After ;in
hour or two rhe difliculry of breatliing refnrncil, nnd finally
bei^ame so laborious that the* parent.^, being ajamicd. dotor-
mined to brin»^ her immediately to lloaton-
I saw her nt 7 oVlock, r.M. The countenance was pale,
nilher livid, and expreBaed great nnjciely. On nny elnin^e of
lb
98
TH£ NECK.
position, a eou^b waa produced, attended vrilh the ejection of a
quantity uf mut^us. On auscultation ol' ttiG bsLck of the cli&Bt,
tl]G Pound of the natunil rcApirfttion waa much obscured by a
\in\t\ niu<?oiifl role : in front, the rile wiia very bud on the ri^hi
fiile; l)Ul, an tho Ic^, the sounds of respiration and the riles
were, in a ^TOiit measure, wauling. On percuasion, the left siilo
wiie a tittle Matter than the ri^ht. There wus no aound, either
in the lungs or tnit^hea, to indicate the movement of a foKigti
body. The voice waa hiiaky, as in croup.
Ill view of the above symptoms, I haJ no doubt that tlie
foreijjTi body was lodged in the loft bronclms, and advised
the following eoiirae: First, in order to ascertain if the Bub-
etanoo was movablOf aud likely to ascend towiirds the larynx,
that tbe'cluld should be suspended with the head down^A-ards^
the throat irritated, and [lercussion laitde on tlie chest. Second,
if the Bubstiuicc could he made to fall into the trathea by these
nicaiiB, to perform the opemtion of triidieotomy.
The first proposal was carried into ertect. Tho ehikl was
taken by the legs, and held with the head downwards; then,
pajiBing my finger into the throat, I carried it quite below and
behind the epiglottis, so as to induce etrong effort?* to vomit.
Percussion of the chest waa abo practised.
The proceaa above described was twice repeated without avidl.
A (Treat cjuaniity of mncus was brought up by cougliing; but
no siraiimdation was induced, nor other symptom to indicate it
change of position in the foreign body- Quiet was now en*
joincdj and an opiate in ca*e of gre:LC irritation.
The following night wn5 passed quietly, nnd only disturbed
by one fit of coughing. These attacks were produced hy the
slightest men tfJ or physical e^ccitement. The rules were sliglitly
increjised.
In consultation, it waa concluded as folhiws : —
1st, That the great want of success attending the oporatton
of opening the inr-pa9sages, and sean'hiiig tor foreign hfnlicJ*»
iirising from the ii'ritubllity of llie parlti, aud the consequent
diHiculty of manceuvring instruments, did not render an imiue-
diale op(*rat]ou desirahlcf particularly as the patient was com-
piu-ativcly ea&y, and the danger not pressing.
FOTteiGH BODIES IN THE ATR-FA8SAOES>
99
»
2<K Tlint the spnnliLDeoua expult^urn of these bodies was nut
3<1, ll' sTmptomg of etran^jlation came nn, to npcTaXt; imme-
It \Ta& tlelermmcil tu give llie diikl nn emedc [>f iikh-Im!., as
roRsiderahle febrile aolion wsw present, and tlie effitrt of vomit-
ing might possihij move the forei^ hady. This was done with
much relief to the breathir<r, hut without causing mty change in
the ^iluatiort of the niihsNinL-e.
On the morning of the 15tb, I found her quite as cotnforlrtlilc
80 on the dnv previoiiii.
Abinil 4 u'cliurk in the afternoon. T waacnlletl in hjistc. In u
p«rti:iysm of mental excitement, proflnced by the mothi^r's inking
Imve uf her, tlie bean was huddenly iljj-enga i^kI , ixntl brought
on etrad^ilalirm. When I nrrived, she waa almost pshmistcd ;
iJie fai^e waa hvid, and she wa-S writhing in di^IrL-aa, like a j>eraou
h&Ying a cord tied tightJy around the nei!k>
I IniineilmteTy prcx^eeded to open the Irncliea. The skin anil
m|)erliciaJ fificiit being divided, nnfl the tliyrctid plexna <jf veins
avoids or lied, b^ I waa Beparating the sierno-hyijid and Bterno-
tlijriiid iiiiiscles, il Huddon cniek vmin^ heard, Jia if m\nc [lortion
of the lung hml given way, Thia wan imniedi:ilely f^jllowtnl by
an ^nphyHema of the cellular tnembntne in the neigbborh(»od of
tJie wound; and a smiLlI tnmor, filled with air, waa foreed up
ont of die chest, on the left aide and in front of the tmcheu, at
each movement of inspinition, A niitif^^ation of the dialrcrw in
breathing Mbiwwl tliifl occurrence. The tumor waa now bold
bark with a spatLiIa, a^^d a fihar[*-pcinted bisttinry plunged
into ihe tniehea. Tlie bran vvjih neen greatly swidleii, uioviiig
ugi and dowii in the tmciieid pass^age, ami eomplelely lilling
its ealihre* The edges of the tnn'bea being m-paniied^ the
be-jin wan seized with some dldirultyT uu account of ile soft-
Dees, and withdrawn. Sha iinmediatelyf od die concrlusicm of
die oprraiion, fell iiito a inoM profound sleep,
Tlic hean bati swollen to more than duuble Its original tizc.
On ineitsurcinent, it was aiiicertamed to he twu-tliird:i of au iuub
in length :itKl half an inch in hrejukh.
The patient reca\ercd without any biul couaequcncea.
lf»0
THE NECK.
lieiiifirlcs. — Tbe rupture in tlic idr-pn^sriffeB did not preserit
any aiilis4?f|uont aymptomd which cotild bo referred to ihcsQ or-
gtuiB, and therefbre there must bo aome hosiintion in deciding
u[Km the eefll uf thi^ accident. In fJl probnbility, it look placo
at the root of the Jun^; hi one of llie Urger hroucliiid tubes,
and the nir made its way out of the clicst without impliealio;^
the jilcunil citvity. A Hiinllar rupture I once before observed
in croup, — the neck and whole ?^ide of the chest becoming
eiupbjscmatous, willi on inimediute relief to the breathings
aa iQ the preeeat cs.bc.
Sulwequenlly, having procured some garden boans of a simi-
lar kind lo the one removed, I immersed them in wiiter of the
tcmper'Ature of the body and found tbat in forty-eight hours
thoy were inrrcnsod in bulk to more thnu double^ and aorue to
treble, the nnliirnl ni/e. This flbowa that wlien suhstanees whieh
may Ijeeunie enhirgwl by the heat and mniHture of the body are
Inlnrtlut^ed into llie air-paBBBgea, no hope can be enterULined t^f
their spontaneouB eiipnlsion. In euch cases, operadcin should
not he delayed.
I aaw ihis patient fifieen years afterwanle, grown to a lar^,
fine-looking womjm. 8ho hrul never exjkerieneed any ineoa-
venieoee from the ctfecta of the jux-ideal or the operutioo-
Case LXIU. — IhrsG-sUoc J^ail in tht Jironc/ius. Spon-
taneous J^jspulsion. — On May 10, 1816, n little boy, be-
tween two and tln'cc yours old, was brought to me with a nail
In its luQgs. Tlie aceouiit girea was oa follows : —
Three weeka before, the child came into the hou^o from a
bhickamith'a ehop in tlio neighborhood, from which ho had lately
ix)en forbidden by hie mother. In order to punleh him for his
didol)C[Ucncc, alio took biin in hei' ^.i-nip, and eet him down iu a
chair with some violence. ilc wua immediately tici^^cJ wirh
ehohin^^ unil with u violent cou^h. Aa i^oon as he could an^wer^
he ^^aid that it wa^^ cfiueed by % nail in big mouth.
The eou^h for a time sulpaided, but shortly returned with some
attendant iiiHamroatory sympt^tma of the luiigs, which luj^tcil a
week. At the end of thut period, Eks the child waa lyin^* over
ft chur, with its hum] hiLngini^ downwardSf a sudden ducking
70BEIGN BODIE8 IK TIIS AlTl-PAfiH AGES . 101
noiM wu heard, ae if a Bubatanco Imd been thrown up into t}ic
windpipe^ and was at once followed hy a praroxyt^m of euffoca-
tion which nearly destroyed bim- He wua placed in a sittiog
posture, and the obstruction was shortly rentoved.
He had twice had similar attacks, always couiiTi^r on when the
head wm in a dependent position. In the intervals, he Imd a
hoftree congh, and also had night-sweats, loss of appetite, and
emaciation.
In this Btat« I saw him. ilo was rapidly failing from the
irritation of the lungs-
Hie signs, on auscultation, were as follows ; The whole chest
was flatter than natural on percussion. On both eidos a loud
mucus rale was heard, ratlier moro marked on the \ch than on
the right side, but not sufiicient to determine with prcei^iion in
what part of the lungs the substance was imbedded.
In the course of six days, he had four nttiicks of snflbcjition
from the dislodgement of the foreign body, which ro»^c into tlio
trachea. The lost attack came on wliilc he was at dinner,
and so suddenly that he fell back as if he had been shot, and
waa with great difficulty recovered.
Being now fully satisfied of the presence of a forcij^n sub-
stance in the air-passnges, I detcrnuned to perform the ojicnUion
of tracheotomy, and directed his falhor to be sent for. Tfiid
was on Friday ; and the time appoiiitefl for the operation was
tha ensuing Monday, as the earliest date at whicli the father
could reach the city.
The following course had been marked out : —
The child being firmly bound to a board, to make an opening
Into the trachea, just above tltc sternum, with the hope that, iji
consequence of the irritation thiia produced, the foreign sub^
stance would be forced up, and present itself at the orifice of the
wound. If this did not h^ipjicni to invert the boily, which, in all
probability, would cause its dislodgcnicnt, and tliuu it might
pass through tlic epiglottis, the ^'iolence of tlie spasm of that
organ having subsided ; or, at any rate, it might be extracted
through the wound.
The preparations having been mode, on the d.ay appointed for
the operation, ten drops of laudanum were given in divided
102
THE NECK.
1T08W, m (ir<Ier to produce aa mrirh quiet an po^silile iluring
the tliseettion of the neck nnd opi'ning of tlie win(I[i[[K?- Pro-
vioufl tu its performnnctit T pn^eeded to mnke n liisC cxaminatLon
of the (^hest, sinil, inui^h to niy surprise, found tliiit llie TUUi'iUJ*
riilc HjuI alitiost entirely disnppojired. TTih mother snid, :djii>,
thjLt the congli hnil hoen miirh Jefi^ for the Ijist two dity^, iind
there had bcM?n no reeiirronee of suffocation since tlie violent at-
Ijick of Fridny- Under thf?a« cln.'UinsI.ini'eH, it waa det'ldcfl lo
invert the hotW before opening the windpipe. Tliis waa mo*t
thoroughly trieJ, and the faucea repeatedly irritated liy jiaHsiny;
A qiirll down the thncit^ Imt withiiut E-ffiM't- The opemtiori, of
course, was not peraihled iu ; and, in fijct, from tliitt lime he be-
gan to improve in health , mul fully recovered.
I henrd from liim some months Jiftenvards. He was in good
health,
JiejtJtirhjt. — 'The Apparent mystery connected with this case
BeemH to be explained in the following luiinner : ■ —
To quefltiniis M to ci re um stances attendant on the hist p:ir-
oxyflm of suffoenlior, the mother Hsiid^ that, while he hiy on the
fiooT*, aa t^he thought iJead, she seized witli her lingers the tough
flud stringy miieu-j protruding fmni his mouth, aud^ when pull-
ing on it, it t^eeuied to unwiud from a body in the throat;
— that oti Saturday and Sunday, the two following days, the
child suffered from severe paina in the bowels, which were rc-
lieve<l nt night by a powerful fiee:d discharge, forty-eigbt houra
after the nCtal^k of RulToeation. It m highly probahle, therefore,
that the nail, rolled up in the tough, adhesive niucua, was
thrown up into the lar}Tis, completely obstimctiug its paswigo ;
and that the mother, by pulling on the muena, jKirrially detaebed
k from the nail, and finally dragged the latter into iho throat,
whence it wna Bwnllowed, and ultimately disehiirged iti the
evAcuationa.
Case LXTV. — A Bit of Birch BarJc in Lf/f Bronchna.
Olfli tt^ed Ei(/ht Years. BarifntjoioTnif on the 'SiXfeenih
i>fit/- Vaiti Alfempts at Extraction. Death at the End of
a ^fotitfi and a Half after the jiiccideut. Injlnmntation
of (he Lef Liing and Bleiira. — Nov, 2C, 1850, a girl eight
VOKKm^ IIODIKS IN THE AIIt-PASPAGES-
lort
^ears old, wliile diewin^ n liit nl^ birch bark, let U *I[p into tlie
win^Ipipp- Th(! nc-f^ident wa* iii^^tiiLtly followed hy a paroAj*ni
uf fiin^hlni; and siilT5natii>n, wUii-li n.ntimunl tti rcnir at 'mter'
\ak for iieiu'ly a week. A eiiddeii thiin^^y in ilin [loiLkm t>C ilic
eiibstiint^e> rnj Hie 1 e^t of TJe'Ct-mbcr, was eucceedt^i] by il relurii of
siicli vIolcnL coiigliiikg and fitianvidutiou us in cxcitt? fvars in ni-
{^anl til ibi^ biiuiediattt result. At tin; end of the [luruxvsjiK tbc
Imi'lt -'iiaiKrd duwi] intu oner of llie bnmfbial lul^'a, viilli n miti-
gation of lIip severe syniptoms. I saw tlie i:bild Dec;. Dth, whoii
llie brealiiin^ vias iniiidi oppn.'rised, and elic Ijiid a rLiiistaiit dry
C4/ugli. fSliL' ]ui>ked ikag*;nrJ, aud ibc cuuQtt^iiiince li^id a IJvId
tue; llic *lun was bi>t and dry ; iJie pul*e one Inindred, and tic
Ap[>etite 1o8C. The Jcfl aide of thf olicdt was dulW, on j»riT.iis-
citjn, ibim thf.' riglit ; ued scarcely a re;?i[ii]~ntory iiiuruiur eoidd be
ilclecicd iu the (jijtlerior jitiit of tlit corret^pundin^^ lung ; llierc
were niueoua ralea on a level with llie bj(\ii'catiu« of ilie ti-acbea.
In fiunt, esjwcially above, the breathing was etJIl |ierf<frajtd,
tbooj^h vt-ry iet^bly. On tliu ri^dit side, the rospiriLtitin wiis
puerile. All dic^e circumstances dencled timt llie aub?^tanee was
lufl^eil Lii the left broiK'bi.d tubo.
Tfic foJIo^vmrr [ligbi, she bud anodier p.jrosyaiu of couching,
iduHDg ^ddcb the bark waa agaui dialodgcd, and pa^acd up
into tlic larynx. The u[.tai;k wne ultoiided with sligbt ejji-;(a\iF4,
Ldryii^otomy wlis performed Dec. I'Jtli, llie pationt beiii^' fully
etiieri/t'd. A pair of forceps, sU inches in teiigth^ and so con^
fltruetwl as to open only an inch at the end, waa then tarried
cIovTTi Into tbc left bronchial tube, but without graspjng iho
uflcndin*^ unbalance. The operation was tbricc repeated; tlie
Iiidtrun^ciit being; retjdncd each time about one minute, wiibout,
aji]>nreiitly, the slightest mconvenienee. She wa-s next fiu&pendeil
by the beds, und the tliroat irritated to provoke free vomiting,
but without avad. Finally, the abdomen waa compressed, fuhI
tlic air in the lungs euddenly iind violently expelled by the liands
apfdZed Lu the rliest. The clnld^ coo^iderably exIiausLed, was
|mt to beil, and tlic openin^r protected by a bit of gimze. She
fijul a quiet night, with less ooiigh ; and tliQ wound mouifesled a
(lisposiition to clu^c.
After ocvercd wccka, she waa taken hoiiiCi The coui^oetlon of
104
THE NEHK.
fli*) limjTs inrmist^l ; and the <isj)irod Jnn, 9, I Sfil, nearly n
tiHintli nftcr tito ojH.'nil!oii, Jiiid [lenrly il luuntli imd a liulf after
TliG riglil. limi!^ wns m n lipaltliy siale. TIip lff\. lung wiu*
dark-colored, pilteil on prt'Sdurc^ wuh finniy aLLiiclied to the ilia-
phriLgm, nnd exc^t^sively lomZeil witli hUu^d Hiid eerum. The
bnmdilid tiibefl were filled wilh iiiuco-[ninilcnt miiHer, and
those on the left siik were in a state of high inlhtinmation.
The (iftending body^ three-*|Uarter3 of an Inch lonij ami one
qnarter of an iudi wide, willi tlie ap|JcarH,^c^e of liein^ much
BwollenT wjw fuiind lying loose i!i lh(? irjtchea. It fiail ovirlenily
hcen ui"i.^iiIentaUy jiur^hfid up^ during the exatiiinfiriiNh frcuu the
leA. hroiicliial luhet where there were marks of itA having becii
Case LXV. — I3U o/ iVrti in Lf/i Bronckug. fiirl, aj/erl
I'^our Ytf<trs. I^irn/uf/ofoii/t/* ^j^cLion q//Ac Sktit (ind JittF'
fiH (iftt JV«^, fuUawi'.d htf ti fiifitrli TiU of tke. ShfU tit fhe fntl
of ti Jt-iu WTuethT. liecovcrt/.^In Apnl, If*.')!, I was i^allLil to
«cCt in conBLdtatioHf a chllil who, four day^ bcjore, had inhal<^I a
bit oP nuL. Slic waa ecLzed with violent fOUghiEig, paroij^iiis of
whii^h had continued to recur at interv-al3, At the time of njy
vifiit, her CDuntenmice was livid, hreathinv dif^iculti and her
Stien^h much iiujijilrcd. Aufic^ullatron le^calt^ n g^reiit dimi-
nution of tlio rej^piratury murmiu' iii the left luu^, with Mimo
r^es; while, on the ri^dit aide, it waa dietiuctty [aierile*
A« the ayniptimid wci'e urgent, the cri to-thyroid im^mhrane
wfia immethiUcly divided, whik tlic child was under tliu iuHucuce
of ether. A hougic» slightly bent, being passed into the left
brcjicldal tube, the iaubetm^ce waa readily dislodged, and the
pkiu and kernel of a nut were espullcd at lijt artificial o[)toiog.
After further search, under the auppopiLiou that part of tlie
offending body might fltill remain, tic o|x;nitiou was concluded,
and the child jiut to Jjcd.
Ua the tbllowing dwy, the patient waa doing well, and ap-
peared greatly relieved. The woaod healed rapidly, and she
waa soon aljle to go about. .Some cough, howcTer, remained,
uccoiLipatilcd witii a muGoua rule in the lefl lung.
FOREIGN BODlEa Df THK AIR-PASSAGES.
105
At tlie eiiil of ii few week*, tlic cliilcl eudiienly broiif^lit ii|i, ui
a ]>arf'Xj5m of C(iii;i;tiinrj, n eiuall bit of niit-slkcll. Ail the
evmpioms now d]dnj)jicaredi and abe rapidly regained ber
lic:i]tb.
Case LSVJ, — I^n in Larynx. SJ^ciion Into Throat
^tirinf/ Ofteration^ Denth, llu'rtrf-si'x hoiirn nj^encardg, from
^t/ioukIioh. — I v,-ii» ri'i|iiost(?d hy Dr. Patc^li, abnut tlie mid-
dle f'f ilie *hy, to f^ee ;i clilld, "liii, lie sard, was in n ttjile of
sufTocation from at pin in tlio windppp t ""^ whom, it was poa-
i« wo should licit find uVivs. JJc had heen c^llvd to it in
morning, ni nine o'clock, when the accident hsid tirst oc-
curreU; but, the sjbstiincG Inviu^ settled down into the lunijs,
and reliff beinjr obtained, nnd ihe doubt existing ds upual in
regard to the i'ncis of the eiu^e, lie left it for further obaerviaion.
The sym|jlonia having recurred, I waa called iQ- The child
was ibcn qnite bkck in tbe fnoe, partinll}' inaenj^ible, and Che
foreijrn body flying up and down in the trachea.
Tracheotomy wu3 ut once pcrforiuod, the dissection being
muoh embirratiiscd from the distension of the fat and short neck
willi veniiu? blood, Aa soon as ibo tracho.i was opened, the
apiuin uf tlie Inrj-nx subsided, and the foreign body seemed
lo dierippear. An instrument waa passed up into the mouth,
ami down to rhe bifurcvitiiin of the tmchen ; but no iraee of
it could he delected. When the blood had ptmscd into the
larvni, wmsing, as h always does, a severe paroxysm of cough-
ing, the pin had evidently been driven up intc the mouth, and
ewnlliitt-ed.
The cliild now slowly revived from the atnte of asphyxia; the
bTVaiMng hecaiYkc free and tranquil; ami, during tbc reniain-
fler £jf rhe dny, nnd the fnlloxving day, tliere vra/i no return
of ctiu*rh. He confimLnd, however, pule, ^nd withnni good re-
action; dying on lliG ni^ht of the second day, apparently from
the shock rereived by the aCL-ident* as we occasionally see in
|}ivtifnt4 recovered from drowning,
Case LXVII. — vl Oiinn of fTom In the Tradim.
OpcrriH'in. EjittftctiQii iif the. SuhsCance. Hccov^iry. — -In
ICG
THE NECR.
tlie Bpnng of 18C2, a clilld of about five yenrs of age was
broiiglit into the Hospital by jia nn>Ll»er, wlio smIjI llial, two dava
before, it had got a ^^raip of corn Into iLe wiiidpi[>ei TKe strug-
gle for life was, for a time, violent. Resort was liad to the U{*ual
meona cf relief; and respiration finally became ([uiet, lejiving
liiin much e^ihausted. Since tben, be had bt-en LoEtrac and
stuffed, but without any return of atmuguktlon- A subcrepi-
tant rflJc woa heard over the whale tJurfjLce of the lungs, on both
aidea; but rather grenter over the 1e(\ thim the rii^^bt Jung,
There was aUo greater abdeoce of resptratory sound on tlie left
aide.
On account of the danger of waiting, it wob determined to
try the following es peri t oca t ; —
The child* being ethen;ted, waty su^pcndtrd with llic liead down-
words, as in a former case, nnd ahaiply struck on tlic back, the
faucea being at the *ame time irriiated; but these efforts were
without cdcct ia dialodgtng the foreign Hubatnnce* The M\d
waa therefore retained in the house, and narrowly watched.
On the next day. the respiration waa eaaier; and he appeared
gentrally in a better condition, altitougb it was very difficult to
make an Lu vest i^i^al ion, on account of his eiccsflive timidity,
which, in children, is often a moat st-noua ob^staclc to diagnoeiSi
On the ne;tt day, the house-pupil reported that the night had been
<iuiet; buti on vi;?iiing him later, the molber infotnicd lue tliitt
he had aiiice iiatl an almost fatal attack of suffocation. In the
course of this attack, the child had brought up a good deal of
thick mucus, which she had dragged out from ita mouth with
her fiagers. I dccx<le<l at once to operate.
The child was etherized, and the traehca opened. On the
entrance of air and blood, the usual convulsive action resulted,
followed by the appearance of the kernel of corn at the aper-
ture, and its almost immediate expulsion. All the symptoms
were nt once relieved; aud the child went home well* ten days
after the opcriilion*
If the opcrntiun had been delaycdi the result would, in all
probability^ hire been fatal.
Gondii etoiis, — The following coaclusiona may be deduced
from a review of these and similar reooi"ded cases; —
totrart to Ike A— at «f
^aj mtoaumoe waxa m ma/am *»
of b^k fa» tbebnl nd ■iiTifii «r tW
^
I
2d« liGbAciJNCHM,«rtk»cMit«nbraadviderd»pv*-
nedin^ bead, vltca cB^agcd in dkc hf^Bx or Kod^vd m tibfr
Img^B, maij W trvsud vith more trnpunitr. If Sal. llicj «aCl^
nitf prg-Mttl aa cd^c to Uie Kobe, so a« to penail tkft ptiW^gi
of air oo dtbo- mIc When lo^cd in the Wo«ich«, nidi m
■■betABOc beooiiic«, after a liine, c&Tdopvd m iiNNrw, m> ■» to
«lMtr«cc tke fm act of rcspintion : il \b theQ farxxd nptrvd?,
«id, in tf>e etra^glc whicb ttisaa, the idim:u» U diACOgai^td^
Tbc bodj then frnDs back* aod mnains quRvomt ontil it ii£^
becovKS om«fed wiit cuira», wheo tlie proce«a of dblodgcanM
U i«pcaUed. Someliaies, m tlie liolcnt cou^h wbidi oeom wi iIm
dMngv of pUcc, it 15 forced out into tlie moulh, auiil QwaJJowtd
or ejected; ai otbere, bj comirg up stiddenlj, when tlir p*-
lieal'd uttenlioii ia diftr^cted, it tnkea tbe Urvnx by gurpnfic, ad
it were, »dJ easily e7ca|re^.
Au iDlere^Ing case of ihb Utter cJa.^ occurred in a little
^^irl* a |iatieat of Dr. ILde, on irhoui tmrheotumy -KtiJf \vf*
formn], by Dr, J, C, WarreD. fur tlie removul of llie wixxlvn
Btup[>crof an inbatanil, nhicli IukI been sucked into the imcfaea.
Am eooa aa thb pa^^a-re was opened. M irrilaliou suttfiOinl ;
the forci^ eub^tancc settled down !nU> die bn^nchu.^; nniJ al-
lliou<^ [lie wound wa« kept open a >veek» achl nttcuijUA mmle Eo
dlsJod^ it, they were wllbout avnJI. Some ukonlhif afterwanls,
319 the pftHcnl was lookijig out of ik wiuJcw, very intcnUj'
watching Lhe phasing of n milltnry company, the ML>p|rer catiio
up. without elFnrt. IdIu tlie Miotilh, nnd un^ lit ouce cji|>vUci].
3d, if the substance is fiitecl iu the bronchus, imJ the jmlicnt
TOting, tile pri>spcct of seizing it by in^trunieuts iiitrvKlticotl
through the wound, and carried down in the direction of tho
lungs, is cxircmeU- emidl- In Fact, I do not know of u sin^dc
iucceasful cnse upon reconl, with the exception of one in which
Mr. Liston opened the tmchea of an adnlt, nnd, introdui^ing the
forcepa with r:ome difficulty, seized a bone, whldi had booornc
engaged in the right bronchus.
108
THE NECK.
4lli, SoTOP flmibts will nrisp, liowever, us to flip propriety of
Ii^fiving, ill !iny cnsc, a fciroi^rn substance, fur n period of time, in
llie hinn;s^ wirliout an pfTitrl to remove it. For nltliough it mRj
finjilly become detaelied und he ejeetod, as ii freqiienilv is, nftct
rpmnining ninny niontlis or ye^irs imbedded iu ihe lun^rg, or
Btowal riway in [he lirom-hinl tiibp?, jet f:itJil orpinic lesions are
not iirn'oniiniinly llie re!*ulc. Tlie aurgciin muse therefore be
guided li_v llie ijnrtiouljir [■ircu]nsI:ini'eB of eni'h cnse.
It is reuiapLihle in how grejiT n nnmliei" of these casea^ whic*h
we lind ref](»rded a» hfivjn^ ot^urred in children^ tlie substance
introduced was a eominon giirdeii betui.
CROUP.
Tnirheotomy is also requirnd in m.iny cjisea of croup. About
twenly yenrs ngo, I openLTed several times in aueh eases, Ini-
inetliutP relief from muffooalion wiis obtjiined, iirul, liir n few
il'AVSf the result seemed iiiiikost ndminiloiid ; but the lun^ri hsid
become allectuil, und the powers of life so weakened tliiit the
iSnal result was futnl. An curlier performunee of the operation
waa neoetksm'y ; but, nt rh:Lt time, the public, ami even the pro-
fession, VkViX' riot I'linviiiced tbut (hi^re wn^ liltle or no dntigcr
unending it. J have never se^n a ease where denth eould be
;i3*.TilH'<l to it, Tracbeoiomv in croup wu,*- it'vived in BiinTou by
Dr, Geor^rc H. Gay; and llie praciice has bet^'n liilhnvi^d *uc-
cefcsfuliy by Urs. Surmtd Cubut, Ht^niy G. Clark, ojid oiany
other fiULgeon^ in Boston »nd elsewhere.
After tlie ii|ier!iliou, ihc- air tA' llie njoio should he kept warm
and moiht. A double cube sbuidd l»e omiI, and eouipek'nt per-
sons euiphiycd to wuteh tbe patient, aui3 remove the inner tube
in cjise of nbfllriictioru 1 )»ne no doubt ihat many lives luive
been lo&t for AvmU iif lliis prcTautluu. The tube ^uddeuly bc-
Cuinuig obstructed by thick, adhesive mucus, tbe patient is
teiiwd with ^iolcut Hvm|itiFins, and tbc alaruied parctJt:^ isKud for
uiedJcid aid ; but the pliyrtieian arrlvcfi uuly iu time to see ibe
ease terininiite, Mony of the deutlia which formerly took pLice
after tbe earlier opeialions fur eroup undoubtedly aro&c from
the wunt of die inner tube.
J
CltOCP. — TLAOiraOTOMT.
109
The following casee nre illustnitive of trndioutotuj'T as re-
quires] in eonic other aftisttions ; —
Case LXVTir. — I^crryngitis. Tntcheolomif. — A womain
jiln>ut 30 jpnrs of a^c cnmc into ihc llcis|utfll, in April, 1^^9,
UTMjor tlie cnrc of Or. J. B. .S» Jiick^^n. Slio had been eiif-
fcring for enrac tinya o|>inireiitly with n eevere co]d on ihe lim^,
and nuidi Konreencsp ; but no alarmin^j pymptoma apjieiireU till
ab<?ut tlie time of Dr *Jac^k5on> mortiiu'!: visit. He hrul just left
the builtfidc and croseeU the warj, when the nurgc called to him
lUat the pnlient wns aiLffijf^ittin^r. U|Min Glopfiiii;^ biick. he
foimd licr witli her face purple, preut dilficultv of breathing,
^Tilirc loss of voice, puldo (juick and fluctuating, the body
bnlbcd with cold sweat.
S^ntj the (Ifln^cr imminent, Im imin&lintch' Pent for me,
mnkin*f prepariitiuos himself to Jo the operation in cioe I was
Dot to be found. I received the mcsenf;;e as J wns enterinu^
the Hoppital, and proeceded nt once to ita jierformnnec, Wlicn
the firflt fneii^ions were mfide, the bhmd rusliwl out of the vessels,
txith Arteries nnJ vcina, of a color nonrly ob black ob ink- As
Boon as the tmchen wna opened Hnd the tube intr<.>Ji]eed. nfter
the firet violent clFort.-' vljii^'b ii^unlly accompany ihie proceeding
ht\*l eubsicJed, ehc bcgnn to bi"cntiie re^nlnrly anU freely, It wrva
five or ten inlnutefl, however, nfter the fi'ee entniTjeo of ivir,
before tbe blood iiHstimed it« natural vennilion eulur.
She wna very enrefully watehed ; nnU the inlcrnal tnbe rc-
inuvod nnd cleansed wlicnover the mucua became drjj and ob-
etrueteil its eannl.
She did reinarknhly well ; and, at ihe end of a week, ihc
tube was removed. She recovered her voice, and wns im^
proving very nipldlv, when phe arose in tbe ni^ht, and walked
into a cold n»oiu willi bnre feel, whieh produc-ed a slight return
of her trraibic, from which «ho Itad a slow convaleeeence. As
Dr- Jaek.^on remarked, in ihi^ enKc the patient seemed to bo
Ulerully enarebed from tbe jnwj# of deadi.
Case LXIX. — Tracheotomy. A Case in whiah ihe
Operation was repeated three times in itn Adult. — Uec. 17,
110
TIIE NECK.
1864. Jolin McK-, 50 years of ope, fislicrmnn. The follow-
ing is the suL>at!\nce of a letter, oirrjUln^ ibe case^ from Dr, H-
E, Davidson, of Gluucesler, MaasflcbuaettB : —
Three years r^o, <Tontnieted ft severe cold, ncpompaioied by
a ciUarrlml jiffeclion, wilh much obulructJon of the noetrila,
This wii3 fullowed by neorosis of the bones of the polate, from
wlitch exfoliulion afterwnrds took place. The following winter,
hortrflpnoss and imjiiurnient of voice cnme on, which continued
to increfise uolil June, when obstruction of breathirg occurred,
requiring the performance of tmebGotomy, which was done
July 22, I8{i3. This ntfonled eutire relief. For three weeks
after the operation, frequent apphcations of atrong ifolutjou
of nitrate of silver were made to the lurj'iii ; after which the
cnniiia waa retuovetl, as tKe breathing had become quite free
through the niitund jjassage.
On the r^eeoiid day of October foliowing, the patient was
seized with violent dyspiioin, threaieniii^r apeedy suffocfttion.
Traeheotomy wob again performed, affording instantaneous re-
lief.
The nitrate of silver was again used as before; nnd, in
November, 18fi3, he was taken to the IMasaachuaetts Geiienvl
Hospital, where he was submitted to laryn^otcopic e^famination,
but without detecting any other diffieully than inHammation of
the epiglottis. The continued use of tlio nitrate of silver wng
adv'ij-ed, together wiih the internal administration of the ioilide
of mercury, in small do^^es, Jan. I, lS(i4, the bvc.idiing had
become so free That the tube waa again removed.
In Au^st, \6iji, while engaged m filling off the coast of
M;ilne, tlie obstniction i*eturned ; rendering it neccs&arv for him
to hafiten home for relief by a third operation, which was per-
formed Ai.ig. 10, 18fi4. Since that date, he bos not been able
to do wnthout the tube,
Thie patient was a large, powerRd rono, and, with the eioep-
tion of the pre*(ent difltfulry, perfeeily heahhy. In speaking,
Le generjilly inserted a small cork in the orJiScc of the canula,
■which enabled him to articulate in a low, hoarse voiee. Any
attempt nt labor, however, produced great rlifficuhy of breath-
ing ; and It was for thie reason that he applied to me tor advice-
CROUP.
TRJlCHEOTOWT.
Ill
The qttesifon was, why clio pnssnge of nh tliron;rli ihe Uiyai
was not na free a« it h:td. boon nfter farmer operjiiong. The
tube, he sftiJ, did not cauee him the slightest unrfLsicess-
Thn iniin waa plappil in a stronLj siiiilin;Nt, nnd llic tube
removed, when it was Ibiind thnt gr^nulationa had shot irilo the
fenestmin, in The upper side of the ramxla, and had pnitially
obstnicted it ; the nperture heJnp, pviilf?ntly, too nenr tlie outer
end of the tul}e. The wholo tube wns now withdmwn, when b
fit of cougliing ensued, foHuwed by the pnijection inro the nper-
tore of two or three polypoid bodies, wliich were hanging down
into the traf^hpjt from tlie lower edge of the wound. These wore
Bwi'cej'sively >ieized, a.^ they wei-c foreed out during piiroxysms of
CMiughing, and retnoved. Another lube was now iutroduoed^ hav-
ing the fencstrnni on its upper Ride, at n ^rent:>r distance from the
shield; tio thnt the aperture wna wholly ineluded in the laryo^.
Re At oni'C breathed more freely, and spoke wilh a tlcnrer voice.
A few days after, this liiht; wati replaced by another, nijwie with-
out the fenestnmi, when he breathed equnlly well, the air pars-
ing on the outside of it. It seemed probable that the wound
h^ been irritated by contttet with the sharp eilgea of tlie
opening in the tidie, not only eausin*^ a crop of granulatiima
t» shoot inlti it, but prmludng also a ihii'keiiing of the parities
of the trachea, from the polypoid growths already referred to.
The shape of the present traehcnfomy tirfjes is generally de-
fective, the lube beting set too oblii|uely oii the bhield ; the fjiet
being forgotten, that it has to enter fir^t nearly In irizontally, und
then vertically. As originally made, they were thus angular in
form -J the present curved figjre biiving been adopted later,
in order tu adnut of the iDtroductiiui of the inner emiuhk. Of
the importance of this iimer movnhle tube, iD may be ir^tnured,
ihftt, in the present case, it had to be removed three limes a dayi
ilk order tu cle^jiL iiwuy the dried JtccLiiriulatiouci which obstruoL
its canal,
Dr, IL K- Oliver, at my request, made an investigjition of
the state of dte lar)'n:c, with the laryugiiseope, with the ful-
loiring rejiidt : In a gocul light, the whole interior of die larynx
ruuld be moHt diHtinetly seen. The vocal cords were both niueU
lliirkcned, and partiidly dianblcd in action, the cord on one t^ide
113
THE NECK.
overlnpping its fellow. Tli(^ jirylpmilil carlilii^jea were nlso ili.i-
ti)rtei]i aiiii muoli liLi|iedt^ la llidr mutioiid' The limzL gluttiilia
waa estremely iinrrow.
FORErON BODrcS IN TITE CESOPnAflUS.
Case LXX. — A Ceiti arrtstvd m th<^ (Empharius. Ex-
tractwif^ — A chilli two and w half \e^ira (ild ivns bron^IU to
nae *m Feb, IC, H35D, wlia, R>ur Jjijs befure* h;*(3 awallmvcd
one of tlie large olJ-la^lkioried centa; ond had not eince been
able tij tnlic ni\y ^olid fuixl, aod, In fiKt, nimost i-cKiided lo
Bwnllow any ibiiiij. The child waa finiily held in a elt(Jn^
po^dirci ltd held ciiiried back by an nasl^iitint, and a piece
of wood pliiced brlwecn the teeth- The fin^'er of tlie right
band WAS novr carried duwn llie thr";it, and nii attempt made
to dUcovcr the aituntion of the foreign body. The epaam
about the throat »nd Lrh^lti:^ wji3 very grcnt, the etni^'glcs of the
child were violent, and the respiration ulmust slopptd by the
explur^tiun. After aevcral attempts, during whieh the first
joint of ray forefinger was severely bitten, a trace of a nietnllio
aubstanre was di^oovcrcd, wliioh mi^'ht, hortcrcr, have bccti ono
of the e;trtila^ca of tlie iaryns- I deelded to make no further
allenipta that day; but to reaunie them on the next^ under the
influence of eliier,
On tlie fullosvitig day, being provided with eufiieicnt nsfliftt-
nnoe, nnd the patient being well eilierizcd, the forefinger of
the left hand waa parsed down the throaty while the teeth were
eeparated by n bit of cork; and^ aUer one or two efforta, by
preaein^ the larynx forward, the foreign Bulifitnnee could be juet
toirch&l by tiie end of the nail. Thie eifort it was very soon
neoof^aary to diacontiniic, oe it itn|*aUd the respiration. A long
curved fwlypus forcepa, very Hat and emooth, was now selected i
the furelin<ror of the left hand waa earricd down ils before ; and
tlie hirAiix being protected, lio that the iti^trunicnt thoulJ not
pai^d into it, the toree|>8 was intrudueed hiteriillv, and, nftcr one
or two attcmpiG, the very edge of the aoin seized, and at onee
Gxlrjieted.
The diffii:uity Jn this eaae arose from the depth at wliiob
FOREIGN ISODIKS IN THK ffflOPHAfiT'S.
\u
the foretjm body hnJ Icxlj^d. mJitiPig; it Jilmost imjyissiblc to
A^izc il vvidiuut injitrv to tUa impurlaut neii^kburing p^rl», Juring
ilie viclent periurbiiiion ouuscd by tlie iniroduciion of the fin-
ger nnd instruint'nt into the viLnnity of tho Ifiryiix, To a person
wlio ia going ti> atteiiipl lliia operntjun, I would ndrisc n shield
prepared of gur(:i pcrcha, tiUcd over ihe fii*^t joint of the for^
finger, to protect it from the teeth of ihe pntient: fla I hiiTe
often suffered fj>r mimy djiva sifler from eonciHioiifl received
during timiW operations, notviiUisIiiMding^ ll»e ordinary gugs,
&nd otlier menna to prevent the (^losing of the teeth.
It U alwflj's very im[>orfniii, wlien n fjreigu body U lodged
in tlie neigUhorliood of the irtryn^c, tlinl tlie fL>refinger of the
lufi hand should 8er\'e as t\ ginde to the inatrunient, to prevent
h from doing injury to the veiy important or^im* in clo.je prox-
imity. Olherwise the cp]<^lollis, llic edge of the Lirvni, or the
neiphboring «iift |n\rt>'j uiiiy be seized mid Jneeraied, AVhen
the foreign biidy U bulged f;irther du^n tl>e (p^ophngii^, thia ia
unneeessary, ns llie pntbaiiT' or hook of Dcipiiylren, hanug
once puaeed by llie lurynx, niiiy be manoeuvred kiw down in the
ce.soplingris without mueh Janirpr. It is, however, proj>er to
say, tliat foreign bodies very eoldom lodge in tht^ lucniiun ; for,
if they once become difiQng;tged from behind tlie bos of the
Juryns, they generally pass easily into the stomach, and do no
firrher injury.
r have genei-fllly observed, that, where eenta hnvo been swid-
lovved, tbey hive made tJieir nppesimnce about the third ihy
ttftcrwards. In one ease, one wns retained about three weelcs^ and
then [inssed without injurv to the patient, 1 tueniion this fact,
na [MU'eiilh nre, in general, execedinj^ly nniioua when a copper
coin reraaina ii» the intestine* of a child.
Case LXXI, — A Cent iit- fhi? (Efcphfigna. H^^frrtcfton.
— A eliild fix-e years of nge was brought to nie, July 2^, 184E>,
who liful hern partinlly chnk^nl bv n rent, whit'h h:ul hjdj^^ed in
iliff <L'sriphagiia_ Aliempta liad been made lu disengagu it,
which only served To force it fiirther down.
In <trder In reach it. I foix.'e*! the forefinger of the left hand
down the throiit ; and, widi mueh effort, waa able to loueh It
15
114
THE NECK,
with the uml oi' llie nnU, ns it byjusl below the larj'n:^. After
giic or two Altcmjfls, ji jiair of l^^rceps, oj^enuig nnterjorly und
posteriorly, and curved on the flat side, were alipped over it,
guided by the finger, and tlie ce:it seized *;nd extracted.
These Cii^efi will serve to show the iiotfhioii of luetallic eub-
Btances in tlie cteophagns, which Boniclimca reraiun there for
Q long time without causing f;i[al con8Cf|uences, I removed n
quarter of o. dollar from u child five or six yenr^ of age, which
liad re[]]ained for one or two weeks behind tl;e liirynx, without
preventiug thepiissage of flolid food. Bouca, for the moat part,
are lodged higher up, nnd require a diEfcrcnt mnimgciucnt.
The finger, however, should ftlwaya be used aa n ^idc,
Withiu a week of writing this, 1 removed, from the throat of a
gentleuiiin, a large fisli-bone firmly wedged across the opeoing
of the larynx.
STRICTURE OF TlIE tESOPnAGUa.
Strictures of the ceaophagua rc^iuire a very delicate treatment.
On the one iiaud, if ariaing from traumatic causes, and of a
fibrous character, they are susceptible of great rdicf ; and the
patient suficriug trora starvation may be restored lo a state of
nhiiDSt pcHcct health by a persevering and Judicious ap]illcation
of dilating instruments. On the other hand, if the affection is
nmlignant, the use of instruments is aometiines extremely per-
nicious.
There Is reason to believe, thjit a stricture of a noii'malignant
charaeter, ailcr a duration of many years, may, from the de-
terioration of health, or from other reasons, take on a malignant
course. It is difficult to decide whether the aflection la can-
ceruus. TJic complexion of patients suiiering under stricture
often assumes a pale yellow appearance, which would, at fii'st,
lead to the supposition that there was conetitutional disease.
By judicious treatment, particularly by the use of malt li<|uorft»
where sohd food cannot be swallowed, a change for the better is
very soon manifest. Where the disease ia cancerous, the use of
instruments increases the soreness, and they arc otlen witlidrann
eovercd with blood. For diktatiou, the beat instrument is a rod
BTBaCTTRE OF THE CESOFOAGUS.
115
<*f wlialebone, with a ptec€ of ivory on its end, of a coniwil nither
than of fl globuJnr shnpe- l^Tiere the atriclure la quite situiU.
and pouched at it* side, I Ijstc had most stiocesa by using a
conica! wax boagie, with the tip bent forward; and rliU will
ofWn succeed in pacing the etricturef when the Etrai^lil one
would be caught in the sac. I know of a Dumber of patients
now living and In hcaltb, for whom I dilated strictures mnny
yenrs ago, who previouslv had not swallowed solid food for
tnonlhs, and In some ca^£ for years.
The foUowiDg cases, seJeotcd from a great number, are given
to illustrate the trealUkeut : —
Cask LXXII. — Stnctttre of (E»ophagu» from Crrustic
^mmonta. — Id September, 1SC3, a you n^ woman, 1.9 ycara
of age, TOamedf and nursing a child^ came lo me in a «t»te of
almoEt complete glarvation, at that time liaviTig swalloned
notliing for the previous twelve hours. She said tJiat, alktut
two Tears before, when ill, she swallowed, bv neeident, a l<*a-
Spoonful of oaUBlic nmmonin. in^lead of her proper medicine.
A violent indammatir>n of the cpsophogu* ensued, and *he hjid
not been able to swnllow solid foad since. She had lived prin-
cipally ou milk, aud animal broths; hat, the system bein^' dc-
preseed from cursing, irritation liad come on at the Btrictured
part, so thiit she could swallow nothing. I made an ntienipt
to pass the smaller l-sizc*I j^rubaug of whalebone, the ball on iis
end being about the size of a jjea ; but it was arre^^red about
hall-way down llie tL-eophagusT and would not go farther. I ad-
vised her to wean the child, and live for a few davs on nutritive
enemas. This she did, and whs then again able to swallow
liqiiftlfl. On the Ild» of October, she was etheriied. Afler n
numlwr of eff>vts, I finally succeeded in pa-i^ing tfirough the
fttrioiurc, into the stomach, a small guin-clasti'* cniheter, with
A itylet in it, bent to give it a curve forwards. This opcratiou
wns iiftrrwards repeated frimi lime to time, wilhouL the use of
€lhcr ; mid 1 saw her last in I8li3, in good heiiltli, enahled to
swallow semi-sulid food, but siWl occasionally requiring the use
of an instrument.
lift
THE NECK.
Case riXXTTT. — Strichire nf the fEfinphafpiti omirrx^t^
rifter Ofiokinr/. — A l:nly, ^^i ji?avs of Jtgp, (/uii.'jultcd me in
DeL-ember, lt*61, for n stritture of tJie CTSophfigus of tiiirtepn
years' sinmWn'f, jirmlnct'il, (is slie wiipinx^^eiU froni ^'ettiiifr fli<ik*'d
wliile avvnlliiwing n jiie(v of beefstPJtk, ivliicli prixJiu'cd a «(ri'ere
spnsm, nml \va.s fitmlly L^t'Cled witli sdmc; blood. Three yenra
before thii^, n luzeni^c huJ ^liiok In her tliroiiti nn<I remained
thi're uiiiil it Iiiid dissolved. Sitk'c Clic In^t nmdi^ni. <<\\o had
with ilifti^nilcy £w?Llluw(?d iiny i^olid food. In fart, die hiid \\een
gt•m]l^:l\\y nidtK^ed Eo the necessity of u^iiig only liijuid noiirijth-
ment.
On the 3d of Dtnmilior, I piiwsed u probing biivinir n bulb
tbe size cif w pen. It went tikmugli a. i-itriuliire, n. littlt- bi-low ihe
Ini'vnXj with snmc diltii'idrv, bi'infring \i little Mood ^\ilh it. She
was ordered ii iiutnlioua diet, wilh ^lortor. Ilia iispect, nt llifa
tinie, wna ih»t t\( a ]torMon with n niiUI^iiiint Jir^cnse. A litile
aoreoi-*/*, ivhidi liiwteil l\vn duvs, fulhuvcil (he oiK^ralhin, On tlie
third duy, llie s\unG iTistnnneni wmj* Hgriiii piissed, with simiiar
effect. The size of llic inslniim^tit wnrt j-nidiiully iiiiToa^ed,
and she wiLfi soon uble to luke ^olld nutriment. The use of the
instmifient wus cinirrmu'd, !(t longer lijlervjils, fur t\ ypiir, ihe
power ill' hiKiiiy sdliil I'uiid iiiL-reii^in-r. She now (ISIiti) no
longer requires ti-entmenl, and enjoys a moderate degree of
hwilrh.
TtrMOES Tiff <ESOPnAGua.
Case LXXLV. — Poh//tns of Phanpt:/' of Lfnye 812^ rtt^
iachf^i to the oufftiile of EjittjioltU. Opfratiou. Cure. —
Thl^ case in inlereNtin^ ns being ulciio^t unique, on OLVount of
the size nnrl sitmillon of the tumor.
The pnfient wns a ^reTitleninn, 54 years of Age, who began,
in 1800, Co bave a sorencHS of the iliniiit in svallowiii"^. About
ten wpf'VH ufTi'rwjinlj*, by a voluntary pfTort, a tuninr enuld he
furLtd up into the mouth, fniUT ihc Lesa[»lmi^u«. ThiA did not
give him much InconrenleTice till al^out three weelca s\vca, when
it begun tti inere:ise rapidly, iMuaing uiunh Iroulile iu deglu-
dtioD.
M
TDMORS IN (EftOPBLiOUS.
117
He applit-^I In mc ATjiy
1, \iMi\y ; »]id I could
Itonlly credit the state-
mem he iriaile willi re-
gard ii> ihu tii/e of [he
tiiiiiur. By mjiking, hoW'
ever, n rt'giirgiliiliiig ef-
fort« he at fjitce con-
vinced mc of the fact.
A hu'ge. Avhittr-likoking
tumor, oF the ahiijic and
Bizc ol' a Binfill fiaufliige,
was thrown up into tlie
inuuih. While in lliia
poailior, it caused <:oii-
alunt ciforta to vomlli
(liTee woodcitt.)
Seizing it with forceps, I passtd my finder down llic tliroat,
Alkd found tliat the tumor ori^Luattrd in tlit nL-i;;iiUnhoud of tlie
epiglottis. By a slight eHort of tlii; pLilient, it resumed ita
eituntron in the orauph^gus*
Being exjuuinixi by Dr. II. K> Oliver, witli the laryngoacope,
ib9 urJ^^LU WKtJ found to be by a broail bnec, conimenciug \^w
down on the left and outsiile of the epi^dottia, wln^'li it driigged
down and over to ilie aanie side : thence a rihbiiu-like peiliclo
extended into the (esophiLgua. On tJie 2d of Muy, it was rcmoTcd
In the latloAvin^ nmnncr :
Bciug brought up into the mouth, it wm transfixed by means
of a curveil needle jirmed with n long tin'eail so as fo control
it. It seemed quite vnscnlnr, and bled freely. IiiateaJ, there-
fore, of exeisin;_y it, [ paaeed a strong li^-^nture down the tlirout,
and lied it as utut the base ns po^oible. The Cuuior vvaa then
cut o6r in front, witli HSimpaon's long curved scissurs.
The pi>riion removed was about three inches long nnd two
indies in circujiiference, and of a fibrous riiamctcri
Consideiing tlie position of the ligature, in the neigborhood
of tlic larynx* the flvnipioins which followed were of a mild
chiu^iictcr. There waa no condtilntional di^turLnucCt and ihe
THE NECK.
patient ewal lowed liquids
without much diSicully.
On the iJiird daj, a la-
ryngoacopic examinnlion
showed the ary-cpi-^dotti-
denn ligament, on the Jefl
aide, in an a'demiltoua stale.
The linfHiiirca, tlic loop of
whioh was eeiured on the
outride around the enr, were
cofioeiJed by this fiwclling.
After being gently dniwn
on for two or lliree dnye,
ihcy came away aponinne-
ously, SLiy 6fh, bringing
wiih llioni the pedicle of
the tumor. The patient ex-
|]ro9Ped himself greatly re-
lievfd, aa was natural, from
die openiiirm, nnd Iiad no farther synqjtomB.
A imiior o!" Hft hii^^i? a ti^e, in thi.-i situation, must be uncom-
monly rare ; and the only cu^e which 1 have been able try find
a|>pro;Lfhin^f it, thoufjh of a different anatomical structure,
13 to ha found in Mr- Gibba's valuable woi'k on the "Throat
nnd Windjiipe," whifh 1 lake the liberty to transeribe, its at-
tachintnta being ne;irly the same as in the present one.
" Que of (he nn»wt reninrkablo on record is preanrvi'd hi the luu-
Bouin of tlie WeaLaiioMer Uo&plUil, oC a pcuduioaA, tatty ttioior of
the phnryux nud liirynx, oociirrla^ id n robust aad nclivu man, *pf.
fiO, vklio hnd throai-3ympioEua for twelve ycurST Hud four yi-arfl be-
Sitva dejklli, during tlie act of vomidag, a lurga uiasH protruded, nlilch
ht wiip obliged i*> rctiiro an speedily aa possible, to prtvcut iinnicdiiitc
sufTothlion- Ho died Hufldealy, wIliIo smoking liis pJpC' A largu,
pendulous, fntty tamor was found Ailing rLe pharynx, aod exlendiog
dowowiirJi^ iuto (he a'aophagun to Ihe exli^ut of uluu ircLes. It nas
atEa^heil hy aa envelope of niucoua aiembraoc and fibroiis ti°9uc lo
tho It^ft Bide oi' tbo opiglotlia, draugmg \i downwurda and to tho left
fliJtf, BO as iiLHirnly lo preveai perfect closure of tha laryas : ii waa
BEMOVAI. OF TOVSILS.
119
■Im coBBedcd with the i^o- put of the phurtii : but, wiib %hmt
Gxccptiooi, il haag pcrfeaJj loose id iIms pharpa mid a^aoplugos^
"Tlw t^mor *-** exhibited before the PAtbolo^f&l Sndtij.bj my
coUcAgne^ Ur. Hoti ; ft&d ii fipired in tlie fifth rolame 4»f tb^
Hw woodcuU itccooapflDTin^ tl^ present case were cimwn t^
Dr. Oliver, %wl represent, Ivt, the lunior a£ seen in the DMaih ;
imd, 2J, tbe sa[^>o»ed position of the lumor. A, in ih^ a>$;(k|ilat-
pi^. Tbe b*M of the tongue, the epi^totti^, the lairnx, uid
trachea ftTC represented in iheir inte^tv, while the remn-imng
paru arc in eeocion. Tbe eplgloui^* B, is dmwn down, aDd to
tbe left, by the tiimor, C &un<U upon the greater corau of die
left tbvroitl eartiJa^, broken down tc expu^ ihe porta beaeath.
BEMOVAL OF TOHSILS.
T know no minor operation in anrgenr that affi^nla greater
relief and more satisfiictory results than this one. I have per*
formed it from fiie hundred to one ihoii^ard tim^^. and have
never lost a single patient, nor had a sinn^le case of dangeroiu
haemorrhage ; and in btit two ease^ have I seen nny such aoei-
dent : boiJi did trell. The ea;^^ were not taken indi^riminaiely ;
nor wag the operation performed eave where the fymptoiiis
■were more or less iirrreai, and other remedies had failed in af-
fowlhig relief, Many of these patients were brought from a
flititnnee, on aceotint of the importance and severity of the
dj-t^ease.
In nJmost every inslanoe, the svmptoraa were ftl onee relieved :
the patient was able to tate his food wifli comfort ; lo sleep
betrer; and eiehange^J a palhd and depressed a«pect for a
healthy and aTiimace<I appearance, gaining rapidly in flesli as
ftoon as a proper amount of oxygen was allowed to peactratc to
the hmgB.
In four or five instaneea onlv have I been obliged to repeat
the operation, Tiie whole of ihe tonsil never U, nor ought lo
be, removed- When the enlargement is very great and irregu-
lar, it sometimes extends down the tUroat, with a brood base,
Mul it ia not possible to embrace at once in the instrument ju
120
THi: M:f7K.
Tnneh of the ^lanJ as it would bo desirable tn rpmnve, and
the sipei only h cKrisp<I, The consequence ia, ibsit the lower
pnrtiuTi ofterwunU risra up, nnd comes into view, causing ob-
fitrut'tion, und requiring nnorher operation. Theae cases were,
however, very eiicf'piiona].
Once r saw denlli oepiir from enlargeiaent of tbc tonsils. An
Dccount of the cnse is ^iven below.
In tlie '*Pliikde]i>hi!i Maiirnl Exummer," ISifi, J jmbllsheil
an account of certain defonutlies of the dieat, nltendpd witii an
ealnrjtement of the tonsils.
The gubstanco of tlie paper is contained iu tbe following
lemsrkii i —
In 1827, M, Dupuytren publiehed a paper on the Inteml de-
preggjon of the parictes of the clieet, eonaistin^ of a depression
more or less ^freut of the riba on eiich side, and a proporliunate
protrusion of the Jilernuni in front, ace om ponied by some
nnlero-posterior onrvature of the vcrtobr-al column.
In 1h27, fltionly after ibe publication of this pjipcr, Mr.
Coalaon, of London, [uiblislied «onie cnses in confiniiiktiun of
tho£« given by Dupuvtron ; ad<.lin«;, nUo, ihree caeea of \\u own,
of n deJVirmity of the chest, dilferent from that before described,
the Mermiin being concave anteriorly, the sides of the ohoel
%'ery prominent, and the epinnl column but BJijrhtly, if in any
de^^ec^ nltercd from its natural shape.
In the three case« Appended to the paper of Mr- Coalson,
and three of the four eases of M, Dupuytren, enlar^emeui of
the tonsils existed; but in none of them does it appear that
removal of tfiese (>rgtina was praetiawit so that we enn not
jud^^e wbiit tUe effect would have been on the symptoms referred
to the chest, Lad this operation been done.
So far aa my own ex]>erieuce ^oea, tliis condition of the chest
is partly loechitnicnl, partly constitutional ; beiTip", in a great
measure, caused, in delicate subjects, by the difficidty of res-
piriition, from the obstruction iu the throat, improving imme-
diately when this is removed.
The operation, ns perfometi by the present improved instru-
ment, U instnntnncoua, not ntrcnded with much pain; in no
case is there any considerable hemorrhage ; usually, nothing
A
REMOVAL OP TONarLS.
121
TTiore thnr a few moutbftila of bl(>t>d are tUachsii^Fod. Tho
patients are able to return home, jusd resume tbeir ordiaary
ootupationa, as if nothinp; uncommon hod iKMurred; only a
slight sorpneas beiii^j; experieiico^l for n few dflyn.
The tbllowin^ Ciwee illuatrato the Bymjilome of thie disease : — -
Case LXXV, — Enlfirge'>ueni of Tomils in a Child of
Five Yenrif-, u-itk Otorrkcfa. Exciifion^ teiih lieli^f. — W.,
of Newton, Mnee., five yeara of a*ro, Xovember, 1833. For
two j'carBi thlfi child sutlered fmni nti enlargement of the
tonsils, first manifested by u swellinpr whioh upijenred on the out-
side of the throat, and supposed to he mutnp^. As the disease
mcreaaed, he gradually bat fleah and Btren;^h, and was subject
to frequent aore throat, attended hy febrile iittacke, occurring ad
often as once a fcirtni;^ht, and laatinn; two or three days. He
breathed At night with great dilficulfy, nnd occasionally started
up, ns if from choking, when the sleep became profound. One
ear was inflamed, and there was a purulent discharge from it :
be wiia very sensitive tu any hmd niusicid sound. He was
small of his age, thin, and of an irritable disposition. The
cheat was found lo he much dcformwl, presenting tluit appear-
ance eulled excavated atemum : ii being very mvruh depressed
in ltd centre; and the ribs, at the union of the cartiluges, ele-
vated, so as to form with th^-in an neute angle.
The lontiiJs were so much enbirged as to touch each other,
and entirely obstruct the po^rerinr part of the fauces. One of
the lonaila whs removed, and aftbrded imme<Hate relief to all the
syraploms. In the month of April following, some difficultv
being experienceil in breathings the cdierwa-a t\Uo excised. 1
saw him Aug. Ji, 1W37, nearly a year after the first operation.
From being a mi^erHb!*.' child, whom, ns his mother slateil,
ahe had not the least idea of raising, he had become a fine,
healthy boy ; had been perfeclly free (rotn difticnky of respira-
tion, and hfiil had no frhrjli;' attack sinre tlit* rpcrarion. The
flensiliveuess of the ear had diminished, mid tha det<jrinity of
the chest was much lews obvious.
10
ISB
THK KECK.
Case LXXVT. — Enlargtmtnt of Tomih in a Boy of
MighUci^ 17'ar*i tvith IJeafncse- Excision^ with lie/^tora-
tion of Hearing* — B», aged 18, No\craber, 1336- For two
or three fcnre, hn.d been subject to frequent nttucks of aore
throat; for tbrcc months, had bud (L piinilent di^chnrgc from
tlic right car; was quite deaf in both cars. He npplicd for
advlec oti fltrcoiint c>f the dcnfncs3i
On cKumination of tbe card by the apecnlnm, the tynopanuin,
of each side, wae found to bo in s, perfectly sound state. On
tlio side Irom which the diselmrgc appcrtrcd. tlic linin:; nieni-
branc of the ear waa rcdilencd, and ci>vcred with n ptimlent
deposit- The toneila vrcr-e found to be very Qiueh cidar-jc-*!,
find there was considerable rodncas of the back port of tbe
fuUCCf^.
Astringent remedies being tried for a fortaiglit, witliout ef-
fect, both toneiis were removed- On tfie fuJlovring day, ho
be^an to hcor bettor; on the second day, hiti hearing wuh per-
fectly restored, and younda even became so acute aa to be
painful.
In a day or two, the dcnfre^s rcturnwl, and Instcd a week i
he then recovered hie hearing, nwd hat* rcmiiincd pcrlcctiy well
eincc. I enw liim more than two ycar@ niter, and he hud cx^c-
ricEiCcd no return of his diflieulty.
To thc^e en^a mi^ht be nddcvl one or two in which thoeo
orj^'ans were removed while tlie patient waa hdinring under an
attiick of severe tyneilhtis. In one cose, t\\e aymplome were
ioimcdintely rcruosed by llic opcrnlinii ; in another, inHommnti"n
had extended to the adjacent pai-t^, and an abpc?t«^tf formed, as is
often seen in thia dificaae- The aHeciion, however, was mudi
ehortened in ditration, Instin^ four daya ine^tead of fourteen, as
hud been iieunl with tliL» patient, who was liable to attuokrf
every winter^ Tlie iipcintiijn was repeated ; and tlte otiicr tun-
B\\ was removed, on a suhaefjuent attack, with the eame result
The iti^tnmicnt UJfed in ibeeie openLtiong bo^ nstiully Ijecn tiic
guillotine instrument us dL-acrihed Ijy Ur> J. C. Warren in liis
vork on tumors. It is without any steel movable nceedle, used to
fix the IoumI and prevent it t'rum fidlin;; intij thf lliroat,, winch
appears to be umclcfk;, ua the blade of the instrument driven the
EEiTOVAL OF TOXSILS,
12a
lining raembmne of the tonsil into its ^ix)V€, and thus Beuures
it ; itn<l, even if thie were noi the case, tlie mucus, which cuvcra
the fauccsi cnu^ea tlie cxt^ieutl part to udhcrc to the btai](j| 90
thfit there ifl no dcn^^Gr of its e&cajjiEig into ihe lliroat.
From a review i>f a large number of" ciwea, I find that many
of the children were of a scnjfulous constitution ; that thp en-
loi-gemeni of the lon^ib cnu^od i^reM loea] Iroubk* atk^uded
with conddenible con^litittioiml disturbauoe ; thiit the palient
was much inoro liable to LEidnmrnatory attacks of the thi:<.)at,
Elmn in enget^ where thia ci>nditi^i] does not exii^t : and thai
tbej- wore le^s liu-ble, ufter the operation, to thcee attacks-
In about half c.f all the cases, and in about twc-thirda of
these of chilJrou- detormity of the ehcst existed. ^Vheiher
thid de[>ended im the ^neral c^on^titiitional habit of tlio patient,
or was induced by the obstructi^tu lu the throat to the free
pas4iL<^e of air, the accounts rectiived he to the cxoet tune when
either aflbt'tion was fii'ijt observed, were not eurtieiently acourtile
to juHlifv a decieioa. It is eertaiu, howtver. ihjU tliiJ* <letoraiity
does not increajw, but ralhordirmmfr:hi7{«, after tbc removal uf the
obstnictiou in tlic throuf. Tlie ojUL'tjUioii h a siinjile one, nt-
teufled with no danger, and almost al>vays atloitU iuinjcdiatc
relief lu the syni}>tonia.
Case LXXVtl. — Slrtriiftith/tion ftom £nhiiyt*d T'mvils.
— -A man was br'iu*,dil into the Hospital, f^triig^ding tor breutlj,
and almost pui^clese, ttuppoj^ed to he luboriTi<j; iLmkr an lUttLek
of Ifttyngllifl. The dun-^er of auffoealion was so iinmincni tlint
124
THE VEOK.
no time coiilj be spnrcJ to iur|iiire into the history of tKc c^ac-
I oL'Jercil Iiici to be pluceJ on \ils huck, iiDti procecJcd to ojjcn
the lurynx, — a umttor of aomc difficulty, owing to hia vioicnt
offortB fur bi'ciith- As soon t\B t}ic iiir ponctmteJ Jrcely into the
Inrynx, be bognn to revive; tbf. (mlec beciimc more eleudy,
tlic rcapirution rc^lor. StiiniilnntB were given botb by the
mouth and jicr nmim ; but tlio eyt^tom hml rcccivixl too fifvcrc a
ehock to rccoverf tuul ho ^^nuluaUy ^unlct miU o?cpir(^ quietly
in on hour or two af^r the o|xTiuiou. Ou rcraoviDg the
Inrynx, iro miirkfl of intlunimction could Lc dotocteJ* On
looking further, however, the cauflo uf dtnth was di^tiuvered,
Tbt lonsiU, ;:;reiitly enlur^ied, nnJ in ii etiite of violeut JJifliini-
niutioD, Hileil up tlie fxretorlor fauoee. TJio epi^flottla hiid he&a
graduuUy eufruiielied u])un, so that fimJIy It wiis pressed
down, iiud ulnio^t corojiletely prevented tlie entnuice of jut
into the ]uu<;ti. The lii^tory of tlie oaHe, n^ learned after-
wardt* froiu bia father, wws tfiia. He had been employed^ four
diiys bof<-»i"c, in unloadiiijL' a ehip ; the wcniher bein^j; very cold
and rainy. The fulluwing dny, he was taken with sore throat,
for whieh £onic eiiuple rejiiedios hiul been np[)lied oq board the
\edttel where he sltpt. He ^vaa fir^t seen Ly a pliytiiciau on
the day he wnjs broitj^ht to the flcepltol.
CANCEft OF Tonsils. — Om^'er of the tooaila. soft pftltile,
nnd uviilu, U excetdiugly rnre, Di\ \Val:^lie, in hln work on
the "Nature and Treatment of Cancer," snya tliot coneer of the
tonitila Ib very tare, whether of the ^eirrhoua or encephnloid
vuriety. He has not t^ijen ii eo^c of primary cancer of the eot^
palate and uvula, nor found any recorded. '^In eert;un casea,^
]ie udda» *' where the pharynx Jiud &oFt psdate are implieated, it is
perfectly po^dihlc thnl the alicction amy have originulf^d in the
pdntc, or that thid purt niny, at loimt, have bt^en the «eut of
Bepttrate formation j but I know of no cvidenee of the faet/^
Tlte following ease, which I attonded with Dr. J, C. Warren,
U one of tlie very few whjcli I liiive eeen. This one U selected
on account of the remarkable trflU3|>08ition of the organe, which
wns not discovered uutii alter dentli : —
REMOVAL OF T0N8ILS-
12S
Case LXXVni, — Cfufcei' ui the Tkront^ Opemlion
and JRecorer}/, l)Gaf/t, at a Snii^fe^nevt Penod, Jrow Pe-
ritoneal Infiammation, HfmarJi^able TmnspoaUtoti of all
the Or^ftiu. — Mrs. A., nge<l 'i5, aoiuewhiit liysjicptic, oh-
Hen'ed, mi January, 1835, a swelling on the left lousiJ, which
gritduiilly incroiiHed in size ; hccsiuip more firm in ncnsistence ;
and, finally, extended to the soft polate, ami attached itself to
the loiver jaw bo ap niateriullv to impede lie molions. She wq8
not niuoh redufred in strenglli hy the dir^eiiee, not itiLt'h emad-
Ated : -her countenance was pale, and her di^e^^LJon good. The
following was the stale of the diseased parts just before the
opemiion : —
On the left aide of the thront, snd occupying all tlie back
pan of the fauces, was a firm, iodnnired tumor, extending back-
wanls nnd upwards into the posterior nnrcs, and forwnrtlfl to
the lower jaw, to whirh it was firniK' Httiinhed. The tonsils of
thai tiide nnd ar»(t jiidnte were a]j4*> impliuateih There waa no
doitht of the L-anceriaifl nature of the difieif^e. The tumor
was renioved in June- It wili of a finn, cartilaginous nature,
almost of 11 bony hardness, suraewh^t ulcerated in the centre.
She recovered, tliough, from her Jijje and tlie severity of tlie
ojieration, it was some mouths before «be was able to g-o about.
In the inonrJi of January, 1836, having eirposed herself to cold,
she wns seiveil with violent pericimoal inflamiuation, and died
alter na illness of four da^s. Tlie examination o^ the body
was made hy Dr. George Q. SiiattUL'k and myself, the day
after her death-
On opening the abdomen, the onlinary appearances preaento*!
by a severe peritoneal inflammation were fouad. The moj:l
remarkable thing, however* wu.* ft lumnr in the lefl iliac region,
at first supposed to he an invagination of the inte>^tifie, but
which, on fmlher eiamiaaiiiia, [tr<ived lu be the crecitni^' and, in
tracing up the intes^line to the slumacb, this organ vfVi found
in the right bypochoudriac region, tho left being otcupied hy the
liver.
Tbe lieart lay to the right of tJie Hpiunl culuiun, occupying a
place with the right Inng. whicJi consisldd of Lnt two lobes,
there being three of the left lun^ : tho cavitiea were all, in like
1S6
TEE NECK.
maiiuert tr;mept:med> From tlie ngbl ituriolc jiroceiMloiI the
fi*iir juilujoijury veins: tlic r^it vejjti-iclc \md the tl>nu and
thickness uaually poascsacd by the left, ami contained tUe roi-
tral valves- Tlie Itft ivuncle received the vena t:ava* tlic left
veuU'icle touLulueil llie tvieuspid \filvoa. From the riylit veu-
trlcle. the aorta h^d its origin ; tJiia, iiller runniug up a little to
the lefts curved over tt> the right, and waa placed on the riglit
Bide of the spinal coKimn, hzuing the vena cava on itfi left.
From the arch uf the aorta, only twu arteries, instead of
three» were given off, tbruiiiig another ijeculiariiy in this re-
markable case* The first artery to the left >vae the Ini'ge^t in
size ; an inch ft-oni ita origin, divSJetl iati* what would cor-
respond to the ianotninata and right carotid. The iunominatft
gave off tlie left carotid and fliibclavi:m ; thtj other artery given
off fi^jm tlie arch was the right subclavhin. The Kpecimen is
now in my poeaeBiion,
The subject i>r thifl rcnmrkahlc iinatoniical structure was the
mother of fifteen children. Nothing' wiitf obr-encd duiiiig life
to lead one to suppu^ tliat such a dispoeltion of organs oxislcdi
FIfiSFRE OF SOFT AND ItAllD PALATE,
The operation nf Ht:tpliyZoruphy is of eouiparatively modern
invention. It was first attCEiipted iii Europe hy Graefe (1617 ).
and was firol performed with aueceas by Roui (181^), who
Beeme not to have knoim of the unauccej4»ful attempt of the
Oenmin profci^sor. Slufrtly aller, it wae aguiu jjcrfDrnicd by Dr.
John C. Warreu, of Button, rtho, not beuig aware of wlicit bad
hean dune in Europe, himself invented new instruriiento fi>r it.
The operation waa tit first deemed applicable only to fiasurcu of
the Nrll palate, which, of eourf^e, arc ahnost llic txceptioaal
casca ; as* out of from eighty l-j one humlrtd opciatious i'or
fiasureof the palate which have fallen under my own observation,
in nut more than a tenth, pi-ohably, of the whole nunil)cr, was
the fissure limited to the soft parLa. Nearly all c^isca uf fissure
exteudiii<i Into tlie haixl palate were rejected as unfit for opera-
tion, idthough Roux liad enggeatcd tlie idea of relaxing the soft
palate hy cutting it completely away froio its attachments at
FISSmtE OF liOlTT ANTl HAUIl PALATR.
137
the posterior ci\^c of the pjiliite bones. This opernlir>n \s very
likely to prorc aborthcT from the 'liviaioii ot" the vi*a3(?lfl whii?!!
supply the flaps with noiirishiiient ; and, eveo if it Biicceeda, it
1enve« an itDneiressarily krge npi^rnire ifi ihc lionon, still to be
covered by artificinl fneans. Being impressed by the very grrnt
proporfiim of the vqscr of v\eft palsile whieh were deemed in-
curable, I WHS ]&\ 10 pei-form an operfition for the esjicrciiil
relief of the more extensive fi-^snTe*!. whieh ineUiile imtii ilie
»o\\ ftn<l hard pjiUte ; nnd. in April, 184,^, J piifilished, in the
"New-KngJHnd Quiirttrly Joiirnjil of Medicine nnil 8nr<rery,"
:Ln in"eoiint ()f a new iiper:jtii>n liir )he cUjsure of fi*<suivj< in the
hard p;date, to^retlicr with r. very iinportiiTil niodifii^uion of
the o]>pnilion of slnphylornphy, iia pmctised for the relief of fis-
sures of the eoiV piilale. The i^peration upon the hnnl pnljitr
(f (jiHJtc from llie descriplion i*f my first nasi', im re|)ortt\l at
that time) consistetl in "diasecting up, wilh n lon<r, dnuble-
cdgeil knife, curved on its fliii side, tlic membmne covering the
hard pnlnte, pursuing the distJet'tlfin ijtiite hnelt to tlie root nf
the iilveolnr prfuvswi^. By this prLU'etlure, whieh was nol ef-
fected vrithnnt conEidcrahle difficulty » the membrane seemed
gradmdly to unfold itself, and eimld he erisily dra^vn iieriisa
the very wide tinsure. A narrow shp was now rcnioveil fr<im the
edg;es of t)ie soft palnte, and with it the two halves of the uvida.
liy this nirnns, a ecmliniion? flnp was ohiiunetl, hei^nninp at
the ruotfl of the [ineisor] teelh, and extenrfiny Iwickwnrds to the
eilge of the velum pnhiti. Finally^ Hii autures were intn>diieeU,
on tyin^ which the whole fissure waif oMiierflied. . . . Thii^
patient retiirnnl hrmie into the country at the end of tliree
weckfl ; n firm, tleshy psdnte l>ehig flumeJ behind, and half ihe
fissure in the hony pahtte obliterated. In the followint^ sprin^;,
I ngiun itjienjled cm the niinairnng fifsnre in the hard j>alate, nnd
Buereedi^l iu I'losin^ liijf tlie extent of it; the lisrtue.'' yiuliliTi^r
witli j^oine diflk'ulty, owin^ lo the induration enu^eil by the
former o[a^ration. The snudi aperture whirh remained, I di-
rected to [)e cl<.weti hy n gnkl plate/' I had. at tUls time, opera-
teil in thi» nuinuer in ruiirteen dilferent cil^jor, " whiiTh, wilfi one
esception, Imd terminated sneceflsfidJy, chher in the elosnre of
the whi>U' fiiH.Hure of lioth hant and so\t |KL|ate» or t*(i i'tir th.^t iJie
1£8
TlIE HECK.
apcrtiire which remained In tlie houcs coulJ be easily closed by
ao obturHlor filled tu the ntjjolmng teeth*"
The improvement to which I have aUudai, in the o|>eratioa
upiin thd poft palnte. cocaisted m the reluiation of the tissiiea
at' the fi^siireJ relum, by meujia of iuclsiooe, unide with strong
ciirveJ BCiHsora, ao aa to divide the attachinenta of tlie soft
palate to the toreU and to the poatenor pilhir; or* in other
vrorda. dividing tlie posterior pillar uf the piUatc juat where it
bepn*" to *tprerid out into the velum. The ctfcct of thiH in-
cision Th at once seen in llie almost complete relaxation of the
|taFtA. BO us to admit of their ctiey approximjition and union hy
suture. At ifti^ time, I hiLd met with uo catte in which this
procedure failed to relax the parta, as I tliought, aafficiently for
tlic rei]uiremciit^ of the operation; and, in the foiirleeu caeca of
opemtioD i'or coiiiplJiutcd cleft palate which 1 had then per-
formed. I hiid met with but otie imauccesaful result- In auhae-
qiicur. opEi'ationa, however, I found that there existed, in some
ca^es, ao additional obstacle to the a}t|>]'o?(imatioji of the Hapa,
which enuld be ovei-corae aa easily, mid in the »ame tnar»ner, as
the former. This obstacle cone iats of fi band ol iirm tia^ue, ex-
tending; nhove and behind the f<oft palate, rmd standin;: out in
bold relief when that or^an li put on the stretch by drawing
upon it with the forceps* Thia resisting masa, like the other,
J have always divided by an a^lditionid atrokc or two with tiie
scissors, whenever the incision of the poclenor pillar and ad-
jifiSnC mucous membrane haa eeemcd insuHieient properly to
reins the palale. By this division of all the piu'ls which op]n>.^e
any active reeiMnnce to the approxiiiinlion of the t^ides of the
fissure, the fipcratiim, eib T have performed it, Avas finnlly per-
fected in its essential features; and, since that fimc» 1 have
known of no unportant impnivcmcnts in it. except in n few
matters of opcnitive detail. Ihuin^^ the pjist few years, how-
ever, I have generally nhf^tained from the attempt tij etteet the
entire closure of very extensive fissures in ihc hard p^ilatc,
owing, in part, to the severity '»f tlie operation, but chiefly
to the fact, that modem iniproveTucnts in mechiuiical dentistry
have furnjdlted us with a mo^t ef^eicnt and eondortablc subati-
tule fur lite nntin-al hard piktc, in lia^ lorm of a metallic or
huid rubber plate.
I
FlSftClLE OF SOFT AND ILlItD PALATE.
129
1^/ tlie intimlur.tinn of thrse imprnvi^mdits in tlie pliin and
JiitduKlft of a|ieraUng, tliu Hiir^'ery of vlvh [mintp at imce ac-
quired a new anil vastly enlarged im^iortance. Tlie O(»eralioc
of fitiipliyloniplij, ae invcnlcd by Rniix, ami practised by ruany
feurgeoiiti, hiolli in Europe nnt\ Ameritai, hud been coiiMilered
npplicalile nnly to simple fissures of tlie velum, a claaa of cujieH
constituting but a very small frm'lion of ibe total nuiuber of
cleifl palatea, a.nd tLie very ones in whifb the need of eurgical
aid in least urgent.
The biglily t^uct^essfnl resHlli*, hitwever, whidi 1 vvas enabled
Uy report m ibe treninient of nncs whk'h biid previtiMfily been
fon^idi^reil as beyond llie uid of siu'ger^', toother with the en-
conrnging success whicb bad been already attained by Rdu^,
DictreiiliftcJi, Olid many olber surgeons* front the operation in
the »ai\ palate, soon exeited the renewed interest of tlie pro-
fession in this inoflt di.strpjaslng deformity*
Mr., nrj\y Sir William, Fergusflon, was led, in 1844. by the
diHaectlmj of ji Hpc*'iim'n of deft prdfite, to Jidopt a rnetluiil veiy
similiir to mine; dividing ibe levntores jiiibui mn?(defl» witb a
slender cnrveil kmfe, snmewbtit higher thtin in my proreditre
with tbe Kcis^orti, iiml dividing the phnlt^riur piUnrs of the
pillule in pre<dj«ely the ^aine tnnnner an I hiul already dc-
etTibed.
The wnhject of deft palate has been still further illiiHtraled by
Beveriil Biiti^h enrgeon^ of distirictlnn ; among wbom Messrs.
Avery and Pollock of London, Mr. Collin of Dublin* and
Mr. Field of llrigbtun, nre espedally prominent. All thefie
gentlemen have (i|)crnted with the nnwt perfe* t tiiecesi* npnr
fissures aa wdl of the bard n* o( the soft puliilc nnd they
have nil adopted the plan *)? rtqmintbi^ the soft text.nn*^* frettly
fr>Tn tUf pahwine an*h. Mr. Pollock dii'ide^ tbe pnhite mufi-
eles by n [inrtially r^nbrnucoud ineifdon, at a point near tbe
bamnhir proc!eaBes, where the fibres begin to spread out into the
Tdiim.
Tbe following flcrount of tbe different ainges of tbe opemtlon,
as I have latdy perfoi-nied it, very nearly re«einble« that wbidi
I published in lS4lif to whidi nlhiAJon Iieui Ijecn imule : —
17
130
THE KECK.
1, 77^6 Sepfirrtfion of tht Ptthrtine Membranes fpGni the
Sones^ — This prcMrediire T hare found necessaiy in fully nine*
tentfis *if tht cnw?a upon whioh it hji^ l>een my !i>t to operate.
In most of the firisurea ivliiuli apparently extent! only to iLe mar-
gin of the bony vmiiIc» the top of tlie fissure is of n round&l
railitr thnn an angular fono, so aa to render it difficult or im-
po-^silile to bring (he flajw tocher at thia part without first
Ion*;pning their nttaehments- By adopting (his measure* how-
cveT-T the upper aatures are applied as eiisily t\s the lower ones ;
and the danger of partiul failure at this parlioukr part of the
pdate, formerly eo common, ia idmo&t wholly obviated- Li
eflses of more exiensive fsfiure of ihe hnnJ palate, tliis eopara-
tion is to he cmrieil funher, in some insinnces even to the alveo-
lar proeessea, T h;tve ailvaya f<impleted the operation, aa fur
as 1 hare thought il: prf»|ier to atli^mpt it at ull, at a single sit-
ting, because in this way we are nlmost certain to obtain ^od
union of the velum^ and a partial closure, par ffltssetnent^ of
at leafit the posterior [xirtion of the fisfiurc in tbe bonee. When-
ever, by tlie re-establishment of the velum and of tlie posterior
part of the palatine lault^ we have succeeded in reducing the
tissure to a simple foramen in the hard roof of the mouth, we
have praetically relieved the patient from bia disgusting and
difltreflsing deformity ; for he only needs ji light mclallic or vnl-
eanite plate, sncli aa is now worn by every one who lias a set of
false teeth, to enable him to artieidate as well aa If the aperture
were closed by the natural hone and membranes- Led by the^e
tongidcraliona, and by the desire to shorten as much aa possible
an operation which must almost necessaiiJy be performed with-
out the aid of anwfilhesin, I have ceased, of late years, to
operate for tlie cloaure of the nnterior portion of the cleft in
extreme cnaca \ and thi*j notwithstanding the fact, that, in ray
cjirlicr years of practice, I aiieceeded in completely elosing a
\ery large proportion of all the fisjsures upon which I operated,
including some very extenaivo ones, and tliua established the
operation as a perfectly practicable one. In commencing this
part of the operalioTi, J have alwajs used a knife eubatantially
hhfi that which I first employed; viz., a double-edge<i, apear-
noint^id knil'e, elrongly curved on its flat side; winch 1 have
I
I
»DRE OF BOFT AND HARD PMIATB.
131
fonnd to answer well for aliuoet all fissures of motleratc extent,
although in some extreme case?, in wbich the huiics liavc de-
viated widelj" frora tlieir nijrmal curvature^ very considerable
diAi<^[|lty has been expenenced in making the first mdatona at
the edges of the Sasurc. lu theae caaes, iheix^ is of^en no pro-
per roof to the niuuth, owing to the extreme obliquity ot" the
bones, which riae. as it were, jilmost TCrticallj from the idreotar
marg^ins towards the noatrila- To facilitnte ihcao Erst mciflion*
in fiueh cases. It has beuu prupo^ed hy Dr. Suiylv to coaimence
the disflcciion with n eleuder knife, shaped somewhat like an
ordinary gum-laueet* and used througli the nostril, where the
edge of the fissure may be more readily reached llian frooi
themouth* 8har[ily r(!t;urvLi] kulvca, worked from the mouth,
have alao been ueed for the same class of cjisea ; and a jmrtieu-
Jatly ingenious one has been invcnte*! by Mr* Pollriek, In which
a abort chisel-shaped blade is attached to a metallic stem by
means of a hinge, and is fitted with r screw muvement by which
it may be adjusted to any rcquireil nii^de, Buth these contri*
viinccs hiivo been tried and ajjproved by Mr^ Culfis, and are
doubtless of ^eiit uLilily in the cases for which they are de-
fligued. This cunimencemenl of the dbseclion at the edges of
the fissure la by far the most difficult jiait of tin: opemtiou ; for
it is at tliis piU'L of the pahite that the membranes are ah\aya
found most llriiily n^dherent to the bonen. As we proceed, how-
ever, llie sepiiration becomes very much easier, and the mem-
branes seem aiioost to peel off from the bnuea- I have therefore,
at this jKiint, gcner;dly abandoned the knife, and have continued
the dissection, as far ds I have thought necessary towards the
alveolar pi'ocessee, by incaus of curved sciaaors. In lliia way,
I have been sure of preserving the greatest possible thickness of
tisisiies in the Haps, without endangering their nuLrilioii by the
division of the prdatine arteries- In most of tlic caaes which T
have seen, llicre hiw been Jiltle or no deficiemy of materials to
fill ihe gap ; but the fissure has been the result rallier of the
iibliipie direction of the ununited aides of the paluline vault.
The <r|ieniLiLin consist:^, then, not ao much In fitretoblug the Haps
tiglitly across the cleft, »s hi bringing them into a more nearly
hurizonud position. I have not, iberefore, eeen that much
132
TKB XECK>
bcm^fit 16 to be expcctal from lalornl inddiona tbrriu^h tlie pnla-
tinc mciuUmnc^, ami linvc jiTwim ab^tuuci) fi-om Dinkinir tlicm,
i'wni lEic i'ciiT of ctLudtig nouUWfi und troublceomc Lcmorrlia^,
acU lliHa unnecessarily proloTi<rii;g rn already too tcdioue operEt-
tion. At the pofitoriur edges i>f' tlic osm paluli, tiic union
botwoen the soft parts ^nd the bono ja very intiiDfilCj owing to
the insertion tliere of the temlinoua fibi-ca of the velum, and
more partitukrly of tlie reflected tendon* of the tensiijrctt pulati
miifioIcA. For completing the Hcpnrntion at this point, I use a
pair of probe-poinled ecisflora, ivbich 1 liave fmind to divide the
firm tiesuee mueli more cunveniently and expeditiously than any
knife. In alJ tlie operations wjiicii 1 liave performed, I bare
QicC with but n single case of troublesome licmorrhagei At the
momcot of freeing the ilapa from tlicir attacljEiienta to the ^hja-
tcrior margins of (lie pidate bones, a few arterial twiga are
generally divided; but 1 have always been able to control the
blccdinj^ by the use of iced water. Jn a single itif^tancc, lawv-
ever, in which the upper stiteli waa iiiinsujilly tcnec, the blee*licg
continued after the adjustment of the sutures, but immediately
ecased when the stitch was divided so as to allow the membrane
to apply itself more closely to the bone.
2. The Jlf-lu. ration of fh^ fwn Halves of tht Vtlum htf Me
Divijfivii vf Rt^ieiintf Band's of Muscle and Mticiiua 3Ifm-
hratit, — This has been a most iimpurlant feature in all the
operations, and is still performed in the same manner as in
the earliest CHse». The instrument employed \& a pair of large
and strong French sciaaors, curved ou tlie flat aide* One of the
ludves \i[^ the *plit uvnla is eci^ed witli appropriate forceps, and
drawn across tlie Hasure. This brings out In hold relief two
etroDgly resisting bands, one below and une above the palate*
The former, conaiatln;^ of the posterior pillar of tlie palate, is
then divided by a pi»weriul alrokc of the scissors^ and the ia-
cisioD extendei] forwards and baekwards, dividing iia mncb of
ihe mueous mem Inane as may lie necessary to relieve all tension
aL this part- The other hand, consistirg chiefly, as Sir William
Fergtiflson hiis ehown, of the levator palati muscle, with its
muci^ua covcrin^jj, is next divided in the same manner as the
posterior pillur, ineluding, as before, in the incisions, u greater
FiaSUEE OP SOFT AND HARD PALATE,
133
or ksB extent of tlie luljoccnt mticoue menibrnncT aa may eoem
to be rotiuieiCe to effect the perfect reluxution of the orf;an.
The complelion of this etag^ of llie opemtion is shown by
the striking chn,agc in the conditioD of tho hitlf of the velum,
which, troiu A state of violent ^piiuiiioJic coaCmctiuii, burying
itself, as it were, in the aide of the throat, bocomea perfectly
fluccid tmd powerlese. As soon as this rceult id littainod, thU
part of the (^|ierntion is to bo coiiBiJeretl as finltiheJ, whothor iho
iacLdioiiti Imve been more or less extensive. By tlijj^ metliod, no
part is cliviiled until it hoB been firj^t brought into a etiite of
tenaioTi, and tUue shown to require it. For fueiUty !\nd cerlmnly
of exceuiioii, Uivldin;^ no more and no less Uian is rorpiireJ, and
fbr nbiiuJiitc fi^ecdum from danger, it eccme 1o mo tlint this
method of reUxin^^ the sofl parts has never been ^nquij^^eU.
That other plana may bo ut^efid, J have no donbt; but wlLOthiM"
they oHor ."Ldvatitage^ eqmil to the present c^n be settled only
by a serieB of comparative ti'iala in prsietice, such a& have Eot yet
b«cn made.
3- '£he Paring of th& Edga of ihe Fissure^ — Thia is per-
formed eometimes with ecidsora, nnd eometimee with a flt-odcr,
pointetl knife ; nud I am nut aware that tfiere is any decided
prcfcrcneo to bo given to eitlier method. The ed^^e of tho Hap
iti mode tense by drawing upun the uvula with n [loir of etrong
but filtndcr-loothed furcepiiT which I have deviiied for the purpoHe,
and wliich is shown in tlie plnte. These forceps^ of wliich two
pnirr* are i-cquirod fur the two eidea, are made with a dfiuble
ourvo, and aro bo contrived m to seizo the extreme edge of the
(hdatc without encrojiclung more upon one jiurtace than the other.
The same furcops are employeti aleo in the prece<l3n^ stap;o of
the operation to put the palate on the stretch ; nnd, aa a ^enorul
ride, after i^iice eciiiirij:^ llic or;;an, I do not let it ^'o n^aiu untU
£ have pared \i& edge. 1 have not fountl it dcslnibk to attempt
to profi«rve the whole uvula j for it generally hanga eo low in tho
throat 05 to eautfc irritation, and thus ijitarftre with tlie Kut^cws
of tho opcrafioa. In moet ca^ice, thoreforc, 1 remove the grentcr
fjortiun of Lhc two ludves of thifi uppend;ige at the time of paring
the ed^Oid of the palate.
4. The Applicutioii and Ailjusttntut of the S'Uiii\:s^ — In
13-1
THB NECK.
tfie enrly days of &tn|jbTlorai>liy. tbis waa by far the moflt difli-
cult ami vexjitjous jjart of the operation, owing to tlic extreme
irritability of the parts ]>rovokiiig violent muflcular retraction
whenever the Hapa were priekeU by the nccjlc. AiVer juloptin^
the pliiu described for the rclnxation of the organ, I obacrt'ed
tliat tbia etagc of the operation was gi'cally facilitated; eo
that, for a. miinber of jeara. I was in the habit of pasalng the
Huturce with a &niftl] curved nctdJc held by furocpB. Incrcnacd
experience hajj. however, denion/^t rated the usefulness, in many
cafiea, of the ingerious croehct-aiguilie of Sehwerdt ; a &»liarply
recurred needle, mounted in a handle, and having an cyc at its
point vhieh can be opened and closed by a alight |)re3anrc upon
a spring. The instrument ia threaded, and po^aed through the
cd-,'e of one itf the flnpa from behind foTwarda, and one end of
the tJiread drawn through by eatching the loop ivith a tenaculum
or houLc. The nceiHc, etill tlirc&dcd, ia then withdrawn, and
earricd tlimugh the Hup on the opposite ^idc; the eye la then
opened, and the thread wholly diecngaged from it by drawing
upon the loop. I have generally adJufiCetl the middle &uturc
first, by that mcanfl controlling the pahife, an<l tluia rendering
the insertion of the othera enaier. The lower one is beat insert-
ed htaC. At the lower part of the pjilate, where the parla are
rery movable, 1 have found it diHicult to fix them with this
in^tnimcnt, and therefore prefer to uae a delicate curved needle
held ia a porte-aignille- The ehiei' objection to the needle of
Sehwerdt is the difficulty of keeping It aliarp, owing to ita being
split at the point. Very broad sutures, made of a number of
wsised tUrcatls arranged in the form of a dat baud or ta]>c, have
been much employed tn France ; and Diefienbaeh used to insist
atrongly upon the advantage of uaing wires of auft lead. I
have always used a single thread of common eurgeon'a silk,
thoroughly wa.\cd, and tied with the ordinary surgeon's knot.
I have prepared the silk, at the suggestion of L>r. C. G. Page,
by soaking it, a day or two beforeJiand, in the conijiound linc-
liii-c of benzoin, by which it acquirer an aUlicsivc property, and
ia lees apt to slip when the knota are tied. U is important
to hniig ihe opposite ed^ca of the fissure into absolute contact
with caeb other without much tension, or the istitches will
FIfiSCRR OF SOFT A>1> HARD PALATK,
ins
oa certainly nit their wny out, uml thus (Ipfea-t the enH for
which ihey :iri! cmj)h>y&l. In an intereKtin^ nnt^c of ojH.*nttitni
for the closure of a very exttneive fissiire of tlic.' harJ paliite,
perfnnnol by Mr. Collis, iinJ rcpcirted in tlie " Duhlin (^imr-
terly JourmJ of Mt!<Jirnl Science" lor February, ISOS^ the
flaps, nltliough of ampli? bieuJth, teiiilcd obstinately to revert
to ttidr nn^inal iKi^iliuii in c;ontuct, with (lie hone», nm] Uiua
catised injuriijiis tenftion upon ihe btJtdier;). Thii^ wii:^ oven;ome
by tlie very hapjiy utid lugenioiia ex|]Gi]ient of piisbitig ths
3apBi ns it wcrCf tnwnnlA the rnediun line, by nicHna uf
wedges of springe intnHhjriHl hptween thi^rn ami the bonea:
these were ejuiily reinovwJ through tlie nustril, after forty-eight
hours, Qiul the result wa^ a neni'Iy complete and mo8t satisfac-
tmy uniopi.
5. ^Yie A/tfr-trea/iiietiL — This was formerly the severest
and mo^t vexatious pnrt of tbe management of the case, owing
to tho HM|ij>ij.s(?rl necci^sily of the intenliction nf the use of food for
several days folhiwhig the oih-nition. In my firi-t va^cn, T pur-
sued iJnH plan, mmrifthing the jjiitient*! for several liiys solely by
Buematn. The ohvionjuly uiifuvonihle effect of thus atnrviu^^ a
person in fidl ln'idth. and accufti.omcd to a (,fcaenms diet. led Sir
PhiJi|j Oranipton, of Dublin, to try the experiment of nllowing
bis pittients an airtple i^upply of soil food, 8iicb as hoilod breail
aiul milk, enstJinI, 8onp» ji^U.Vi ^^'V* during the whole period of
the treJttmcat. The piil.ilication, in January, 1^^43, of the two
ctiBGs ID wliicb thiH pl&n had been aucccasfully tried, was im-
mediiitcly followed by the abandoiimeiit of the old and most
irk^inne rcstnction ; and |iuticnt8 lire now »llcnved jub nmch
lli|ald or tiemi-solid food as they desire- ^fiieli [rouble \^
oflea experienced, afler the Grst three or four days, from
the secretion of tou^^h adhesive luucus in and around the
line of suture^ nhich *;ive& rise to an irritating cough of
such severity as Aoraetimea to threaten the destruction of Uie
newly foriiit.'d adhesions. In this:* condition of the partn, I
liuvc aeeu inucli heue£t from tlie ust.; irf n'arrn ov acid drinks,
or ironi bruahlng tbe pjirta with a weuk solution of nitrate of
fliher*
At first I wiLs UiaposttI to I'einove the sutures ut the earliest
13«j
THE NECK-
popsible perirtil ; but latterh', from having onoe hrnl all tho
adheaiona p:ivo way Uurirg the H.ct of withdrawiii^ tlie threails,
I have lillowed tliem to reiunin a very lim^ tiine. It is rather
iniportniil that the month should not bo too widelv opered
during' the Oiirly eta^s of tho adhesive proepsB. Onco, on the
fifth or sixth day, I have known the entire wound to give way,
from ti»e patient opening the mouth too widely for the purpose
of inspection.
The number of onaea of cloft palate upon whioh I have oper-
ated by these methods h now about a hundred : of this number,
in less thun onc-tentli wna ihe fissure eonfine<l wholly to the
Eoft parts ; and, in at least three-fourths, tlie gap cstentled into
or through the maxilhity portion of the pakiino vault. In not
more than nine or ten cases, therefore, have I found it practi-
cable to close the fissure, without first dissecting up the mem-
braues from the poaterior part af the hard palate, and cutting
tlirou<rh the tendinous attaehmenta of the v<>lum to the ORsa
palati, I have in no case been deterred from operating by the
extent of the deformity ; and, in several cases of niotii formidable
flspeci, I have eiiceceded in improving the voice and facilitating
deglutition, as completely na in ovon the simplest fissures of the
velum. In one case of simple fissure of the soft palate, I was
tempted to o|>erate without first dividing the musclea. The
edgea cf the 6ssm*e came so easily together, tliat any farther
incisions seemed unnecessary ; and for several days e\Qry thing
hjoked fair. About the seventh day, however, the adhesions
gave way, owing, as I believe^ in part at leaal, to the imperfect
method adopted. As to the proper age at which to operate,
in one case of a fissure which extendei-l but little more than
through the uvula, I operated on a child of between six and
and seven years : but gonerally it i^ necesaary to wait until the
patient is old enough to fully appreciate the importance of the
operation T and to submit patiently to pain and inconvenience:
fsr this is onp of the very few opcrntioas in which the use of
ana^sthetica is inadmissible. Under very peculiar el re urns tan ees,
I suppose, ether might he administered, but not without some
rijik to the patient, and much onibarrasBmeut to the surgeon,
from the constant flow of blood down tlie throat.
FISSUHE OF SOFT AND H\KD PALATE,
137
Tho result of tlioao operations niny ho etafcil briefly ne fol-
lowe ; With tlio excejiliun uf pcrhnpe hjiif a Uosfln cflpce, 1
hnvo nt*ver failed t<> ^'ct more or lees union of tlie Eoft pnlnte,
Stinietinies one, or more rnrely two, of tlie sutures have f»iven
wjty at tho upper pnrt> wlicre ilio tissuca nrc put most Cully nn
the etrctoii. IJ' nny oC the ttiichcs hol<], however, nntl the
smnllcet union tnkes plaee, it niny be nfrcrwnrds extended cither
by the renewal cf tlic BUture^, which 'i& now it compnrntivdy
tfxsy matter, or by the ooeitaional ripiilieiUicin of xUq eobd nitrnte
of silver to the nngk of the remnining fieeure. The r;reot point
id to cntiiblLfh tlic nich of the soft pj\htte ns oomptelely its poe-
slljle : nnd, vrhca this i^ oneo acoom[>liiihed, any aperture which
niny rcmiun in the hnrj pjilnto ciin be effectually eloec^I by
aimple nteehimicid nieitns. In (<ti6C« of extreme fi^aure e^Iemlin^
through the nlveolnr iirt'h, wliero u few ariiiiciid teeth are ahuciet
ahvayfl rerpiirL-d to fill the ^'sip Cittieed by the lo^t or didturled
incieon, the phite upon wbiefi tho new teeth are luounled serves
also to clo^ the remaining; eleft In the rotjf of the moiith. Of
ooui^e, in aJl onsei^* the more completely the tii^eure ean bo
closed by the operation, the better it i^ ; but what I wieh particu-
larly to enforce is the fact, that, even in the e>ttrome cuBca of
very wide fif^surc in tho bimcfli an operation can bo performed
whieh ifi aa cfFeelual in restoring tlic voice, and almost n& easy
of execution, ns in cages confined to the veljm or extreme back
part of the pidatine vaidt.
The question U ufien at/iked of the Burp?on whether the voice
twill b« immediately restored by the operation ; and, if not, iq
what time the full restoration may be expected. The anawer
mu&t* of com-jje, be very iiidffinite ; fofj in fact, the pntient Ima
DOW to learn, for the lirut tiuie, the art of uain^ the pnlaCe in
articulation. Almost cvcrv patient, after the opening is entirely
clo,-iCiI, experiences a sense ot i"elief, which u owinjr both to the
gi'cater ca^e with whidi <.k^Hutition U peHormed, and aUo to tho
protection afii>rded hy the new jialate to iho mucona membrane
of the poetoriur fauces, which, bcfurc the operation, was dry and
parched Ironi the constant pnssit<^ of the air over it- I have
Intisly had occaeiou to see several patients two or three yCnirs nller
the operation. Two of them are toLicheie in public institutions;
la
138
TKE NRCK,
anil ilio oijjv clcfeut to be perceived la n sliglit liuskineBs of ihe
Toice, vihU'li wouUl h:»rilly be noticL^iI by rtnj une ignorant of
thtir fiirmer conditinn, I do not retneiuher la have seen a case
in wlitL'h ibe pnTient \va^ not mnieriallv benpliteil.
Tboou rt'ni;irks nre i^ondenseil firinm|iiil]y frurn ti report mnde
to the Ainorif.'iin A^i^oeL^ition in liSGi>. nnd borne out hy litrtber
experience. It is lliougbt unnecessflry to introduce cuaca in
iliurttnitlon, wliicb Is done In tbac pnppr, fiirlber thsir one or two
wblrli lire reinnj^knble for eonke peculiarity.
Cawk LXXTX, — Coi)pi?yiitnl Fis-^nre nf th^ Soft mul
Iltifd PaUtU, ii'ith iJiHthtt I[fVf}Jtp. — Putient, 20 jenra of
age. By an operation performed on tbe Up, si:c yenr^ before,
tlie ir](or[ii.tvillnry bone bcid been nlninst wboDy rcmovec] : ns ia
UHud afti^r llij:^ uperiLlionf tin? innKillary boncd binl [Hron dra^n;ed
into contHCt wilb cucb otlier in front. Tlie pnluliiie pn»:eyBee
of tbe mnxilUry und piibitinE^ bonea aef'iiicd iilmust waTitlng, and
ihu wbolti ttitli wiifl very narrow. Opevatinn : From ibe ex-
treint* deficienfy of tbe bony viiult, the membvjLnea could not be
tniide to iMjme together across tbe yp. Tbe Telum, bowever,
nnitt'd, Afler a Pn-tniirlit^ iindin^ dml tbe coverings of tbe hard
imlur<? b:iil bci-oinc Acry nnicli tliicltened, I iignii] dissucled diem
np» Jind rbiH time wae able tn unite the tinps by auliire. J?f-
m^h : Piirtiid :"Io^uri? of tbe gap left nfter the first operjilinn,
wilb i\ ibir.'keEi^il* HcFtby F^tatB of it^^ edi^er^, whidi ^eemeil to
pr<nriisc a tiX\\\ furiber Jiciiijiuiion !n ita iAym, or pot^^ibly e\i-n i(H
tntiiT' oblilerrtlion. Tlie reinjiining bole, wbicb was quite
Hiiinll, was clitsed bv two bits of elastic Tidcanized India-nibber,
alifelied l<ii;L't[iei" in fbe fiinii (tf n shirt-stud. A pliisJio ii[)errt-
tioti wnM ullerwards perfonned u^toti tlte lip and uoj^e, with the
effect of very greatly improving tbe iippciimnce of tbe pittient-
Case LXXX. — /"/ji^ttr?* of tfie Hard and Soft Palritc,
^r'lth j\Fediirti I^inntn-c of tht Alvt^nhir Arch, n/rd Dn'ihle
Harelip. — Tbe paT lent was a young mini, 17 yejtrs^ of iige,
upon wboni a very deiten»uj^ and |nLTfe(.-t operation fctr doubJe
bareli[> liad been |)erti>niicd ui bitiniey* by my friend Proressur
WilUrd Parker, of Ncvv Yuik. Ai tluit lime, as Prufep'jior Par-
pibbuhe or soft aud hard palate.
139
:er line kindly informcJ mc, he rcnoorctl, IVonk Uic cxh'cinily of
llie vomer, n smiill os^cuiia lubtR-lc, wliirli jorcicd a pnij^jctioa
similuf to ihiit ofton oauactl bj' the mtcrmJiKilbiry boncB in cneoe
of double bnrclip complicnlcd with double tiflsuro nf fho nlveolnr
arch. I hnd bwrn coiifiiilte<]» from time to time, on nccaunt of
i\ic elcft in Uii^ pulHtc ; but it woe not itnliE lie had nttiiiiied the
ape of scTcntoon ycmra that ho finally camo to mo for on o[>era^
tifm. Tiiia wne pcrfurmcd in tho manner nircndy dcpcribcJ
at length, with the result of pcrfcf'lly rc-eetabliehin-^ the vtlum,
and covorin^ tho posterior portion of the olcfl in the bonce.
The operation wus more difiicult thnn ufiUEil, owing to the
email size of the month, resulting from the previous opota-
ticn on the lip, nni] the unusual obliquity of the two ununited
bnlvea of the pfdntiuc vault \ yet the tmprox^otnent in nrticiiktion
waa more a[>ccdy and more decided tliun I remember ever to
have observed in nny other case. A very few weeks after the
openilion, he was able to wear a gold plute, which vrtii made for
him by Dr, Hufus E. Dison, of this city ; and it y\iie at this
time that my utlcution was purUcularly ntirnclcti to the dvtulur
arch and the anterior portion af thf t]6tiure> Tht? upper Up vfue
so eloHely ap|»licd Ui the teeth in front as wholly to t^onfcnl them>
except when lifted with the fingers. A glanec at this part of
the mouth reiealcl a renuu-kable deviation from the ordinary
condition of the jaw in tliid deformity, inaanmeh as it showed tho
exietcncc of a pcrta.'tly eyTmnctncal medran fi^purc extending
oomplotcly through tho alveolar aroli, between the eontrol la-
ciBor teeth. Upon the right eide of the eleft were eeen the firat
end second jionnancnt ineiaorfi ; then the canine tooth, out of
line, and pIa<Td ratlier abuve and in front of il^ normal posllitm \
then fhe two bicuepidd ; nnd, Inetly, tlie two molars. In front of
and abcfvc the ri:;ht Literal inei^or \va» the corrcttponding niilk-
tooih, hanging quite looec in the gum, Prceiaely the adnie
number of teeth existed on the left aide of the eleft, even to the
preeem-e of the Intend incjsor of the temporary eet. The cen-
tml milkHncieorri lind also formerly existed, one upon each side
of the fifi*U]-e -, but had been removed, a few years before, on ac-
count of a tendency to croae ench other, and proBC against tho
lip. At my request, Dr. Dixon removed the two rcraaiuing
1*0
THE KECK,
.--^'
iiiilk-tei?tli, anH alsn the
riglit cenimi iiiL'isor of llie
p c rm :j TIC n t tct^ wlilcli
f^eftiit'J i;lI>i»op[xl lo take
nil a^vk:v!Ln] poitiaou im rc-
^■itrdt'd both (he lip au(3
the jaw, A cnet of llje
moutli lias Iccn (Ji-eservol
□nd £giireJ, 8lius\i[ig (Ije
[iiiMtldii uf the £pfiure iind
(he UTLiiiigenjent of the
teeth. See woodcuts
Tlic woodcut preset] tfi
tlie siuXe of the [n\rls m
tijc case Df mccUiin fissure. Being taken from u ciiat made
after ihe opemtion, it shows the resloratiun of the posterior
part of the hiird pnlate, together with the reluin : it serves
alsc» to g^jve a geneml idea of (liu exti^iit to which It is aiiucd
to clo£e cxLeri&Ivc iia^urud in the hociy urdi.
Thlfi i£, so fur UB I am nwAre, fhc onlv case ever ohservod of
a true mediun iisfiure of the alvcolitr urcli, or. In other woida,
the only oiie in Vklilcli tlie clelt lioa Ijeen st^eti Lo occupy' ihe
poftilion of llic line uf t'lituro nhich sepnmles the two Inter-
muxilljirj hoiic^ from CTieh ot]Lt;r- In all cni^G^ hilhcrto nollccil,
the r'left in Llie nUculcir jiidi hii» beeo upon oni; or hotli tides;
oorrcapondin^^ In nii^at c^cs, to tljc Ihie which Lunrko Lhe union,
in early ftctol life, of the juoxlllary with the intermaxillary
bones.
I
QAti^ hXXm. — Fissure of Jlard and Soft Palaic,
DouUc llardip, operated oit 11 i/eizra f/e/ure. Oprrafioji,
Cure, — The fuUowing eaee is interesting-, aa bhowing the
miatoiiucitl nppcitmneod preacntcd hy the puktc in i\ person LU
yearn of ngc, \v]io Imd been operi»t<jd on eevcnleen ycnrs hefurc
fordoullc harelip, witli rcmovnt of the iotcrmEVsillnry bone. The
lip w'lie short nnd contractcil, and prescQied a large i-ed pkcc in ita
centml pj»rt, pri^duecd hy the prolnhiiiri, which rnn quite upi
through the whole ccntnd rcgiLin of tljc lip, to meet tlic middle
FlSSUTtE OF SOFT AND IlARU PALATE.
141
portion of ftVm wliirli (■i>v[*rp[.l iKc interiiinsillary l)onG. Tina
had not l;eca vk'ork(!(I info llie lip aa 1^ ■;;i;iit:rELl]v Udiie, but bini-
p\y fonaetl tlie ecptuiu uf the nosei The ri:ault derni>Qfitratcd
tljis mlvnnla^^e, tluit no snuT Vfna left* aa usual, ItJiJiuj^ to both
njsirili*; but the cii^Urix an tUe ri^'-ht Me was ronce;ilfJ nliove
in d plait of akiiii thnt on llie left sute beuig iiltmc vi:^ible. This
re^iult was Uepemh^iit probiiLlj upmi the fat'I, thnt the opE-'rution
hm] L>een perrormcd ;it tvvu nepariile t!ui&» upon llie (wo ^ides t^f
tliu lip. The cn^e 8U^'j?;pste(l the: idea, Ujat, if the inleniieiliiUe
pijrtion ofeltin were more fullj removed » niid only suffident left
to fiinu u ^eplLim for the nose, the eear nflenvarild, lustead of
preaenting the unsightly form of ii letter Y, wuuld have tlie him-
pler fonn of a single cicatrix in the noedlan line. Tlie ftppear*
Jince of the bone;* wus ns follows : —
The mitxillnry honea hiid not eome together, but were acpu.-
rated hy an interval of at leneit nn Ineli. The Grst teeth upon
the ^idcs vei'e the eani[ie»; itud there were, upon each fiide of
the juw, five teeili iihove iind ^evcn below. Tlie vomer was cen-
Iru] over the buck part of tlie fij^stircJ palate, which is ^en-
erully the case in ftimple cleft palate uncontplicated with hnrelip;
bijC ill front it curled Eo (lie jight side, and aecuied to unite with
the jmterior jmrt of the u|i[»er j?iw. It resembled, to a eertmn
extent, a ti^t^ure of the palate complicated with harelip on one
ftklc only, iu which chhp the vomer 'n generally conttminus with
the pjJatine plate of oi^c aide. Wliat the njLfure of ihi^ a|>-
]>nrent union was, does not e:iaet]y uppcar, when it la remem-
hered that (he intermiixillnry huiie, whieh is nlwny* nttJiehed
lc» the end of the voiuer, hiid been removed* It ia posAjble,
that, from the early age at which the o|icrjition had Im^co per-
formed upon the lip, iheae parts may have been dra^-n to-
jroiher, and coulesced,
I operated on this yonng ninn in June, I8f53, for the fiasure
a? the palate; the o|jenLtiun being perfectly bucceasful. An
artitieial phite, widi incisor teelh attoehed, wna aflcrwards intro-
duced to 111! [he ga[i in the jaw, iind cover the reuiaining Hsnure
in lh<f hard ^^date in front.
Tfie fidldwiu^ ohservatiiinfl were mndc eighteen months after
thia (jperution, when the patient consulted mc inedicully. Jia
148 THE NECK,
regards the reatoratioti of the voice, it was less than in the
greater proportion of cases in which I have operated ; for what
reason I could not exactly determine, as the sof^ palnte was
quite flexible, woe united as low down in tlie throat, and protect
ted the fauces as well, as in the natural state of the organ.
The improvement, as regarded comfort in breathing and de<£]u-
tition, was very great; as previously he could scarcely take
liquids without a portion being rejected by the nostrils.
DESCIilPTlON OF PLATE.
INSTRDMESTS EUPLOTED IN OPERATIONS FOR CLEFT PALATE.
FigB, t and la. Forceps for aeiEing and holJing the edge of the fissiim!
Tclum. They ar« in p&irs, one for wh sido or the AMure ; Fig- 1
being for the lull aide, and Fig. la for the right.
Fig. 2. Strong French sci*ftora curved on the flat side, shown in profile in
Fig- 2a; uwd Tor diviilmi^ the posterior pillar and other resisting
bandSi and For paring the edges of the £aAure-
Fig- 3. Slender spear-pojnted knift^i which I have someUmes usvil to pare
the edges of the liaaure.
Fig. 4. Curred Bpear-pointed knife, shown in profile in Fig. 4a, irhicli I
originally employed in separailng tlic membranes from the palatine
vault.
Fig. fi. A knife similar to the former, represented oXso in profile in Fig. 5a,
liut broader and fihorter in its t-urve. Tliis h thv kiiife wliirh I have
usedf for the lant ten or fifteen years, !n commencing the disaoftjon of
the uorering of the hard palate.
Fig. G. Curved flri^pors, Bu^allcr than those shown in Fig, 1 . and with points
nearly 0hnr[j ; u^ed in eompleling the dissection of the membranes from
the bony palatine vault. Shown in profile in Fig- tia.
fig, 7. Crorhet-aifTUillc of Sehwerdl, r^-prcsented as closed, and wiJh a
thread in its c^ye. By pressing upon the lever, the eye t^ opened, and
the thread disengaged.
HABELIF* 143
HARELIP.
It ia of much importance for the future appearance, and even
for the heulth, of the child, that this oj>eration ehould be
well (lone, and the proper time selected for it, I have per-
formed it, with succeaa, as early as seven hotira after birth ;
and its early performance was advocated by my grandfather.
Dr. John Warren. Dr. A. L. Peirson, of Salem, has also pub-
lished a paper advocating this being done enrly. On the whole,
after much experience, I ehould advise the age of three or four
months, just previous to teething, and after the tissues have ac-
quired sufHctent (irmnepa, as ihe best nge to Bclect.
For mnny ycare, I have advocated nursing immediately after
the operation, and w^hile union is ^ing on. By this means,
the digestive organs are kept in a good condition, and diarrhcca
avoided, which was often produced by change of diet when feed-
ing was formerly practised. The muacutur action of the lip,
induced by nursing, ralher favors the coaptation than the sei>a-
ration of the edges of the wound, though formerly the contrary
wos supposed.
I um convinced that sutures are much preferable to needles,
no matter how wide the reparation, and consequently great the
tension required to bring the parts into contact* They have
these advantages i first, they ore more easily introdueeil ; second
tiicy produce less irr!tati<m ; and, third, they can generally be
removed at the expiration of forty-eight, or, at the most, of
scvcuiy-two hours, without danger of disturbing the tender ad-
]iesi<ms. On the other hand, if needles are used, they must be
left until they are aufKcicntly loosened by ulceration, otherwise
there is great danger of tearing open the wound. The part of
the lip also embraced by llie figure of 8 over the needlea is
ofieu left in an excoriated state.
When the stitches are uaed, the inter^-ening parts are e3cpose<l,
so that the process may be watched; and, by the apphcation of
a small comprc&s kept constantly wet with water, the influmma-
tiun liable to occur in very young subjects is so moderated, that,
on the removal of the sutures, I have frequently found the line
144
THE XECK.
o£ nilhe^iDn quite perfect, free from reJnesa, and after a aliort
time EGArcely to be discin^uished. In iLict, the liBsuos seain to
melt into each other, witliout any perce|}lible cicntrix rein!iiniii<^.
Small, fitrnight suturp-reeilles, Leid firmly by forceps, wiil be
found miit:h more coiiveiiient to use tlinn curved ones.
In reiriird to ihe method for avoidiu" the irreuulantr wliich
80 often takes place where the eUgei of the lip are brought
together, I flhould say {having trieU the various menna that
have been Ku<rj^ted by cutting the edges of the lip irregularly) ,
that die only sure way is to remove fl liberal portion of the
margin of the fi.isure hpyord the red horilpr ju.st befrire it begins
to curve u[i\vards. The UEtlon of the parts is much facilitated
by taWng n very fine stitch oti the ititiide of the lip_ Ko dress-
ing.* are required until the stirches begiu to loosen, then a piece
of adhesive (thislrr of a dunili-bell shape is of much nsststflnce in
mnintaming the appositiifii of ihe two sides. With infants, the
hands ehoukl be H(!^ured iluring ihe Ireatmeot, aa I huve known
a single blow defeat the whole operuiion.
Case LXXXII, — Opet^ation for a ITareJip on a Child
three thtijs ofiL Ivhrrtiyt. Ilemorr/i^f/e. Reamrkabh Cloning
of the Fi^ffitre. — The child wos a fine one as to size. He
was first seen by me on the day of tlie operation. During;
the operation, it wns observed that thei^ was a yellow tinge
about ibc eyes and furi^hcnd. This was so slij^ht as not previ-
ously to have altracteti attention. When the incisions were
made, 1 remarked to the bystanders that the bleeding was un-
usually free, the bhiod bein-; dark -colo red , and comin^r from the
whole cut surface. The bleeding, hoAvever, ceased ; and the
wound wiiB brought together by autures, A wet compress was
fljiplied. Suspcetiug something wrong, I visited the child im
hour alierwards. I found the Up swollen, and bleeding tpiite
freely- All other means fuilinjr to arrest the hemorrhaire, it
wftH found necessary, !n order to save the life of the patient,
to cut awny the siitclies, and to include the whole ctit edges
in a series of ligatures. Considerable infiammatory aciiDU fol-
lowed ; but, at the end of a month, tlie whole wound wns entirely
healed, leaving the fissure, of course, much hirgcr than before
HARELIP. 145
it waa interfered with. Shortly after tliis, a contmction of the
parts took place» commencing at ihe upper end of the fiasurc,
and gradually extending downwards so as ultimately to produce
complete obliteration, no ecar being left except on the very edge
of the lip, which was rather projected downwarti thnn hitched
up, OS it often is nfter the operation of a hnrelip. The pro-
cess of closure^ in tliis case, was so rcmarknble as to demand
special attention* The occurrence of hemorrhage in connection
WLih the eymptoma of jaundice is interesting. Dr. Francis
Minot, in a valuable paper, read to the Boston Society for
Medical Improvement, has shown that out of thirty-nine coses
of umbilical Kemorrhagd thirty-two had jaundicC' It has also
been shown, that the bleeding from wounds of icteric patients
is arrested vvith difficulty. It therefore seems proper to avoid
operating upon patients in this condition, if possible, until the
symptoms of jaundice have passed awoy.
19
CHAPTER IV.
CJTEST-
FAHACENTEBia TEORACIS.
TiiE operation for the removal of fluUls frcui tl^e cavity of die
i:heflC, W jjuticture, or by ihe hitrodiiction of the trocar and
caDul», has been for a long time employed in the practice of
aiir^ery. The cnses. however, wljlch generally fall umkr tlie
hnnd of the eur^eon, arc those of chrouic dbcaHe where collec-
tions of pua have taken pkce> In the^e cases, the simple widi-
drawal of the fluid , followed in fiome inaliinccs with iodine or other
injectione^, dues not seem to acconjidJAh the oliject; and I have
oute or twice made incieionp into the chest artcvwanU. or left
the canula. in pJaCe to allow the eacajie of the floiil aa 00011 as
formed, before a cure was accojnpliBhed.
The e\iatence of a connection between the bronchial lubes
and the pleuritic cavity, allowing the eocapo of air into it. liaa
not been an objection ; the aperture in the lung being obliter-'
atcd 03 that organ cxpanJcU.
In tubcrculoua caeca, the rcLcf jiUbrdcd, in general, ia but
tempfjraryp ll is in cases of simple pleurir<y, with cftiision of
serum or pus into the pleuritic cavity, that the 4,Tcat beneRta
of the operation arc obacrvcd* In one or two caaca where a
ajjontancoua or artificial opening has become lialiUous, — the
passage being narrow and dcvioue, — I have seen serious irrita-
tion eet up, giving rise to hcmurrhage more or Jcsa aevcrc, anj
leading to tiic euppo&ition tliat it was caused by a carious condi-
tion uf the rib from tlie lon^ contivct of pus with it, which
occasionally is the fact* These eymptums have all been i^elicved
by making a irce incision into the cavity of the cheet; one or
two cases requiring the removal of a portion of the rih in order
to keep the aperture freely open, owing to the iLickneud of the
pleura &om intiammatorj action.
■ATUCETnrSIS THOItACIfl,
147
•
A caption may be given in some old capes in resnrd to punc-
ture when the pleura has beconic cxccf^eivdy thickened. The
intitrumonl shoultl be driien in with & ccrinin amount of force
and decision; otherwise, the pJcura is I'urced before ite point,
anJ no fluid is supponed to he present, when, in fiict, the cavity
of the thorax Ikfia not been cntcred-
Of late ycara, the removal of recent dfiieionB of Huid has
been practised in our vicinity with uiitat ^ucocsafiil reanlte bj
Dr. Morrill Wyraan, of Canibridi-c, Dr. H. I, IJowditch, and
others, by the uee of a amall cflnula, with euetion applied bj
mcnns of a syringe^ so aa to prevent the odmisBion of atmos-
phcrie air.
Case LXXXIII. — i'w/jyemrt- Fistidone Communication
icit/i Lungs* Pai'an'tnteMs Thoracis* Gure* — The polient
woe a youn^j man, aged 20, of good constitution, and not of
a tuberculous family. In March, 1853, he waa aciBed^ ftft4?r
cspoenrc to cold, with a severe pain in hia rip;ht eidc, which
couBncd bim fur blx weeks to hia liouac and l>cd ; it wn? not
attended with couj^h or expectoration. After this period, he
went out, and waa able to employ himeclf partially in hia
ordinary avocj^tions. In June he waa suddenly seized, wbilc at
dinner, with a violciit fit of coughing; he left the table, went
into another room, and e3(pectorated about two quarte of pua.
Prom this time hia cough and purulent exjiectomtion continued,
being more aevero at intcrvala of u week, when the chest emptied
itself of about the eame quantity as at firat.
1 waa rcqiiEr*ted to ^ee him in the country, in October- Tic
waa then pale and emaciated ; hia akin hot, and pul^e one hun-
dred and twenty. Ilia appetite was good, and he took the sanic
amount of food as in hcallb ; but hia system wna gradunlly
giving way under the di^cnac. He wns very desirous of havin;;
an opening maile into hia client, the idcn being original with
him, and not derived from othert^.
On exaininatj<*n of die chest, it was obaerved that the right
j^ide was enlarged, and that the lower intercostal spacca wore
ruthor protruded than depressed- There was no decided promi-
nence or pointing at any pnrtienJar spot* On percuseion, tbe
146
CHEST P
riglit Me wns quite fliit, fxcppt fir cue or iwn indies Ijclnvr
die tluvicle, wliere n siibiL're[iit!]iiT. r/tle w.is notjcciL Succussiim
caused n luiu1, awju^hing SLHind, which vaa heiinl by ihe piitient
liiii]pelf» jiml luul [inilmlily Imni^ht tu liis initnl [\io irit-n of relief
fium ji puDi^curi;. Tlie respiraimn an llie lefL ^iJe wra dcciUeUJy
puerile.
The cliest was pimrtiircil witli a ddicate trocnr^ nboul four
inches IVorn tlie njiine, liptvvc^ji ilie iiinlh jind tenili ribs; nnd,
Gij<?rlna Byrin<rK being iipplied, ii pint ami a linlf ijf tliirlc,
hedlliy, modnruu;^ pun wjih witliilrawn.' No cougli or canstitu-
tJGtiul tIi(fiiirbftTH!e fallowed. Gri?rtf ivlit'f In brearliing wiis nt
oni:e iiercepnljlt^ : urid lit nrute, ntid wnlkcil ubtmt rlie room in
liitfli Rjiii'ila. Tlie liin^ eTipjmdod, Jiti<I res^pirntior cutiU be
bejjrd nlnng tbe ftplne, iind fur one or two int'liej Iieltjw the
ECapulit, alsit muck lower down tlmn before in llie fmut jinrt of
tlie L-hesf.
Nov. 4lh, ibis pHticnt was ^d imich better as to l>c nMc to make
ft visit to Rofitmi- Tlin foiiyb was now lesa; lie bad n^iinrd
flesh, and his strength was Jncreasinj^. Tbe rpspiriilory mur-
mur emild bp distlnguisbed all along the ^pine^ rpiile eloar, nnd.
frpr from rrcjiitua. Tht' j;ide wns fljit on pfrcusaion, and tbe
respirjttiiJn and smincl-'s cif Itentl bcrird hh if ni a dintsmee. Nov.
ISfli, finding that the pua was again collecting, ihe chest was
pntictLirrd. and twelve ounces nf fluid dmwn off with relief.
As the purf uorlimied to i-olleL't, and die aymplinns lo recur,
there seemed but liide probability of a cure wiihout having
Teconr*ie to a permanent ripening. Tt wns thf^refiire derided to
intriidnce a large trocar, and leine the tanula in tbe wuLiiid.
To facililnle its intriKlurrion, ng it wna feared the thickened
pleura and faUe meinbmnes might resist, an incision wa.s first
noLde tbriHLirh the inteiTiiment, and tbe trocar then pnsbetl in
fitrcibly. Whiit Imd hecr feared as a possj^ible oeCL[rrence hiip-
petieil, — the ioetrument did not penetrate the cnvity of the
rbi'sr. «nd inilbia:c but u Rw dro|ir* of libiod U'^j^ued. Tt was
tbojgbl best to delay a I'cpt'lilion of tbe jmncluie for a few
dtiy!4, and wjitt^h dte HyniptoinH, A alight irritation took jiUee
in tbe wound, mat the con^rb subsided* APicf a week, be pro-
posed to n-inrn home, nnd, if reccssary, make nnothf^r vi&it to
town, and have the o|>c:rutiuu rej^ieatcU.
149
TTc was not henrd from a^r^in until J-in. Olh, Ifi.')!, wlicn I
was nillcJ to sec liim In the cmintry* timl fdunil liini Iftboi'ing
uiwlei' very alnTiiiing syniptums* lie was cunfiiied to hie bed
in nn cxlretne de<j;reG uf emncintion ; pu\K coe hundred And
fifty, ekiu cknniiy* Tlie expectornliou wn^ pri>ru&e. nnd ho
ofiensivc as io niiikc it difficult tu remain in the same ruom ivith
liini. lie said Ehat. on his return from Buaton, the weather
being \cry blealc, he wne'nmdi expo,*ed, nud tw>k a severe cold ;
from uhidi liine tlie ^vitiptoui* lind slI) been unfuvorable. The
e7( pectoral i*»n wfia ao nnuscous n& cnlii'Hy to destroy Wis nppe-
tlrc, nud the coii^h -was cunetfint nnd painful, lii^ vilnl powers
were eo rednfcd tli-it »<»mc lieAitation wn.^ felt in aticmpiin^ any
ojicrntion ; but the pnticnt ivna ao urgent that it should be (ned*
and it being the only chnnce for life, it waa resolved upon* The
fine trocar was used aa nt fir^it, and two quarts four ounces of
fetid pus were drawn off", with ijnmediatc relief. Tbc nir pnascd
freely In nnd out of the cnnula during rc^piriition. lie waa di-
rected to keep the npertiirc in the fjinuln do'^ed with n cm-k,
whicli was to be removed twice daily, nnd the pus cvHcuated.
The pjitient from this time, under the judicious mana<^nkeut
of hia phraidan. gradually recovered ; and, \i\ May, he was aUe
to ]>re,^ent himaclf in Boston In good health. I saw him in
November, quite fituut and healthy; and lie had no cough nor
expectoration, JIc enijiloyed hiui?clf in his trade cf watch-
tnnkin;r. The lower piirt ufthe rigrbt side of (he cheat wnfl Hat;
there wna no contraciii»n uf that i^idc. lt«spirati<>n wna heard
bidow the acapuln, without erepitus. I was aaeiated in the
iihove cpi^e hy the able advice of Dr> Bowdltch, and in the Inst
operation by Dr. Slade.
Case LXXXIV, — PUnrlf^. Ewpycnin. Pus drajcn off"
hy a PtiHCfiij-c in Bm:k, Aflentttrdff Pointing, ffnd nn Op^n-
in^ intuit in /•'I'ont. Ifernorrfifitfe, ttl ikr* eud oj'lito ytara and
<i Jtt/ff, fi'om i/te jiaterior Opening. I'*ree Inoieion. Qtirc,
— A gentlcnmn, a;^ed 45, had iin attHck of pleurisy on the left
side. Van lia-mod there, and waa ilruwu off' by a puncture in
ihc back, with q Hne trocar and canuln, and greut relief flffurdwi.
Subsequently, there was pointing in tlio front cf tie chest •> an
CHFST.
opening WAS mndo with n lancGl, fluil the pus ovacunicd^ Tbo
pjitient recovered his health ; but a purulent di9chnrge continued
to flow from the njwrtnre maJe hy the lancet, A few weeks
before I aaw him, a eudil^^n di^cliargc of blood toob place from
thia opening, find, reeurring onee or twice, reduced his strength,
and incctpnclrAied him for buaineas. At thia period, the pua
escaped througli two openings in the integuments by a tortuoiia
route. With a j>rohe, the i"ib» in n onrinus stnte* oould be <le-
tected- It was thought probable, on eonsullntiou, cither that
from the pua being retained in the cliest on necouut of the
small size or irregularity of the openings, or from the diseased
rib, a eoureo of irritation existed whirh guve rise to the heraur-
rhjige. With this idea, it was decided to dilntG the eKtemnl
openingfl by means of prepared sponge. This wa** found to he
a matter of ponie difficulty, on ancoLnt of the great irritability
of the wouod^ and could he done but imperfectly; still the
patient received a temporary relief from it. The heinorrhagei
however, was shortly repeat«l, was more severe than at first,
acnompjmiod hy the appenrani'e of purpura over the whole
Ijody, and brought him intu an alarming state of prostration-
It wtia now clear that something decided must be done, or the
patient Avonid sink; and^ on further consultation, it was agreed
that the rib whoidd be eut down upon, the carious part removed,
and, if thought expcdieTit by the knowledge ihun aef|uired, a free
opening uifide into the nhoat. The patient being rtherized, a
somewhui lab'iridus dissecrion was required to cKpoae the rib,
on account of the accumulation of ly^iph over it, xvliich had
gniduully co!le<!lcrl, and obscured the opening into the chest.
About an iuch of the lione, in ri diseased statO} was excised^ nud
the pleiini, much thickened by inflnmmatioTi, expoBed. An
aperture aibout an inch long, with thickener! edge><j was now-
seen, which, being enlarged laterally, allowpd the forefinger to
pass freely inttt The cavity of the thorax. It was ascertaineil that
the interior of tbe pleura waa lined with a highly vjiscular »]"ongy
tiESfiue, bleeding on the hlighti?fit touch, which, probably being
irritated by the retaineil pus, had given rise to the profuse
hemmrhage. Being turned on bis side, a large ({uanlity of
blood and puti ran out.
PABAC£lST£die THORACIS.
151
From the tim^? of the operation, be be^n to improve, nod
with the exccplioD of a very eli^ht iliatrJiarj^e of blood from the
cheBt, on the dtxy ducccicdingf had no farther diSculty. He is
now, oiany yciira after, ip good health. Hia chest is i!untraGte<l
on that Hide, and bi^ shoulder gi^atly dcpreaacd ; otherwise he
had tho appearance of a very strong and healthy man.
In another cjiae (that of a boy about H? years of tLge^ re-
ferred to mo by Dr. Bowditch), where severe cough, emaeia-
tion, and other di^ap-eeahlo eymptome, were dependent on
^empyema with an iiaperfeet escape of pus tluough iietulona
openingfl, ail symptoing were relieved by making a free and
direet opening iuto the chest.
The ludt two oosea are selected from quite a number which
have oeeorrcd to mc. As a general rule, I would repeat what
I have before said, that a free iiieiaion, with the removal even
of a pieec of the rib if necessary, gives the best results where
repeated puncturce have foiled.
In regard to tlie excision of a portion of the rib for tumors or
other diticoee, gcDcrolly spoakingT the danger is leas of pene-
trating the pleura than wilJ at Erst be BUpposed. The tcxtnrc
ia so tiuekcned by indammation as to bo easily peeled from the
bone.
CH.\PTER V.
ABDOMEN.
BER>'TA. — STRASCrLATED HE&_\1A.
The whole trentraent of strangulate J hemu has been allered by
the itilroduction nn<I (i!c o? ether. Mnny atses which re^ieted
the i]£e of jcc, Je{iletLon, nnJ dehililnrint; rt^nieOiea, ^ucH nfl
antimoD)' acd tobaeco inJeclhrEia. nre now, with rhe pjitient well
etherized^ and careful manriiulniionB, reiluced without a cutting
operation. I have aeldom bad any dlfficully in reducing hernia*
of large aiie : it is tlic very amnll licrniM tumor* that occur Bud-
deidy after (in effort, in which the tnxh under ether otleii
fuild. After n. moJerntc nnd c;niTfnI oee of the tnsis, I have
never delayed the ojjeration, nnd liave nvftiJcd rnys^elf of tho
patient's bemg under the influence of the nnte^thetic to proceed
at once to Up In ekUful hands this is aluiosl always successful J
and I have never had reason to believe that the patient died
from the effects of the operation, it nimoat always being from
the delay in performing it. Some caeea of large hernia hove
been under my care at the Hospital, which at first appeared in
a fllrangnlateil condition, but which were simply' impacted fronn.
A sudden addition to an already pretty firm tumor. If tho:
ayniptonis were not urgent, rest in fl horizontal pOdtlioE, a
Starving diet, 0|nnte3 to relieve pain, and, in some enj?c*, com-
preflAion, have, after a Few days, succeeded in affording relief.
Jn one case of a very small strangulated liemia, in which the
aymptoms were very urgent, nnd where dciith eecmed ifnniinent,
I advised an immcUinte operation ; but the patient positively de-
clined, preferring to die as ehe was. A week ailerwards, to toy
flnrprise, I was calletl ta her a;;^in by licr physician, and found
her fitiU ulivc, and ready tu have the operation done. On open-
erttANOULATED HEHNTA.
153
■
ing the tiimor, the aac wne found entirely j^an^^ronons ; but the
pre^UTO of (liQ stricture had Ijl-cd expended on tliii4 pnil, mid
the emull loop nf the intesline, though very much disccjiored,
etdl prcaervcd ite vitahtj. The i^tricture wob dirided, find the
intestine returned. The pnticnc recovered, Tliisoa^c* however^
is a vcjy rare one. The nile shouM he* where t]ic hernia ia
not at once reduced under the relaxinj^ cffecta of ether, not to
dekytlic operation uitli the idea that the tumor mcy be re*
moved hy looul fippliciUlons.
The di&tiiiguiflhed eursp^on, Mr, "William Lawronco, of Lon-
don, whose trcatitie on Hernia elill remains the best ailtliority^
^ afi do nil hit W[>rhr* on s<;ientitiL' eubjccte, — eojfl, " The dan-
ger to whieh the patient ia exposed by the operation is lesa thiin
that whieh ho under^^oea by delay. In the Inlter case, ixiHiun-
mntion and gan^^nc of the part, which is thus rendered inea-
paUc of exei-ei^ing its fiinctiuas, nnd cKteneii^n of intlanimatoty
disorder aluni; tlie canal nhove the stricture, as well tka over the
eavity of the nbdomcn, with rnpid cxhuuetlon of the vital
powers, ure fiiirdy produeed hy a continuance of the inearecra-
tion," And a^iin lie «ays : " Our eonduet tnu^t not be guided
merely by the duration of the ease i tiie kind of etrar;;uUtion,
the nature of the flyinptojiia, the effect of the mcjvna ciLiploycd,
&nd the state of the pnrta, mn&t influence our determination*
Small and reeent hernin;, or such as, havin;^ Leen kept up for a
longtime by mcnufl of n Irufls* arc suddenly reproduced, admit
of little delay. The atmngulalion ia violent in such inatancea ;
inllanimaCion nnd gangrene soon come on. In old and large
rupturea, whieh have been often down and oftcu replaoed, the
fiymptoraa are not ao urgent, nor the necceaity of operating so
preH*ting."
I propose to adduce a few coflce in ilbiatration.
Case LXXXV. ' — SlfUi^gttlatnd Ftmoral Jlcmift, Omen-
tum forrnituftt Cijet QotUnhiiitff the InteHinc, Large Ab^i^eaa
•icithin the ^ildomeii. — The fiibjeet of this caf^c waa a laborer,
40 ycnra old* The hernia first made ite appearance five ycarg
before, in \6'61^ and woa ditHMivcrcd HJIing the eerotum after a
bard day's work. Tiie patient waa able to return it himself with
20
154
ABDOMEK.
ffome little difficultv : he made no application, however, and
wore no tmsa ; and when the inteatinc was occivaionali^ pra-
trudcJ and a^ liltlc pinched, hy quiet and abstinence, lie 9iio-
cccded in replacing it without mcdiciLl assistance. Two years
before, tbc hernia suddenly diauppeared, and did not m^peur
again until the time I waa called to him, io 1842.
1 Wh13 rcquc^led to ecc him l>y his physician, Dr, Brown,
under the following- cii-euni3tancc9. Forty-ei9;iit hourd before,
while raiain^ a hejvvy lo?id, the hernia waa again suddenly forced
out, and severe jiaJn in the abdomen imnie^lintely enaucd. He
niiidc repeated eflorta to reduce it, and the following day even
attempted to re^iuiic liia work, but faiulcd from pitin, nnd wag
taken home* He did not ace hia physician until the next morn-
ing, not apparently being aware of the daugeroiis nature of
the diseaaep He vnxs immediately bled, ice w.ia applied to the
herniQl tumor^ aad a}] the ordinary uieana ibr the tasiB resorted
to. In tlic afternoon, the s^'inptome becoming aggravated, I
was retiueiitcd by Dr, Brown to perfunn the operation.
The tumor at this time was nbout the ^ize of an oran^, very
tenee and painful to the touch \ and the scrotiini, from the long-
continued effbrtd of the patient by eevere rubbing for its reduc-
tion, hftd become eonaJdcrably indaiuej. He complained of a
Bcvcre dragging aud almost insupportable pain in the abdomen-
Ou opening the hermid aac, a large niase of omentum presented,
very red ami swollen : this had an eiafllio feeling, aa if it sur-
rounded a mnss of intestine.
The stricture, which was formed by the external abdominal
ring, xviis e,\tremely doac ; and it wae with the utmost difficulty
I waa able to insinuate a director luidcr ita edge, and divide its
£bree. This bein^ acci>niplisiiedi the strnnipiUtcd parts were a
little loosened so as to allow me, after some ex.imi nation, to in-
eei't the llltle finger into an aperture formed by a folding of the
omentum, and discover a knuckle of the intestine, which was
thus almost completely encysted, IJy a slight pres^jure, this
was cattily returned into the abdomen. The reduction of the
omentum wns, however, a matter of more difficulty ; and it waa
only after a further division of the etrietiue, and by considerj;hle
management, that it was ultimately i-edueed. The omentum.
STBAJIOULATED HERNIA.
156
though much swollen, was not at all imiiiralcd. and wns other-
wise ftuUe Jicrillhy- He esprcaecd him^^cll' immcrtiatcly relieved
DQ tlic complcEioD of tlic openttioD.
The following morning; he waa free from pain in the bowol&t
which ncted well after a doac of cjiator oil. There woe a reten-
tion cf mine, which required the use of the catheter. Hia pulse
wna fi iittic accelerated. On the third day, I perceived a slight
rcdncflfl in the gr*/in, nnd he complained of a decp-soated paia
in the left iliac regioUi The piilac wns quick, couatcnnnec
ftnxious, and the tongue considerably conted. On the tollowing
day, t]»e redness had extended itself nearly linlf down the thij^h^
and over a port of tlie ntidoinen ot the aame side. There waa
^cat pnin at thia point, on pressure ; but tho abdomen generally
waa not over-sensitive, and presented no iippearanec of extended
peritoneal infianinintion* Ilia bowels were freely evacuated by
inenufl of castur oil, and Iccchea were applied to the scat of pain,
followed by a larg^ poultice to promote tbe How of blowj, and
incren*?c the capillary circulation. In the course of a few dayfi,
an indistinct Huctuatiou could be distingnisbed deep in the ilinc
re^on^ whiub finally, ton days after the opcr&tion, began to dis-
charge itacif through die external abdominal ring at the upper
part of the wound made in the operation. So hu: aa conld be
ascertained, about a quart of piia wad contained in tbc abaecsSi
The parictca ^rndunlly contracted, and the patient recovered
without further dirtieult}'.
The three points of interest in tliia case are, first, tlie disap-
pearance of Q large hernial tumor, which for three years iiad
been unrcstr^incil by a truss, and he sudden return, and Imme-
diate strangulatioti by tliC external ring, two ycara nftorwarda.
Second, The encysted state of the intestine, which waa so com-
pletely concealed, on the tiret opening of tlie aaf , that it could not
bo exposed i for it was only after the protruded parts had been
relieved by a free division of the stricture, that the omentum
Leonid be nnfolded, and tlLC intestine discovered through a small
aperture at ita po&tcHor portion. Tj^iinl, the formation of the
large abscess within the abdomen. Nu appearances were pre-
sented, on the evacuation of this abscess through the ab<1ominal
ring, to Justify the idea that any portion of the omentum had
IS6
ABDOUEN.
become gnn^^nous r tlic pus wob well farmed, nnd in all probtt-
ability must have been derived fnmi a tiUppHi'iitiim of the
proliipeeti ojiicntuni, wliioh h^itl bcea inrtumod partly by the etran-
gulntioQ it bad been subjected to, and partly from tbe iong-
contiiLUcd anfl violent efforts of the patient to iorcc it back into
tliQ abdomen.
Cabf. LXXX\\[. — Slranffufated Hernia. Hcdaction
undf^r iSt'ffffulfir Cii-cHmstajices. — To the above case 1 may
add one of eome intereaC, ebowing the powerful iDdiioncc uf fear
in ctfeeiin^ the rcthietiun uf an apparently irreducible hernia,
whieh had rosUtcd all ihe onhnary moans of treatment. I waa
re'jueetcd by a medic4d Iriend to perforin the cpenition for a
patient laLoiing under the most urgent and dietreeeing- symp-
toma I bii^'e ever witnessed in thie disease, Tlio hernia was an
old one, and had firat bceomo 6tran;^lateJ two day^ before.
In addition to severe pain in tlic abdomen, the palicut bnd vio-
lent ^'patimodic noti<»n of tbc whole bixly, espeeially of the lower
cxtrGmJtica, and oti almo^^t eonrinned vomitin^;:. Before I saw
liini, ho had been thoroughly bled to avneope, ico hiul been
applied to the tuiiior^ nnd a lohaeeo enema had Ui^en adminis-
tered, but nil without cirecl ; mid the only hopca of saving life
appeared to be in the apcetly reaort to surgicfll means. All tbc
preparations for the opcratitm being made, aa 1 waB just on the
point of eomnicncinj^ the inoi^^JDU, his coiira;:(o gave way^ and
he obHtinntely detoruiincd not to submit to it>
I thtn elated to him the great danger of any delay, and tha
probability of n very spcctly fatal terniinntiou if the inteatino
waa nllowcd to rcmaiin lunger in ita present situation- The dan-
ger of death before hia cyos seemed to have a powerful effect
on hini ; and, while 1 was speakings the apaamodJc action of the
body eeaj^ed, and tlie patient became deadly pale» Having my
hand on the tumor, I felt R slight relaxation in its eontents. I
immediately ^ei^ed the intestine throiigli the abdominal pariotes
with one hand, and, making a strong extension, used a slight
uompre^flion with tbc other band, on the aac ; and the herniA
slipped baek into the abdomen. His recovery wn^ complete*
Had it not been for the oecurrcncc of the accidental circum-
STRANGULATED HERNIA,
157
Btanra mcTitioncd above, 1 have evcrj rcneon to believe that
the mere mtcntilty of eutrcring must have shortly Iciuiiaatcd hia
existence.
IntrodiicfioH of J''ecal MatUrs into jleV J^a^
coraceous
'J,
Case l^XXXyJI.—StranffiilaicdlTEmm.
Vomit tag*
eagea. Death, — On Sunday, Julj 6, 13€Sf & woman, 43
years of a^. wne brought into the Hospitfll for »trflt»;^dnted
hemiii uf iive Jnja' Jumtion. She hitJ autlcrcd wiih an inguinal
bemia on the right aide for four ^^cars> It woa rctluciblef and
she wore a truae,
A week before her admtseion to the Iloapital. aflcr violent
atrainingj the hernia came down, and could not be reduced.
Constant vomiting comiuenccd* which, for three daya before her
entrance, was etcreomccoua. When ehc entered, she was in the
greatest atate of ptoatratiim, countenance piUe and livid, and
very apnlhctic. She answered qucations reluctantly, and only
when atron^ly prcaacU. Stimiilmits were iirat admiiiialcrctl to
her* After sonic rc-nclion had taken place, ctbcr waa given
opnringly ; and she came easily under its influence. The opcnv'
tion waa performed with great mpidity^ only oeeupyjng a few
minutea. Some eerum wad found in the eac, and the inteetine
much congested- The atricture waa divided, and the intestine
WM replaced- The ether was diflcontinued at about the inid<Hc
of the ivpcrntioD.
The ed^'cs of the wound were then brought in apposition, the
patient bi^eathing tran^jnilly, and the usual preparations made to
return htr to her bed in the ward. ,Suddenly the patient (who
had made the u.*ual ^Toana and sighs of a pcraon recovering
from ether) made an clibrt to vomit, and was placed on her sidi^
tofacilitnte the cscaiie of the fiuida from her mouth* Tlicse efforta
were once or twice repented, when the face l>eciinie livid, pulse
begnn to faiU and a loud subcrcpitant rale could be her^rd all
over die cheat; the symptoms rcsembhng those of a person
asphyxiated by drowning. All ttie uaual rcniediea were em-
ploycfi to re^^lore the vitid powere ; but the pulee and reapiratli>n
gradually tailedf and she died in the courae of ten or iillccn
minutes.
IM
ABDOKE3E,
0> ajttnwtm of Ae bodr, t^ Mb>wui^ dav, tke ■ppor^
MW*fi§ pi'CMjiied w^erc 1mm : — -
The Intwtitw umI itflpmrii were cntireh" filled wiA m
qvflntiij oT yeDow fluid of a tctt fedd tidor- Tlie moatb mud
boeci were al«o filled witik s uMOftr fioid. Ok opta^ ^«
mt-yammgtXt tfau Biake fiiod w fisctad to faftTQ pear tried tbe
okmC remote ramtficaljoiu of the brorkcJux.
Tlie mcarecAted inCeMifte, wiikb had beat freed 1^ tfaaj
operaiioD, dkowed the ms^ of dw gn^ oonctnetioii Id iHudi
it had been subjected, bat would probftbJr Lav^ recovered ic^
«elf.
Al Gnt fti^t, I tboagbt I had foec with » cue of death &md
tli€ nsc t>f ether ; but the mQt4>|»7 reTe^kd tbe nstsre <»f the
Tbe patient, as hae been et«ted, bod pariiAllv recorered from
ethetizntion, so as to mike articular sotmdd. The medical gen-
tienien who were present at the operation had, in ^ct, mott of
tbem retired, thinking the caw finiifhed* From the rocnrr^iice
of the cfforlB to vomit, partlv from the great rcducltoD of tfaa
vit4it p<fwcr0f in connection with the insensibility of tlie glotlio
from the cifects of ether, ilie fluids had gained a ready entrant
into the air pa^aagea.
The fullovring caac from the '' London Jledical Gazette^*' to
which my attentioa has been called br mj friend, Dv. Fraocia
MiDOt, ie interesting &« IlluEtralive of a simiJnr occurrcncct
though of a diAercnt origin. As the oase if ia^tructiTe, I trao-
ecribe it-
"St. Thomfis's Hospital. April 23, 14(59. — The following case
ilJufltmto^ flome of the ill clfcctD of drunkenness, and showa the
impropriety of leitvlng pcreone in thid condition whoUv uncarad
for;—
" J^ W-t <* laborer, 32 years of age, wju brou;:hl to the Hos-
pital by the police at T o'clock, a.m. He hndf somo little time
prcvioiifily* been taken to the station -ho use in a etutc of com-
plete and iielplcjjs iiitosication ; bad rcmaincil there a few hours
without having much uttcution bcato^^-cd on him ; and, at the cud
of that tiinCt hie eondition then exciting some alarm, he woa
brought to the Hospital.
BTBANOULATED IlEBMA.
159
** Oa admiaaion, he -was fijund etill tf> be somCTrhot comatose ;
but Ilia face wae livid, liis Lrcalliing labonoua nnd whceziug,
his pulse dlmoBt imperceptible and rnpiil, hi^ akin moiat. He
preseuted, in fsict* moal of (he fcnturtia whi*.'h chumctcrizc the
Uat attgc Iff hroneLitia. He diod in the course of a tew huure.
'' A^utopfii/, - — Bftly in good condition, but nnasarcoiifli The
BupetficHil veins of the bruin were more IcMidcd with blood than
usual, and the eubctnnce of the or^i^ap waa somewhat con^cated.
Pericardium and heart healthy ; the cavities of the latter wcie
dilatcdi and iilied with soil black caugula ; pleura ircc from ad-
hcaione.
^ Jjitngs* — Large, much in Sated, but not emphyscmatoue :
they were crepitant throughout, and a little congcated ; but there
was no oedema. On BqiiecziTig the aectional surface of any part
of either organ, all the cut bronchijd tubes yicMcd teiiacioua
cylinders of a dirty yellowish hue ; and, on tracing the tubes, It
vaa found, that all of them, from the largest trunke to the uii-
nuteat ramilicationft, were Hllcd almost completely by a material
in some places eoftcr, in some more tenaeioua, but cvcrywiicre,
in all essential imrticulara, reeembling that squeezed from the cut
orifices. The mucous membrane of the tubes waa deeply con-
gealed tliroujirhout, and in some instances it ap|}eaitd aa thoug;h
email extravaentions of blood occupied tJie &ubmucou» tiraoc.
The mucous lining of the larynx and trachea waa likewise in-
tensely congested ; bat it nas not thickened, ami there waa no
exudation on tlie avirfaco. Under the microacope, the material
occupyin;^ the hronchijd tubes w^is found to preaent a large
quantity of free oil, cella of potato, nnd innumerjtblc frapment*
of muscular fibre, together with a good deal of stuff of which
the nature was not clear ; the whole bcin^ iiiEermixcd wi(h ciliary
epithelium, and some imperfect forms of cella belonging to the
luucua, which cemented, aa it were, tlie varioua subatanecs inU>
the form of tenacious cylinders,
'* Peritoneum healthy. Liver, of uniform, reddish-brown
hoe, congested, but heallhy. Spleen, of usual &\zg, pale. Hnb-
by, and wriuklcd. Pancreaa, kiOneys, and supra-renal capsules,
healthy.
"The mucous membrane of the stomach (cardiac end) was
160
ABDO^a:^^
aomewhat coiipeated and aoftenei^ ; but tlint of the real of the
organ and of the intestine was lieaklij, presenting, however, a
more tlian ordinary quantity of niucua adliering to it. Aorta
health J.
" lie marks . — It ia evident, froto the resulla of the esnniina-
tiun, that the mnn, while in hia drunken ataXti, had bi^en conlinn-
ally vomiting, or, rather, regurgitating the conJcntB of Lis
etoinnch ; anJ that, owln^tohiauneonaciousandperhapaijartially
paralyzed cmiditlun, he Liid dmwn ihesfi continually through the
laryui, and thence into the bronchial tubes, wljicli had grailnally
beeoEue choked uj}. It la clear, too, that the irritation of t!ie
forti^ matter had excited in the latter intense congeation, and
coplour^ effusion of ninctia ; and that, from the combined eiTecta
of the abundant accumulation of vomited material, of ct ingestion,
and of eirutiiun, die patient had been anffoeated, aiul liad devel-
oped those fiynifitorns »hic:h liad ainiulated bronchitit».
" From the complete way in whicli even the aiujdieat bronchld
tubea were filled, fruin the history, iniperfeet thuugh it l>e, and
from utlier circumataocer^, it la obviona that the proeeaa had been
a gradual one : and one cannot help regretting, therefore, that
Le had not before bc^cn pl^tced under competent aupervic^ion ; and
that such prci^autioniiry mea*uro^^, and hnch Ireatment as would
have etiggested theraadvea to any medical pi^clitioner, had not
been put in force at an early period-"
Case LXXXVHI. — Case reaeiitdliufj tSO'atijulated Her-
n\a.. DiffhuU Dltti/ntms* — A girl, n*,'ed 23, entered the
Ho.spital, in the iiiedieal wanlrt, Jnne 23, IHGO; »nd, on the
following day, was referred tii me by the physieina, under the
euppoAitioa that she had atrangulateil henna- She amd that,
seven weeks ago^ from a alrivin, she felt n piiin in both groins.
Five week* ago, while lifting a washtub, a tumor ap|)enred sud-
denly in eiioh groin, vi'hich had Ixvn painful since. For the laat
week or two» ehe had been confined to her bed, with ninch pain
in the right tumor; had had no movement uf the bowels for a\x.
days, in spite of the uae of medieinea ; and had been troubled
wllh vomiTing.
The right tumor waa so painful that she could not support
STRANGULATED HERlflA.
161
jtijj' ex!immatt*>ti without ether. This being given, a flli;,'hLlj
inflftmed elastic tutnor, the tize of a hen a eg:g, was IbunJ, just
below Poupart'fl ligament, on the riglit siJe, and a smaller one
on the left. It wits Jeoided, on coneuJtntion, that though it was
impri;bal)le tlmt tiro hcE-nia^ should appear nt once, yet, as there
had been vomitiurf and obetinjite eonstipation, there wiie reason
to believe tlmt the bowel might be in the tumor, and delay might
be fatal. It \va& therefore agreed to make an sxplorntor}' ojiera-
tion, aa, in cnsc it turned out to bo a BLi|Jpu rating, glandular
tumor, this would aiford relief.
The ri!_'ht tum^»r was, tiiercfore, cut down upon ; nnd» thofaseifl
oovenng it being expoeed, there was a dark appearance under
itf like the sac of a hernia. This being cut into^ pua escaped,
and the tumor was found to be glandular. A similar operation
was done on the other ^idc,
On recovering from the ether, ebo expressed hereelf greatly
relieved, the pain previously being alcioet inauffernhle.
On the following diiy, there had been a siitrbt evacuation from
fin enema ; but no further cvneuation, no tAvith standing a doae of
flenna. The senna being repeated, at stated intervals, on the
fiocond day after the operation, and the flcventli of the constipa-
tion, the brjwclj* were finally acted upon. After this, she began
to recover.
In connection with thia case, I would mention the following : —
I waa requested to see a patient, Jn the spring- of l^ijlj,
who had had, periodically, for a number of years, a tumor ap-
jwar in the ngbt groin, attended with flcverc disturbance yf ttie
digeetive orn^ans, with constipation. Thia ha*l recurred, as
iifiual, and the symptoms hnd been treated without relief.
On examination, I detected a hernial tumor in an Inflamed
condition, which was at once cut dovin upon, and the sac and
the iatestiue found ^rf^ngrenous. The upper and luvrer open-
ings of tije inteatine were aboat largo enough to admit a siuall-
Bijsej bougie, their pnrietea being greatly thickened.
The patient tlied about three days aftcrwartla ; it being impOB-
eiblc lo get any evaoualioii, though injecliona were thrown into
the upper opening.
At the autopsy, the upper intestine waa found fljitly applied
21
in
■o ^ tigs* «f Ae i^k faaval rn^, m m^ ■uyilin viik tfe
of the ft»liMl Ib^ Mne ad» oflke
fifarm lovor Ae a« ^ in on^e, wkkfc, by tbe
■MBt of tfaM «^^ «i 1^ fifimrniil pma^ ™^ poaUy
t^p*** uw wnodieal mrcinc uupu of tbe lopuuv-
Minr rean since, whm m ■mJenl, I oonMvd Dr. Jolui C*
W«rrai in ui opcnUm on & Uj vln hod bem trntfed h^
a fknkimn far failio«» «Qfie ftr m. nHttber of ib^v, wkcn ft laftll
Da Dr. Wftfren't bfliBg olU, he lba>4 whot appvovd tti be
ui cfiLATffed ^uvt tbere. Aa ilw sjvipcoBS buil h^uUL, w
opesatioo mu dijiie- Tbe gland trsa expooed, and dMwtfd
op. f oder a wi« disfMvcr«d the end of a knoekle of lateitme,
in a dark Aaie, ju^ projernng frum tbe tumoral ftt^.
Tbe cnostrk-doti tras rvlkMred, and cbe imeadne reomieJ ; but
tbe patient died.
1 hare met myself with a dmiUr imafl sinngtdaied b^iw*,
coocealtd by an enlarged ^lud : but fbrttmatelT ^oc tbe tmt m
tine Ut tare ibe paiieai. As a poiaL uf pnecke, tber^br^ U
would 0«em proper, vhtre the $_TTDf>-Tums ul' strai^;iilaced b«Bit
ate |nf<aant, to &x|ilofe» ilthuugh the nanire uf tbe anaor bmj
UdoobUbl.
Case TAXXrX. — Stran^lattd H*m\a^ vcith Untuwil
^pptarHncet.^A.^VL^ 30, 18^^, a woman. 37 veus of age,
entered tbe Uo^pUal. with a strongidated m^iiind bemu of the
nght Bide, of two dav*' dtiratioD- She bad been troubled with
a «mkll reducible hernia ^ome rear^. which h?Ld b^en funded
down, and Je^ easiJr retuint.'d for the la^t fortnight. She liow
bad iutense pain, vomiiin^, and ^ tbe trmptauu of strangu-
Ution.
Or opening the 6ae, a little bloodv fluid escaped, and what
aeeitteil to be the red and aivollen inieiiiiuie presented. No
probe, however, could be made to penetrate arouod its tuargin
into the ring. I requested tnv collen^e. Dr. Clark, to esjiniinc
it; and }» finally di4coTerc>d a small iiperture at the inner side
of tbe tumor, where a probe penetrated- Here I incised the
FTKIMJUUITED QESNIA.
in
^id, after moeh mftoipuUticQ, the tnrcff in# n« radu««dt
amd m lar^ ipHiitiiy of ecro-«ui*nnMCi*;>« mailer «««i|>rtl froio
iko Mkimhni cttvitv. Whokt the ob^tadc wu in ihU n««. I JUtt
■Bfthk ta dcci^. The iDoeC probftUe ezpUnfttinti U, thjit the
iDlvftme had pushed before U a very thin ]av«t of ommtunia
wUA was €nnJy adherent to ii, nnd iil#o tc the niftrxin vf (He
with tiie exoepcion of the ^m&lJ opening when itio ptvbo
Hm piiieat had a good recovery.
Ca5B XC. — iSimifjnl/itrfi Ht^mitt in fx Chil^ on* ^nr
aid. — A dkild v^as brought into the Ho«pitali Mari-h fO,
[, with a hard tumor in the npper part of the \vtt ^ide of tltn
Tl»crc ha«l been ^rcnt eufferin^ for twenty-foar hoiire,
ttnutttnt Tomitingi and complete rctcnDr^n of urine. The mothor
mid dut, erer pinoe birth, the ehilil had had a ttinior, furnif^ltniiM
on one side of the fcrotam, and pometimea on the other. It
however, never before been hanl, nor hai] it nt nny thno
rue to anv mcoDvcnieQce' Ijotterlv t^he hjid observed %
^teiDor only oq the lefl side, where it now appears. Dr. BUke,
rlj booae-snr^eon at the UotipitaJ, £aw the caMt and( Mi^
pcctiDg Eta nainrc, H^nt it into tlic hoo^. The chiM PMmed lo
bctBgreatpaiD. and dtrennou^lr rented any exanunation. The
waa very teiue, gtobiUar, and had the appeannoe of A
liyilrocdc of the epennatic cord> When pbced ia •Uoig «»-
fight, however, it wad not at all tran^iuceni. Ob pftMWe, It
WM qoiic tmyieiding. In order the better to utvmtjgat« thi;
tkeeUd WM placed under the infiuence ofclbcr. Xbtto-
r, bcmf aei^ed by the fin^cra and thumb of the fi^ haadf
Gndy co^pruoied. Tlie left hood, being pJaced at the root
the tOBor, BBade a t/aetion aoasU) wvrk the intf*tir»a throogb
of the nek, in the ea«e of it* being a hervia. It WM
tktt the tumor gradually bccacne «oAer uaAa tiM
exerted, aad haif of H diMppcaredt loving atill m
l^np ia the groin. Tbe preawife being ponrinnwi, the n^
pniiiiMiMirtAiilj niH ■ImI iiifiiik ■fwfaiiMn It nught
Jwfc he«n tfated, ihnt an dBbrt at redntlMo ^1 been Made bdbf*
oT the ctW^. but vUbotf pra&Miiv dw alight-
IM
AEDOMKN.
e.«t pjfect ; an[1 n fiurgicftl ojioratitm woiil*! nniloithtedly bave been
rrquired Ijv the iiri;t'nL";y of tfie symptiims, had it not been for
the a8HiHlrLiicc^ Atr<]rdeil }>/ the ma of ether. ThiH is tlic earliest
age at wbit^h I liave ever seen fitniiigulutlon occur in a hernia.
Radical Cure of HERNrA. — Within the last twenty ye&rs,
operfttion!* fur the rad'tcal cure of hej^ia liave nttracted con-
fliJerahle iittentirm ; antl fiir Ji ilisoase sn cctnmon, so incon-
venient, and in some c»se» so d^ngerouB, it \& TemarkalAc that
no wife and effectual operation haa yet been discovered for iis
relief. Tn IH.^2, Dr. George Tlnywanl* Dr. S. Pnrknmn, and
inysdr, were sippoinlcd }i Ciiminittee of the AmcriL-Tn JMedionl
Asaoeifttion lo prepsire \i report on tliis subject. Tn that paper,
I fiieotioned a number of cases of smrall liomiffl which hrjd been
treated with success by the injectiun of stiinuliuin^r hquids in
the Mdghhi>rhr>™l of iho nock of the sin*, in the manner practised
by the distinguished Professor Pancoast of Philadelphia. In
Bomt* of the^o caspa, as I have since been able to coavinee my-
self, the cure was permanent, Sinee ihen, uiiiny different
methods have been proposed, abme of whieh I have tried with
success. The one must in fiivcir at the pj-eeent mcimcnt is that
by Mr, John AVood, of Ivin^VCollegc llospitd, London, which
has been fi^tiently performed in thiij city. It consists, ess^n-
tinlh'T in the constriction and partial ohiiieration of the inguinal
canal by means of a subcutaneous suture or ligature.
The method pi^opofled by Dr. Piincoast, referred to above,
luav be described as follows : —
The contents of tlie liernisd sae bein^ retnrned into the abdo-
men* and the ring explored to ascertain that no portion of the
intestine protrudes, the pad of a well-fitting Irusa is slipped
dmvn so as lo make prcEJ^ure on the inguinal canal, and prevent
any escape of the lierniii. "VVitli the forefinger of the left hand,
the tpernmtic cord, as it pat^sce out from the external inguinal
opening, i.s (jreesed upvTanls on [ho pelvic bona, so as to prevent
it from being injured. A delionte trocar and canula, the latter
Laving fitte^l to it n email Auers syringe, is now eai'efully but
firmly forced tiirough the inte^Timents with a rotatory motion to
facUitutQ its progress, and puslied forwards till it enters the ex-
RADICAL CURE OF HERKJA.
165
terniLl in^innl rin^, or neck of the eac. The Irocnr hemg now
witliJrawn, the canula is kept £rtnly in place, and twenu- or
diitty drops of the tincture of iodine, tincture of canciinndea,
or sulphuric ether, throim in, and lodged in t!ie neck of the sac,
when tltts is prncticable, or eUc in tliG vidnity of die external
abdominal ring. Subsc^quendy, a email compress is itpplied
over the minute wound made by the trocar, the pad of the truM
slipped down over it, and the patient directed, for a week or
two, to muintuin the recumbent puaition.
In addition to the injection, in some of the operations, a
tenotomy knife was previously introduced, nnd the :nternd sur-
face of the nack of the sac BCnrificd. The wound made by the
knife in these c^es much facilitated the enb^equcni introduction
of the trncar, which id with some difficulty worked throuj^h the
integuments. In no instance did any bad result follow, the pain
and inconvenience Lurdly ami»uniing to that presented in a case
of hydrocele treated by iujectif>n, or in any simple operation.
The tullow'ing case, attended with success, will serve aa an
illusLraiion of the eourac geneintlly pursued : —
Case XCI. — Hitdictil Cure af Conf^tnilnl I/trfninaf Her-
nia^ — A mule child 3 years uf ajje^ with con^^enlliLl inj^ainal
hernia of the rjj^hc side, was brought to the PIoi«pitnl to obtain
relief, if it was possible, i\s no triwa had been found to retain
ibe protruded inteelinc in the abdomen* and the ]iain ami incon-
venience from the infirmity were great. A lumur» the eizo of il
small umnge, was found to occupy the Hcrotum. By a little
manipulation, the contents were aacertniueil to be a portion of
onientmn. a loop of intestine, and the testicle, — llic whole
of which, by care, could be easily returned into the alxlutoen.
The question wna, whether the testicle could be BOparatwl from
the other parts (the adhesions bein^ fjuite intimate between
them) so as to admit the return of the irtestlne and omentum
into (he abdomen, leaving the testicle in tlie scrotum. Thia
bein^ found possible, the operation was performed as tollows :
The intestine and omentum being retunied into the abdomcn»
and the testicle preventeil from following, the spermatic chord
was held out of the way In the manner stated nbove, A sub-
166
A»POAIE^<
cutaneous int^ision was then ninde with aciLt»rac:t needle, llic poinl
of whii;li wnfl rairii-d into the aac, mvl tlie neck flCiirifieJ In Jif-
ferfTDt dtrectioDs. Thiougb tbe aperture thus made, a emnll
trocar mid canuk were Introduced : tlie former being rtithdrnmi
the syringe xvos ailapted. and thirty drops of t^ulpliurio ctber
were injected. The trusB wa** then iipplied.
The opcr:tlion w;ls performed Oct. 28, 1647- There was
everj^ pros^ject of eucceea untd Dec* 9lh, when, during a viujeot
paroxysin of eryin^, the hernia was fon^ed down- On the 12th,
the hernia was returned^ and the injection repeated. It result-
ed, on the following ilny, in a swelling of the acrotuui, such us
is observed »fter the iiijfction for hjdi^ocele. Dec, 22d, the
report waa nmde that tliE? hernia come ellghtlj down, and waa
returned with difficulty, "the aperture being apparently quite
Mnrdl.** By tlie end of the month, it was stated that the herula
was perfectly retulncd, I have been informed eijice thnl the
cure xraa permiiuenti
During the treatment of tliis cape, a sliglit superficial sup-
puration took phuM! under tlie pad uf tlie trups, whicli. tbc
patient being i^omewhnt fraetioiiB^ v/bb nece^arily applied pretty
firmJy, to preyent the recurrence of the iiemia after tlie opera-
tion.
Id a lurge proportii^n of tlie other cnaes operated on. the
patient experienced much relief, though still obliged to weiu" a
tniflfl. In one cjiec, where the heriiia wna quite bu'ge, no relief
was experienced, A female, with & double femoral hcrniai on
whom tbe scarification and injeetion wpre onci; or twice repea-tcd,
expresacd bciself much l«^neiiled by the opcriition ] tlie hernia
being retained, and the suffering previously experienced much
relieved. Another patient* i\ lalxjriug man, was seen by me six
months after the operjLlion : the rupture liiid not recurred, but
he still wore a tnise* Previous to tins time, be had been unable
to work without forcing down tbe intestine under the pad, cas-
ing him much pain and ill health.
From a compariilivcly limited experience, I derive the fol-
lowing concWions : —
First, That the operation, when cmefully performed, is safe.
Second, That, in ruptures where the neck of tbc sac is small,
RADICAL CUKE OF TIEEIMA.
167
an(J the abdominal nfipriuve not loo innoh enlsirgcd by rejieat©!
dei*ccnta of tLe hemiu, there ia a proapeet of a radical cure.
Third, Thai, in moat cases, llie operation mitigates the infirm-
ity, aiiowJn^' the hemin to be more readily retiiined by the or-
diuftry mecltanicol means.
Since the above operations, I have frequently performed that
of WiiUer, which coDsiats of the iEvagiaation of the skin of
the ecvctum into the mguinid cthdjiJ, and retniuing it there by a
proper iufltrument uutU adhesions have been foiTiied. I ha\e
also done some operations by invaginatiTig the akin, retainiu^r jt
in pJaL-e by means of a atiteh, and applying caustic to the cul-
de-saC| for tlie purpose of producing iuttamniation, adhesion,
and a solid plug, tiome of Uiese cases have succeeded; others
have failed, tlie hernia forcing itself down again behind the
in vacated ekin-
Cabe XCII, — Wiif^ers Operation for Cure. — In Juno,
1?*I>0, a young man, 28 years of ape, entered the Hospital for
the purpose of bavin<T on operaliou performed to eU'eet the
radical cure of an inguinal liemia on the right side^ which
had existed! for thtee years, and was as lar^ as a hen's egg.
Ho wna jdnteJ upon the Oficratini; table ; tlie jjemia was re-
duced, and, after introducing a portiOD of the skin of the scrotum
to form a plug, Wiitzer'a iastrument was applied, the needle
passing through the invaginaled acrotum, the hernial sac above
the internal ring, and the abdoininiil parietes, and secured by a
clamp.
On the second day, there wa« slight inllamination around the
needle ; and on the iifth day, when the needle was removed, jms
flppcaired in the wound- On tike eleventh day, lymph was dis-
cernible along the course of the spermatic cord, which after five
dnyfi furmed a firm plug, sufficient lo confine the intcetine in ihc
abdominal cavity, excepting upon violent exertion.
Case XCIIl. — WatzCT's OpGrntion for Cure. — .Sum
after the above oporjUion was yicj-f »rmcd, a boy five and a Jmlf
years old was brought to the Hospital on account of a congeni-
tal inguinal hernia on the nght eide, which formed a tuujor
168
AB DOMES.
<le8cending nenrly to tlie kne^s. It wns easily re(liip«l. He
waft ctln?ri7-ed, ami Wlit^er'^ insirument was npplictl> its in the
previous case. The needle rjiused sufficient Trritntion to give
rifie tci ulceratinn^ Uy wh'ttih a passage was ma*Ie alhnvm<^ it to
slip down about ihree-qiiazters of an inch. On the Hevenlli clay,
an effusion of lymph had oceurreJ along the track of the sper-
matir cord ; but, two days later, the hemtal protrusion vraa
noti^^ed behind the phig.
Subsequently he wjls again etherized, a fold of the Hcrotiim
waa mvaginated, and three ligatures were passed through it and
the ahdnminnl parietee, and secured by jneiins of piect-s of
bougie. There waa mnt*h inflammation and swelling ; mul, on
the fifth day, the ligatures were removed- The result wua in
every way Batiefaciory,
ARTIFICTAI. ANUa.
Artificial anua is an affection generally oansod bv the flough-
ing of the intestine in ritmngulalt'd hernia, nlthough occasionfllly
the result of abeoees and penetrating wounds. SometimeB a
amail portion only of the calibre of rhe intestine is de^Troyeil,
the bowel becoming attached to the parielea of the abdomen, and
a flstuloua opening is the result, usually amenable to the ordi-
nary method of treatment. At other times, a whole loop of the
bowel alougiii* off, and both ends of the mtefitjiie unite to the
fdidomimd walls, leaving an opening from which the feces are
constantly dischnrgedf only to be remedied by surgical meima. -
Cases of the latter character are of umjsual occurrence; and
the means for tlieir strictly seientific treatment by surgical opera-
tion have not, until within a few years, been fully established.
The one I intend to relate is, as fur as I nni awarc^ one of the
first BuccostiCullj openiied upon after the motliod of DupiiytJ^eti
in this part of the country.
A patient with this affliction is one that may fullj' claim the
Bympatbies of those called upon to acTminidier to and alleviate
human suffering. Sus|»ended, as it were^ in the po^^efsion of
his mental faculties, between life and death, he is destined, ud-
Icas relieved, to drag out a miserable existence, an object of
ARTTFIOIAL AMT3.
lUJ
iTTsgnKt to filiuficll' aiid ii bunJen to Lia t'rientls. or to smk< vs'i>m
out hy paiu :ii]"] tlie emrn."iatii?n prmluced hy deiicient uutiiti'in.
It IB a auurce of greoi flflliafHCtion, therefore, to the BurgeoOf if
he can be ilic mea-as of relieving so dietreaaiog n miafortune.
Casr XCIV- — Artijii:ial Anna from SlningulaUd Iler^
wm, Flffi'douf^ Opeiiiiii/!* in iht Thlfjh dlHchmgtitg Fncul
Matter, Ojieralttrii, Ctirf. — Tiic patit^nt, of whose cjirte I
propntie to givo an account, wlu ^cut tu mo hy Dr. Dro\vu, of
Nova Scotia,, in June, 1847. She whb thirty-four yeara old, tiie
uiothtr of eix duldrcn, and, ]irevioLk8 to the occurreoL-e of the
present ucoidcnti oi' g^ioU conatitotiun. A email crurjil heniia
had exiHted on the ri^ht eidu tor iin indcRnite period of time.
Dr. Bi'LUvn w!is czdL'd to liei' loLirlecn montlw hHorc, and
found her labuinn^ under u atni ululated huroiji of Ibitj-ciglit
huufft^ duriition. An o[)eration was iniutediji.tely [jerfonucd ; hut,
on openhi^ ihe «iic, the inteatine wna c?cposed in a gun^Tenoutt
state. Tlitr f^Lrlctui'e ;viL» therefore divided, and tlie intestine lefl
in the wound. At the end of a week, the sphiicelalcd [lurtiori
aeparaiedt itnd tlie feces ilowed freely through the o}>ening-
Aftcr Bonie tlnic. ^lit partially regained licr licalth. waa able to
Bit up, and fiiiiiliy tu work moderately, until tlie folhrniJig Sep-
tember, when abitueaacs begun to form jji diflei'eDt pnrtd of the
lliigh- From llua period, ehe ^'raduaJIy loat her flech. and de-
clined in Htrengtlii Two of the absci'saes were opened Ijy ilie
hmcet ; the others, on the under eurfare of the limb, opened and
diseliarged sjjonlaneously. Pun ut first iesncd, fulhivnl by
fecal matter; and jfreat suffering attended the dfusion of the
latier into tbe floft parts* Until within a tew weeke prcviuua to
her coniiDg under my care, there wei'e occasional Iccnl discharge*
peranum; hut the pealei proirortjon af mutter was evacuated
tlirough the various lisud'^ua openiiigaH
She arrived in town in tbe early part of JunCf 1847, and
entered the Jlu&pital,
^he wa4 cxtrcoidy weak and emaciated; the countenance
pale, nearly exsan^^uineoua, hidicating the almoat totjd failure of
the a*»iniilafing piucuss. From long cuniiiiciLient, she hud
hccoicc nervooa and timorous, hardly allowing the ahghleet ex-
2-J
170
ABJJOMKJfl.
am ma tic II ; sinJt un i\i\i day Ijcfnit! her entrance, elie waa «a
completely hoiueaii:k, thul, notniLliatandiiig tlie p;reat IrouUi;
and expetiec undergone by her pliy^idaD and tricndd to cnEdjI<
her to accomplJah her journey to Bostin, she insisted on retarn-
mg heme at oucn by tl:e ?miie ve:wel m which *iie cuiiie. After
VL djt/ 01' two of couaidenitioLi, huwever, and by a liltic per-
Huasion, ahe wa* induceil I" diaiige her mind.
Tlie fioaitlon of the patient waa ahiiost entirely on her back.
The ftves, in a vtry licjuiJ ^tale, wtrc conttLantly ruiiuing out
tlirough two cpeniugia in the- ^^rum, and three in the podlerior
pnrt of the ihi^^li. Thu ri^dit limb v^m drawn uji almost to a
right anglL' witli tho budy. and llie whole thigh much enlarged
and hardened. The ekin around the a|>cn[ngB in the grom had
a redf ixritated ]oi>k, wns thickened :dmo!it to calJo^itv. and ex-
coriated. The openings were i^mte ^niall. so as hardly to oduuL
an instrument larger than a eoiamoji director.
A nuurithing diet wiw alli>wed, and great cleanlinesa of the
wounds eniuined* with ihe more espeeitd object of preventing
the painful excorintionj^.
The situation of the intestine could net at first be determinedi
whieh added to the frabaira&sment of the caee. In those of a
tainiilar nature AvhiiJi 1 had i\n opportunity of aeelng abi'oad,
under the care of Diipiiytren. the lutestiDe opened on the but
face of the abdomen, by a hivge aperture ; and tliere was no dlfli-
ciiliy in exploring at once the end of the Ijowcl, with tlic finger
or by instruments* In the present inj^tarice, the liatulouB open-
inga rpin in every directiim : those in the groin wei'e immediately
in the ncigliboi'lnmd of the probable critice of the artificial anna,
ollowin^^ a probe to peiicti-ate for ita entire length-
I therefore determined to dilate the two latter ojH:nings, wliich
*vas dbne very gtadually, by apongc-teiita, on nccuunt of the
aetiaitiveneaa of the |>jtticnt to any manipulations ; and it re-
quiretl the peraeveting application of this method for a month,
bcfure the two ends uf the intestine could be with ccrlaiatv di*-
titiguirfhed- This* however, was tinsJIy accomplished, and a
gum-^laatic bougie pa^ed iuto the upper, and another into the
lower, orifieca uf the interline. The bougie first penetrated
tlirough a thick, callous muss of tategumcrt, then through the
AliTIFICUl, ^NOS,
171
niiiHCKlnr nv
•
ti^nrlinoiiiiJ fcivi?j'mg nf tho abdoHicii, in nil nbimt an
in<?h in/leptJi, when the septum, or spur, us It hue been (bulled,
whiuh aeparateB the twn ends^ waa encountered, and with diffi-
culty euteretl, hem<^ s*i clospiv applied to the pariete?* of the nb-
donien as to prevent the Ia*9t pnasnge of mntier from the iip[fer
into the lower part of the hoxrel. There hnd not been, in faet,
for two months, the Nlighreni fconi discharge per ftnum. The
intesLinal ends f<eeme<l to lie parallel to efich oth^r^ ho that the
hougies introdiieed for exploring nuide but n very i^li^lit angJe.
The patient still remained nerroiia, and cjuite feeble.
I direeted Thtit the Hpufige-Ienra should be rontinuwl ; slflo
that !i pint i>f oatmeal grup] should l>e given, per aniim, daily,
Ibr the purpoi^e both of atimiikting the intCHtiiial coats to the
performnree of their nntnrni fnnettonfl^ and with the object of
enlarging the esilihre o(' the boweli which must hnve become
miich contractcvl from hm^ disitse.
On the following day, I fbumi that some scyU'da ha^l oorae
nway with the eiienm; and, on the neirt day, the injenied duid
niwde its appearnnee at the apertures in the groin-
In the course of a few days, tha prircipal opening had he-
come so dilated, that, hy a siendy and pjitieady applied force,
I could insinuate the liule finger fpiite down to the intestine.
The septum eoiild now be distinctly felt lying against the wall
of thp abdomen, nurl be hooked up so fis to permit the end of
the finger to be earried into the lowtr portion. Its sensation
was that of n delicate membrane, like ifie ci:»ronary valve* of the
aorta, though somewhat more reaistijig- A director was now
carried down, at iho side of the finger, for the purpose of koep-
Ing the inte.atine open, a giim-elnstic enthrter passed In, nnd a
quantity of warm water injected, to make sure that Uic lower
orifice had been found. Thi* water afterwards Appeared, and
was diHcbarged per viim niiturnlcs.
The pfilieut being well prepared, T determined to apply the
eaiprofomc, whieh wa^ doap Julv 1 ^ih. FLiving made aiire of the
lower opening by a iiirector. as on the day previous, the male
hranclj of Oupuytrcn'e enieroiome wjis carried inti> the lower
inter^tiiie : the director was then withdrawn, atid the fetnalo
hnincU introrluced with ease into the iipjier. The two part*< of
172 ABDOHEX,
the inBtniment now occupied nearij the whole calibre of the di-
lated \Ass»^e leadiD-r M the '^t. I found ai <*nw that it was
impi^^ible to lock them; for ihe jitws nf the female portion
would not allow of sufficient muiion* at [he hin^, to lock with
the other part of the instrument. If the inie?iiine had opened
directlv on the abilomiDol surface- there wnuld liave been bo
diffieultr ; but the I'x.kin;: of the forceps under the eii^ting <nr-
cum^tuncei^ m-vlS imfiracticablc.
I therefore witlidrew the inr?trumeut. and had recourse to
nuother, wliich ha.^ .-ince |irove<l much betlcr than the enterci-
tomc *}t DupuytrcQ. Thi!^ in^truniCDt wn? four and a half
inches in len^h. It-* handle was cun?lructed with a gcrew-
vii.-C» and th(: joint wilh a movable pivol» a5 in that of Dupuv-
Iren : the hlade^i, however, were dltlcrent. In the jilace of one
blade b<:injr recelvcil inVt a jrroijve in ihe other, thcv were ser-
rated, like the jwlvpufl fijrct'j>s, lor ihc s|>ace of three inches,
The hiaileri, Itcinjr intnwluccd in tbe manner already described,
were locked witliout diffifulty, zind at once brought together as
ti^hlly a.i tliu screw wiruM pormil.
On the next day, I fouml her free from pain. She had cotn-
plaincfl a littJc for a few houra after the instrument had been
put in ]ilace ; but there waa a question wlicthcr tlii^j niii^ht not
liave arisen fnnn itmr.
The te<^al matter" pUJ^J-c^l by llic ^dt? uf tlic instrument, nnd
w^arm water wii:^ daily iuji-r-ted lui't tlie wound, to prevent any
obstruction. She hud al^i» an enema dailv, wliich kept the
lower bowel in ar|ii>n.
On July loih, ihree day?* after it.-^ a))p!ication, the instrument
ciunc away. In the jaws of the ibrteps, and l)eurinir the im-
prcart of the Iccth, was a blackish slou;rli, two inches and a
half lon^;, four Unc?^ wide, ami about three thick. Tlie finger,
lioHseil into the ori^cc, could distinguish an ojK.'ning, conespond-
inj; in size to the slough, betwi^-n tlic two enils of the inte?itinc,
the cdge^ of which were ;:rcaily llijckcnc<l and fleshy, imjiarting
a sensation entirely unlike tliat nf a \g\v davs previous.
This examination was couduc-tcd with the greatest delicacy,
from fear of destroying the adlic^ioiis, ;\liieh mu^'t have been,
of course, at tlus early period, ol' cIjc ^lighte^t kind.
-VLTtJlCLU. jtvr*. ' 17S
In (he aiieni<v^ci- ;iw Lki a ?ciall :V-il *i:M.'!vir'^ ihn*u:;h clu*
wound- She o^mr-uu::**! ci ro p-^L:;, acJ Uwrv was n^> ceniier-
ne*^ ol" the aNiomer,.
On the tV»lI"»wiiLj 'h.v^ i^^ I">i> ?m tra? »]tiiie oonitortable*
haJ had a n^e -ie'Tt^ri n r^r azuiii ^.-m an enema, more slimv ui
its diaracitr than ^ifuai- Th-frir ha^l ''*ea n-t Ji^char;^ 6vm th*
wound ffin'?e the dar h-;T>re, A jentie Ci'niprfc*i:>>n wis made
bv mean^ oi' a i^-mrr^^i azd V-i:>i3_:e i.»n the ^■■pealair? in the
gn.iin, and ihe orlli'^c^ vrier^i :■:■ be loLi-jberl dailv with the ni-
trate ut" silver,
?^he iDiprivtil b healtii. nroUj aoiuirtil her itreiLzth, u»l
had nij larther di-H-hirje a: xiji artin:bl anus ir.'m the dav
of the sej-arari'^a ■:' ii«? iL*m;x»rnt un:il sht Kii the U'>?pital.
at which lime th.r ■jj'-enisj* in the i^-Ati liad aliu'j^t eomj»IeteIv
cicatrized.
On -July ii'th, }^ln^ very ea_-er to rettira b'ime. she wa? dis-
charged at her own rw>:"?t- but ni'ain^t my wi-he^. aa I was
anxi<iu^ to uacch the ^■rj_Tt:-.* ■;jt'Ebe *"a.*e to it- very clore.
From a d-^rire t^^ bam ::.- linal result "f tlnr ca:?e- 1 attei^
ward:* addjvsr^l a lett«rr t» I'r. iSr-.wn, '•{' H-^rr'-'U, N.^.. her
physician, and reiveivt^i a r-j-lv Tearinj <iare May '», 1^4'*. In
hi* an=wer, this ^rentktii:!:! i;it'.-nae<l Tiie. that. iniuLeiliaiely upon
her return, ^he wx- jreatly impr-*ve«J b-»th in health and sj'irit*.
the li'Ccd had tb*-ir tiutural <:\\l, and every thin_' b>»ke<i very
pTomHiD;/. In a ^b-^t time, b-iwever, owtn;j to over-indulir^noe
in the u^e of coar-i^. rijfulorit t'-A, and the want of that Ltneral
eurvei]lant.-e -■* nei^e—an- t^-r tbi* cla-'* of [taticnt?. tWal matters
had a^in n^pfieare^l ;it the oli| --fritire. a? well a> ut several i>lai.vs
on the hip. p*>nie ot whi<b «i;re fre-rh outlets- This wa^ the
condition of thiniz- in liertniJ^r, when 1)t. lirown war s^um-
moned to a nn.-tEin:.' uf ibe leiri^bnurc at ilalltax,
"On my return in April," writ^- tbi- jrentleuian, "aUmt a
week ago, I w^a^ fpiit*- luken bv surpri-e to find our patient |ter-
t'cctly recDVLTt^l, b'-tkini' a^ plump and jiiy a- ever, and busily
employed almiii b*;r b-m-e, It^riuL'in bsu-te-ajid she Ivini; busy-
I did not e\aiijinc Iter : buF ^be inforrLii.-i| me. that all the ubvrs.
aa well a? the oriixitiMl i^utlet, were entirely hialed. ixivpt "ue
new one, and tb^it bail not dL-ehar^td fe^.-al matter fi-r «'n.r
174
.liiiJUMEN.
timR, iLTiil wii^ in fnrl neJirly healwl ; thnt tl»e lilp liRfl ^reuhly
Uecn^asttd in si/e, and had 3w*smueil quite a nalural ii|i|»enraiice ;
thnt lier IiowcIh were entirply regular, anil she nuuld take \wy
kind of fuiKl withuiit tlie leaat iiicciiYCJiiiinnp, She even hh!i1
ehe had not enjoyed m> good general healib fur several years
previous it} her mififL>rCune as now."
Oil reviewing lite ubuve ijaae, il will be percE^iveil that it pre-
aeiitcd di&'uJtLe^ uf a funuidable dianioler. In the first place,
llie extreme deliillty and eniueiatiim of the patient, and her great
mental depression, were ohataclea almost a^ r.niuhleflnme to con-
tend with as lEie disease !ls.elf. Twli^, atler mncli lahor hud
liifen expended* and auinc progieee made In (he [ireliminary
treatment, Mie insisted on reJInquishinir it »t once, and retiiming
home; and, on the day when the instrument was tjj be jvpplTed,
the Jeiihired that she was cerEahi she niust die the fitllowing
night, und that !t waa quite uaiilesti to attempt the operation.
Tlicse depicesed tiirnt geuerally passed off atler a tinic, and tlion
the ptttient waf* very urgent lu have ti^e Ireaiinent eiuitinued;
but, for the moment, ihey were aaffieienlly diat'ournging to the
sorgeuji.
The aiimeroufl fistuloufl openingi*, with the effiieion of fei^
lUfitlrr into the ^'uin niicl Imrk part of ihe thigh, iKTaaioned
conaidenible end)arn<^!*Tnent in parMuinjr the treatntent for dis-
eovcrinjr the end of the intestine- Added to thi>;, and cantfetl
by it, the thighs were flexed neitrly to u right angle with the
body, and were con^tAiitly in the way of the inatrumenta usecl
for exploring the artificial openingH.
The, instrument uahI, 1 cijnccive to possess great advantages
OTcr that of Diipuytreo. In fact, it consisted of, or may
be almost exactly represented by, a coramoo pair of old-
frisliioiied prdypiis fureeps, with tlie branehes detaclied, and
united by a movuhle pivol, instead of a fixed Joint ; the hiiudlcH
perforated with a ecrcw-vice, and the jawa serrated tluxjugliont.
It IS lees ehmiM' thji.a thai *if Dnpuvlri^n, enuses more coajplete
atrangidfltion, and dues it?* wtFfk in leas than balf the time. By
an examination uf the cn^cs of tliis diaiinguiehed French surgeon,
it will he foiuul that the cnterotoinc geuendly sopiiraled about
tlie seventh or eigbdi day : in the [aescnt instance, it came away
AKTBTICIAL ANrS.
175
on the tliinl. yvt no efTuHiui iir ollitr cvU [^[jriseqiienrp refJuU;?(l,
iilUi'tEigli ilio it^tlcnl war) lis luilc ^jruviilcd with ihi^ iiiaU'mls for
furmiiig pWlic lymph ae can well Ire iruagineO.
Ill t}ie ri'l^tiuii lit' lliiis ca^c^ we liitve \Mi\y iti^Dlioned tlte
euurwi iif ireiiliuent ordinnrily piirsuetl hy Du|iuytren, witlniut
allmling lo the raethoda of Physit^k, Gross, fliiJ uthera, in ihiti
country or in KuropC) wliu liave done ho much to jiJ\iatce thia
branch of surgery.
Cask XCV. — Artificial Anuft in om lufani. Fratl Dh-
chari/s fiw/i ihf- Naifel. Pruhjpi^t*. itf thf ffitt-atine. Ojjcjtt-
tian. Thath^ — A case of a siinilur kind to thiit luirrated
occurred to nie in an infunt, some ye.ar« aince ; nnJ, hpi it illufi-
trates one of the accidejils liable tu t;ikc pluce at any iTi£»inf?nt
in pBtieiilH luLorin^ mwler Uii.s nnfortnniitc nffeerion, namely, n
|injhijise (if the end of the Ixjweli the dclaiU may he here given,
I w]t4 rtqiiesU-d* by the iiiedicid iittcndant oP [he fLimilyi to
see mi iiif^tiit fighn inontlu* nld, aod reeeixvd the followinj^ his-
tory from hi[U. lie wiid 5r8t called to it when three weeks old ;
the pHreiits sUited to him, that, for a few days after its Lirth» Jt
was in nioeh difitres.St and had no ulvine evacuiition onlil the
cord se|]arule<l, wlien an eiodnfion took place at tlie navel, fol-
lowed hy [nucb relief, Shortly after, a t*iunll red tumor ap-
peared at this ftpot, froiik the central [lortion of whieh tlit: fecal
evacuations occui^red: tliere waa no dLfichai'<2;e j)er anaiti. Fie
dircctLHl ihcm to nmkc use of a coiupre&a and binda^ over the
tumor; and, under thU treatment, tlie ehUd lie^^'an io have
evacaalione by the aoiia, to ^xiva strength and ilcBh. I advibed
that thi^ treatment ahould be |jer:4evered in.
Aliovit two tuootiid after, from a sodden exertion, two tumors
protruded from the naveJ, attended witli Home eoni^Litotiooa]
symjitom.s. and an entire atop^Nige of Uje evncuatiua^. I t^aw
the pacietit two days af^erwardd, »nd at onee recoguizeJ n pro-
Up3iis of both ends of the intcaCiae. The tuaiora lay aerow the
abdomen, one to the right aide, the other to the left \ one |ior-
IJoiii whieh proved to be the lower, waa dark-colored, ami more
conlmclcd ihau the other. The second or up[»er pari of the
bowel was lari'c, covered with mocus, and tlic vcrmiealar motion
176
ABDOMEN.
cnuld bo difltint^tly Rccn in it. An ctfiirt hnJ alrca<Jy been raado
to rcilucc tlicm intt) the (Llfdomcii, but wltliuul cUcct; and a
prupottition hoA been mode by ^Qine phyeici&n, who had ficen
the oiLse, to upply a li^^iture to tlie roott Thia was admed in
doubt ns Ut the CKa*it niitiirc ut' tho aficction ; atid, in fart, tiio
parts were bo changed that thoy wero with difficulty diatui-
guiehed ae l3c]on*;iii^ to the mteatiaal onnaL
The child ho3D<r cold, ite piilgo siuliU, and hiivin^ every ftp-
pearapcc of rapidly sinking. I dccliuod, for tho inomcnti any
operation, but advised stiukulantg, and n^^rced, if it revived, to
attempt nn operation on the t'ollowint^' day, lor the |>ui'pi)ae of
retuniiui- the bowel.
On the next morning, the child having revived under the
Ireatmenl Bu;^L;eatedj the following operation ivaa pnictieed : A
[ftxiiill nock or tunnel esiated iit the nivvei wbore the intestine
protruded, boin^, in fact, the comaion evorted orifioe for the two
opciiin^8 of llio bon'(?l. An incL^ion was miide at this spiit,
being \vitij[ji the peritoneum^ though protruded from tlie abdom-
inal cavity* The two ends of the intoMine, as iheyissued, were
now seized with a blunt hook, and »hp;ht traction made on them.
The inverted portion slowly began to recede ; and, by ctintiiiuiog
tliia manr^uvre, at the same time L^ing some external pre^gurc
on the tumor, it gradually returned into tho interior of the ab-
domen. Tfie neck of the Inmur, wlierc the inciaion was made,
and which reprc^Gutcd the tunneK^liaped portion, was retaiiiei.1
outside, so as to prevent tho cffuBion of fecal matters through
it into tlie peritoneum. Immediately on the relnrn ot tho bowel,
free evaeuations took place from the anus, nith ij;roat apparent
relief- The patient, however, lUd not rallvi but airnk, and *3icd
on the next day.
An examination after death [iroj^ented no peritt>neal intiam-
luatioti, or ertn^ion ; and no at1em|rt seemed to have been made
by nature to close the incision of the operation, ehowin** the
low s^ate of tho vital jKiwera at the time it was done. The
upjjcr portion of liie bo^vel which had been returned, loolced
comparatively healthy : the lower was quite dai-k-colored, and
ehowetl the clfectis of the ))rirfial strangulation ; an invagination
of ita ciMits for about un inch aUo wa^ dt^erned-
ARTLFICLAL ANUS.
177
Case XCVI- — Art\fictrtl Afui^/mm Injnrif. Opernfinu
fmni
Oure. — May, 1859. A man, ageU ^ll, wii?* irirowii tmm a
fileigh about two ycHrs since, and nli^htral un tht; sharp pulni
of the rjiil of a Fence, whit-h ptnoiniletl the l(?ft Hide of llif
Abdomen, in llic iliac ami inguinal r^^giuns, jtrodjicing a wonni]
four or five inehi?* m length, allowing the inteatinea to eacupe-
A physician being called, the contents of ihe abjonien were
replaced, and the wound cloBtd by sutures. Pretty severe nb-
doruina] syinploms supervened ; and, at the end of a wei?k, feral
matter be^n to issue frora that portion of the wound aenr the
anterior wiporior spinGus process of tbe ilium- He wna confined
twelt'e weeks to his bed, after which he wiis able to get up and
move about, ihougli much reduced in atrengtli. The fecrd mat-
ter coniinued to discharge from the wound from that time until
the present operation.
The patient was a large, powerful raauj over h\x feet in height ;
and although he was able to do some work, yet hi^ usefulness Uatl
been in a great meiwiire impaired by the accident, and the in-
firmity consequent upon it. He entered the Flospital on May 6,
1859, tc see if any thing could be done for hia relief. I wae
encourageil by the eucceas of a prevtous case to operate, ibe
condition of things being aa follows: —
On tlie left side of the pelvis, about an inch below its brim,
and in the neightMirhood of the anterior superior spinous process
of the ilium, was a puckered npei-ture* about large enough to per-
mit the entriinee of the little finger, surrounded bv a red, indu-
rated margin. Extending from this, a little upwards and also
dowQwar^ls, to die pubes, wa^ a long sear, which I'cmained from
bija previous wound. A probe, l>eing passed into tlic wound up-
wards, penetrated three or four inches freely, as if superficially,
and under the integumenrs : it could ije pnseed downwards in the
same manner without obstruction. The impression given by tliis
examination would lead one to euppose, that the fecal nmttera
must have an exit under the integuments, and afterwards pnae
out by a fistulous passage- This supposition, however, proved
eubeequently to be incorrect. The fecal discharges took plaeo
from tbe artificial opening at irregulnr inten^als, two or throe
times in the day, were beyond the control of the pntient, and
as
178
ABDOMEN.
were partly solid, partlj Jiquid; Uieir coEsietence depending
jircttj much on the clmriictcr oi the fooil mnilc uee (^f. In
iiilditioQ, he hud a. timaJl operation. ;>Dce or twice a d^y. From
the natural passage; tins being Yoluntnry, indicated that tho
barrier between the two portiims of the mleatine was not com-
plete, lie did not Buffer particularly from cclic or iiidigcation.
The patient being etherized, the little finger was passed freely
in an upward direction, into the nrtiSctn] nnus, and ;in ineifilon
made upwards of about an inch in lengtli, lowjirdd the ^Igc
of the pelvia, which at once expotied the LUte»liLie» showing
that the two cads tiame quite up to the external orifice. The
septum between the two could now not only be readily seen,
and taken between tlie fin;iers, but could even be drawn out
externally. The finger was piiflaed up into the upper portion of
the intestine* and downwania inti; the lotver, which seemed.
00 far ^B could ihua he aiscertalneil, to be the bigmoi<l flescure
of the colon. The very euperficial upj^earance preeenled by the
probe, when puascd in, was found to be due to tlie thinness of
the integuiuenta, occaeioned by die injury. The i^eptuui being
carefully exiinilned, the (?ritei\jtome of DupuyEren was applied,
and screwed up to make a moderate amount of preaaure. In
order to inaiiiLaln the iiiarrumi'nt perfectly firm, H^ it wai^ ou
the bide, a.nd not on the front, cf the liody, it waa neccHHary to
jind it with cot ton -hatting, and secure it by a bandage around
the hip8.
Ou recovering from the ether, he made no complaint of pain.
Pie WHS put on a diet nf wjiter-rrruel, pjtssed a good night, and on
the fidlowing day. May llrh, was quite free frmn piiin. Tic was
art well on the next day. On tlie 13t.h, I finmd that, during the
night, he ha<l complained of Bciine pnin in the right side of the
abdomen, rc([uiring rhe application i>f hot fomentntionft and nn
0|>:ate. At the time of my vtr-il, he was rclieA^ed. He paeseJ
wind» boih through the natuml and nrtificial anus, I stopped
the drinking of ciiM water, in which he had been indulging freely
without my consent.
On the 15th, he wna doing well : two small pelleta of fecal
matter paase^l from the artificial opcnmg im the night pi'evioua ;
wind was pa^od through huih the natural and arlificiiil passages ;
the pulae eighty-one.
ILIAC TCTMOR.
179
Oa the 17tli, I found the instrument hnd come awny doriop;
the night wirboul the knowledge of the putieDt, ucid tliJiooveTetl a
Bnudl, ihin, dried jnece of inteatine in lis jaws, nn inch and three-
quarfei^ in length, looking like a bit of (mrchiuent- He waa
entirely free from pain, and without nnv distention of th(? abdo*
men. The wotind woe dressed with a pledget of lint, and a hit
of adhesive pliuter was placed o?er it to produce a aliglit oom-
presaton.
From thifi time, the feGol matters reauxned their aatund
course. It was found, however, after a time, that an obstruotioa
OccurTcd In their passage, iilwul a oi>uple of inches below the
aperture ; oiid, ou investigation, it waa discovered that the intes-
tine, at thia epoi, turned short on itself. A second operation
was therefore done, of hooking up this second apui', pulling it
up to the external afierture, and iipplying the enierotome. The
reauh was the same a^ before; the instrument coming away on
the third or fourth day, without having produced any constitu-
tional sj-mptouis.
The oontcnti* of the inteetines, after this, took a natural eourse.
Tlie following year., I did a plastic operation, for sliding a bit
of skin over a fiatuloua opening which still remaine<l, and
through which, occaslonallyi there waa a serous dietiliarge.
Since tliea, I have not heard from him.
ILIAC TCMOIt,
In this connoction may be mentioned some tumors in the
right iliac region, which occ^ieionally lead to abscess, and fistu
lous openings on the parietefl of the abdomen. In one inalanee,
a man who had been a tailor changed his vocation at a Inte
period of life, and turned farmer. Tiio etoopin;; position in
working waa, after a timCt tbilowcd by a pain and aweiliog in
the right iliac region. Very sovcre eympioms followed; and,
finally, abdue?scs brnke tu different directtone over the abdo-
men, througli which fecal matter wa^ discharged. In this
condition, a year or two ailerwardi*, he CQtcrc<l the Hospital,
completely diciiLblcd, and unable to use hia right leg, piirtly
from stitfnet^fl of the lup-joint, owing to the inflammatory action
in tlie neighborhoudp
IBO
ABDOMEN.
After n ^eT]p»< of operations, die various fistiiliP wore explored,
(li]a(«l, iind henJeJ^ with tlie exception of oeo lending to the
iniestinp, which, «o far as could be diaocverod from its very deep
aitiialion, or a.cj*ouiit of the Ivmph deposited over it. wna the
ccecum, — being nearly three inches from tbe surface of the ab-
dcimen. The fecial ujjilter was nowdischnrged tlirough a single
opening. Fy this meiins, the irritation in the integuments wa6
relievml, nnd he partially rc?corered the use of his right ]cg.
He went into the country to recover strength for the final opera-
tion, anJ died there suddenly a nionlh or two afterwards, so
far ns 1 eoiild nscertajn, from some other aHTectJon.
Shortly aftem-ards, another jmtient applied to me in a similar
oonditjon, the abseesfi liavini^ been brou^rht on bj a aimilftF
change of life and exercise. Probably it waa id some wny con-
nected Mith the iJiao muecleis. He was too emaciated and feeble
to undergo any operation, and, in fact, decliaed any.
1 removed for lum, however, a cancer situated on the end
of hts loa^JT^ie, by ligature, which had cftU9e<i him much trouble,
and prevented him froni taking his food tn comfort.
Not long eince, I had under my care a lady — paet the crit-
ical season of life — who was seiKcd, Jan- 1st, with a ehnrp
pain, with tendcraeaa in the right iliac region, pre*'eded by
some daye' uneasiness in thnt quarter. She waa treatet^i by rest,
mild pui'gatLvej:^ and fomentiitinud. She recovered in about a
fortnight, F(?l>. l=tj four weeks fj"otn the first attack, she was
again Ptiaed, more violently than before, lifter having taken a
long walk, and been much exposed to a cold drought.
An clnetic tiLmor appeared gradually, in the course of two or
three weeks, fiJling the iliac region, and extending up to the
ribs, and, laterally, to the medifLU line. It was exfjuisicely pain-
ful, 60 that it was examined with difficulty ; Btill, I deteclei] a
dccp-seatcd Huctimtion midcr the ctncimi, and my dirtgnoJ^is was
an iliac abscess, reeembhng somewhat those deneribed hy oh^ietrie
writers as occurring in puerperni women. The ubecees, how-
ever, which in lhi?sc cases can <ronerally bo felt through the
oiLlural p:i!^KageB, and often breaks into one of them, could not
be found in this ease. At (he end of about three weeks, after
ver3' eerioua symptoms, 1 detected a small, hard lump, deep in
tae ^rnn. usiaci rinniXTS i^^wnMir, nut ni. tm nmf^ui! re at*
I'T^c iLwo. in*ia tthi- .r^^m: ^jti PTiil- in. rETi!!im:r x. 4 ^onLL
car** iiv~*- rji; ^'^miiriiu? t'-s* ic ;iii^ yttl±f*^L^ Z*ie *ja^
n^^^tnuti T-te^ ir !:i»iir-^ siiw Sits iinimicii7 srarsiSr ;r!-
Ii isi.intir at**?- i ji«£"'- ^iuur tL."n. j. »c™!t uH r:''fr^ vj^
Si:ct*ciiitr iUii r-""*?! ir»xT ji xd ^ndj^^ mint -i«*rT?T f*-~T r^
ti^n^ 1 £11 liX **t-; its mnl i'.aut ▼'f^ki tisr ^ a.-^'o^a^
?ro= iflvi -ea Tiiuiiui 7. ▼'lTc- zl -dn ntttLT umi- '"r:^;fa: fr«a
[«£=. i :i» i-'jii.raisL tn: iaii ilu'.:; Zi*c:=r:iiafri; ::i ;m irrwdaa.!
w»f fch-j* :: -_*ar ^ E*.idi;c :^' t a^rii^- -wiir-c: aa?£ix 4
"i j^--^I ^;^iii:^ ireor lue >i-:r32-' W tit »:■:' lilida^ ."^ , *OQi^
1 hjve Trif{>^zlj ^^ir^. l<e:' -T^ ^zri ^s-^ lii* paf<er w*j |>^^ii:^b«d.
A paii^nd, «Ij^: r^:::^^*. '-^ ^^r^axer or !&» fiz«. b leit la the
re^I'jD of tot f^tcr^Hk. anes'i^l •-ith iVver, iMaf«=i. i>-»D?tipa;ion»
and a ^rtai ft^Iisj ^,f .i.it«;:; >a- ReLet U c^ned irom ^iihar-
lics, which. h'^ir^Ttr. I have ^enerallj been ?paTiD^ ot* having
tnifted CO r^l, f'^m^Eitaii'^nf, and ^>mp[im«s leeeho:^. In <>ni-
ca*e. Id whi?h powenul pur^ativea had been tried for > W(vk*
wiihoui effect- the sufferins* became dreadti]]. and intT\\*u*oe[*-
tion na.? foar««l. I advised that the patient should bo pta^'^l
under thcr iuduence of opium, and mean« uf«d to nnln^^ Uh^I
inflnmmaEiijD- Thb being effected, evacuations to^»k jdiX^v *]h»*n-
tanei»U!-lv. and the patient recovered. In one instance, I hn^e
eeen the i]iH?a?e recur twice, with an interval of one or two ycjir**
The duration of treatment bjis usuallv been About two wovk*.
182 AMDGMEN,
Thii tumor ii important, as it ie often not detected by s
pbyiidan unBOcnutomed to it ; and I hare leen a number of
CAMS wbich hftTO gone on % week or more before tbe cauae of the
fljinptonu woa found out. With Dr. Jackson, I bare never eeen
it anppnrate, thougb it ia difficult to say exactly how it differs
&om thoae that do. The principal distinction seema to be that
it ia more eluggiab, and its oonfinea more definite, than in thoae
tomora of the iliao region which terminate in suppuration.
CHAPTER VI,
ANUS.
IJEHOICICHOIDB.
Thb nimmon oppmlicm for hemorrhciHMl tiimorn, for the Inst
thirty yrairn, han been by lignture, BefLire thnr time, I Imve
seen exr.iKion practiBeil, but, 1 may any, fi1mr>st alwny^ followed
by troublesome, if nut dnngenms, lieniorHingc. The li^tiire is
wife ami dfe^^lufLL I have generally [lertbrmeil tlie openidon aa
follnws : —
The bowela are cleared tJie day before- On the same day,
prior li» tlic operalloti^ no Htilid fowl aliould be taken. The pa-
tient bting etlieriKed, the tumorti nix* e>Ltmded liy the finger, uml,
one after the other, eehetl with liooketl forceps, ilie bajie tmns-
by A double ligarjire. und tied on encb side with greut
3e, anil the ends crut riff. The riVm of the edgea of the arua
should not be impinged npun ^ nncl, if tbia cjinnot be iivolded. a
griMive shonld be in^jde for the ligntui-e widi u kidfe. The
tum^rA lire then returned M'itbbi the anim. The pAtient m kept
veiy rpiiet in beil, avriidin^^ opiates, if possible, and can almost
(dways go for eight days wilhont an action of die bowfls, unless
the tftomneh is disturbed by impniper food. A mild ctitfiiirtio
may be then administered, though fiometimes tlie bowels are
freed qtonraneoubly.
The swelling which takes plare sonietimps eauaes a retention
of flatus, wbidi gives a senjmtbni of great preaaiire. This is
relieved by the eantiuns introduction of a large gum-elaetLC
eatheler into the rer^tnm- Retention of urine, requiring the use
of the catheter for about ihree days, — and 1 liave once fleen it
laj4t eight, — ifi not an unfrct|uent tweurreuce. I have onee or
twice tried, soeee^sfidly. the use of the fjeniBeur; but, in very ei-
trenie case*, slinuld think, unless it was very earefully managed,
tliat its lue miglit be followed by hemorrhage.
184
ANCS.
Cask XCVII- — UtimoTrhQidv. Operallon. Cure. —
W. A., 42 years of iige, u iargo» musuuljir itian* hud been
troublL'd Tor Hcventeen years wllli exFcniiiJ and luternal lieiuor-
rliulda. lie was habiluallT constipated, ;uid fre^iuenily, during
iLe previous eevcn yeiira, ball lust bluod when the bowels were
evac:iiHted, ao i\n\i hid puhe w;ia wcztk, and lie cxliibiced an
aiiniTiic coEidkiuD, and v/txs unable to wark> Sometimes tbe reo
luin witB prolftpaed tg tliB extent of two at tbree indies.
(Jii tlic 30lb May, 1803, 1 o^itrulL-d. He vraa ctberized ; and
^VQ birge, liemorrboidal turaore were dniwn dovrn, transfixed by
doulile ligatuffs, and tied at tlic base- Care wiia taken not to
include liny of tbe skin. Two Inrge cjtternal Lemonhoida were
also cut off. On tbe aeventb day, tbe ligatures uuueaway;
and at tbe end of a furtnight tbe bowela were opened by
caatur oil and enema. On tbe 2'2d of June, an cxnaiinatioD
showed that tbe internal tumora were entirely removed: tbere
was no pain, and no blood waa passed at etooL Tbree more
external piles were cAcIseU, wbich completed llie cure. Tina is
au extreme case ; and I have faclddui found it Deceasnty to in-
terfere with tbe external tumors, the remoTai of tbe internal
onea generally euffioing for a cure.
Case XCVm. — ll^worrhoUh. Opcrafion, Curt^ —
A man rij;ed 47 entered the Hospital, June II), 18(13, suffering
with beaiorrhiMdal tuiuurt^, nad much bluai^bed from luss of
blood. He bad bad ao attaek of bleeding from tbe rectum
tfiirtecn years before, and another attack seven years al\cr.
Tbe Inat five years, Le Imd bad frequent ntticks, lasting iwu
or three days, the tumors and inueoua membrane in tbe vicinity
remnimng in a prolapsed condition during the paroxyamfli
Oil the 2nth, an ereaia having been pi'eviously aJniinislered,
tbree cr i'uui large [umors were dragged dowa ^\ith hooks, and
included in ligiitures ; care being taken to avoid every thing but
miicuas meinbrane.
Aficr the opcratioji, he required an opiate. There waa for
n few daye conniderabic Jiffieulty in micturition. The bowela
were kept rjuiet Jbr seven or eight days, and were tlieu emp-
tied by niciins of a mild purgative.
He waa shortly diachiirycd, entirely cured.
HKUORfillOIDft.
185
Case XCTX- — Hemorrhoids^ Opemiiou, Cure* — A
woihaDt 27 venra of a^, enler^ the Hu^pttal in Morcrh, 180U,
in an anii?iDic BEate, and f^iDtin», even in the «iipiDe posi-
tion, from confiUiDt and profuse Iom of blood from IjemorrhoicU
of t^velve years' ftanding, brought on by constipation of the
bowelA. She aaid that eometimee she had lo^t a^ much ti5 half
a pint or a pint of blood a dav, for three months at a dme ;
bill ihU, doitbtle^a, was na €xa^;^ration.
Fctirin^ to u|>crale on her in her r^xlijeed <v>ndiUotti she wns
kept fk>r about a week in a horizonlAl pu^iCion in bed, a tannin
injeetion r;dniinia1ered daily, and noumhin;:; food <;iven in aeon-
e^ntnted form, ao a^ not to excite action of the botveU. Br tliis
menns, the bemorrhn^^ was aloioet completely checked, and ehe
rftpidly ^aincd etrcogih enough to qUov an operation. At the
erul of about ten days, four or five tumors were drawn down
and tied in the wav mentioned abo^^.
Very liitle febrile aetiijn followed the opemtion, and the pain
was relieved by the local application of ice. By tbia incau^,
opijitea were avoided and her nppetitc prcsert-cd, bo ttutt^ ai llic
end of three daje, she was allowed to lake animal food.
On the ninth day, having ?omc nausea, a doee of oil vrod
administered, bringing awny a large evacuation, without bloi>d.
For the first few daya, there waa some retention of urine, re-
quiring rhc udc of the catheter^ She gradually recovered, the
bowcle bt:ing only allowed to act erery third day- I aiiw her
two months atcerwanl^ in good health and tletih, and with a fine
color. She complained of some local irritation on making any
extraordinary exertion, or atanding for any length of time;
which ahe waa then, for the accond tinie, cautioned against.
External bemorrboid?, aa alreadj stated, do not olten require
interference, generally diaappearlng with the removal of the
internal alfectioD. Where a trotibleaomc exuberance of integ-
uments is left, it may be eafcly eicised. When esiernal
hemorrhoids become inHuncd and painful, tbey arc generally
dependent on a derangement of the digestive organa. If this
is rectlficil, the paroxysm pnasea by. ^Vhen one of tlie tutnora
becomes atrangulateil, so a.a nut to retain it^ position witliin
186
ATCtjS.
tin? nniifl, relief h almost at once obtained from % puTicture,
wliicfi irives issue to a clot of blood.
risscRE or the anus.
It wouW be difficTili to find any disense nttended with such
unmitigatel Buffbrinj as this appiirently triTial affection. Tlw
symptoms arc us follows : pnm ns of the papsage of a hot iron
through the anue, cooibinaj with a aousalion fia of cutting willi
a Icnife, aometlmes ntionihint on the net of defecation, at others
coming on at !in interval of a few mirmtes or half an hour nfter-
warila ; and lasting ofren for ^ever^d hours with sucli severity as
to confine die sufferer to hia bat^k, ot even ta Lib bed ; this r&-
nurring day after day, and sometimes for months or yearH.
Generally a alight mucous, [iiirulcnt, or bloo^ly disehar^ is
voided with the fec^ca^ giving the idea to the piitient and hi* phy-
siciun that he is lulioring umler fistula. Witli this impression,
he often nsks advice of the eurgeon. Oti examination, hy care-
fully pulling down and separating the folds of the anun, a small
fiseure, or crack, is discovered just within the margin, and ex-*
lending inwanla for an ireh or more. If the diseafte is of long
standing, an ulcerated surface, with elevated edfrettf take^ the
plaec of the fisauto. The sent of the dieeafie is often the centre oFi
a hemorrhoidfti tumor; and, ao fitr aa my observation goes, it
occurs 1:wice or thre9 tiuiea as often in woraen as in men. In
nine eases out often, I have fiiund it on the coccygeal side of the
B,nu«, on the median line, scarcely ever on the sides. Sometimes
two fissures are found, one behind and one in front. In regard to
Irenimenf, T have seldom seen it yield to the vaunted astringent
injections of rhaLiny, ^c.^ as used by the French, or to emollient,
or aoodvne cnemata, A numljer of timesT when ihe disease warn
recent^ I have found it yield to a thorough cauterization with
a stick of nitrate of silver; bnt it seldom gives w^y under any
treaTmcnt short of the use of ihe knife. The surgical operations
which I liave seen practised, many years ago, for tlic relief of
this affection^ were of a eavage description ; comprieing not only
the incision of the stricture, but n cut through the whole sphinc-
ter muscle, extending nearly^ if not quite, to the coccyx. My
nSSUEE OF THE ANDS-
187
OTTTi practice hoe been us follows : to have the anua well diluted^
and the mucous membrane drawn down so as fully to expose the
diaenaed aurJace, If there was an ulcer of lon^f eCondinir', the an-
terior part of the ulcei* was eei7ed with torvo[)a, and the whole
dibFcaee carefully exL*ised from without inwards, hy mcane ot
ecissora; the wuund, after its i^moval, making the centre cf a
portion of ligeue, witli a mar;[^4n of heiilthy mucous membrnno.
In case there luia been much 8|>aamodio contraction of the sphinc-
tor, Avhioh, however^ ia uhnost alwaya dependent on tlic ^rcnl
irrttahihty cf the fissure, I have Gomctimee made a aubcutaneoua
division of that muscle- In otlier coeee, by passing the fore-
finger into the rectum, and hookinf^ it under the gphinctcr, a
Bninll opening is made into its shciith ; tlie muscular hbrce ure
then exposed by brining them out upon the fin^fcr, and di^
vided, Tiiie plan I have also i^ilopted witti Eueee^, in opera-
ting in cases of rupture of the pcrinspum : its advantage is, that
it avoids a lar;^ wound cxtGudin^ into tho rectum, which may
cause deep-seated heniorrhu^T and allows the blood to escape
externally, if there should b>e any tendency to bleeding af^r the
division. I should have etnted^ in Bpcaking of the treatment^
that in one case in which there was frreac ^utferin^, and violent
contraction of tho sphincter, tins was relieved, and tho fissure
allowed to heal, by wearing a short metallic rectal bougie, of a
dumb-bell shape, with on aperture in the centre for tlie cacapo
of Jiotue.
Case C, — JV**ttre o/ the Amia. — A man 35 years old,
who bad been subject to honiorrhoiils for a year whenevor ho
had an action of tho bowels, was attacked with a most aeutc
pain, not only during tho passage of the feces, but for an
hour or two afterwards. Ha had been under constant medi-
cal treatment^ both local and general ; and, from the feces being
oecasionally streaked with blood and pus, it was supposed to
be ft case of listula, although nothing of the kind had ever been
discovered on examination. He was mueh worn down by auf-
fering, and was entirely prevented from doing any buaiticss* On
aepantting the nates forcibly, and making traction on each sldo
of the anua, so as to pull down and expose the folds of tho rec-
188
AUVB.
turn, T lit once clisijrjveretl tlir commencement cjf a fissure, jii&t
Miiliiti thir uiiub. Tito jkutit^ut Letiig nindc to brace liim!^i;lt up.
rln- lissure wa-s graduitlly forced duwu, nnd exposed to vjcvr
lljcoit^diout iieiiHy it>4 vkhole extent. Its wlmle fiurrace was
then tliorougldy cjiiilerized with the auliil ultrute of ailver,
whielt npplit^iition seemed like tlie lunch of a. red-hot iron, Af-
ti^r the I'tim^ whii^h liiateil for un hour or two, hjid eubaldedi &
distinct relief wtis eJtperienctil. At tlic ueit eracuiition, which
(i(5turred two days JiftLTM'anla, there was uhfloliiu-ly no jmin»
Suht^t'queiitly, In the ('.ourse of n fortnight, tlicre was a relam
of jKJin [liuing defecaliou. A second n£)|jlicLttion of the cou^tJC
coni[>Ieled tlie cure*
One or tvra other ca«es of this di»ea?se, wbieh h&re come un-
der my observation, in males, Lmve been cured under a similar
uieihod of treatment.
Case CT. — Ftsmre ttf (lie Anux. — A lady S-") jeara old,
who hiiJ tfiiffcred severely fi'um hemorrhcidd during pregnHiioy,
aifter her luHt confiacineiit (wlunli was two ywira before I saw
her), began to have severe buruing mid Inneinating pain after
every r)|ieratiozi from the bowels. Her ttiiflbi-irigsi gradmilly in-
crea>ii>di uutU th^y beennie almost inanji^iortjdde, and eonEiied
Tier to the beil during the grenter part of the day, nfter each
evacuation, wlilch caused severe constitutional diHturbance. sueh
aa chilla and fever, with profuse sweating- Every kind of
treatment had been tried, in the way of liwial applications, iu-
jectiona, lUid laKuti^'eg, together with occatfi(»naI opintefi, but
witiiuut permunent benefit. As uny ex am inn lion with the finger
WHS utterly insupportable, nlie waa etherized, and pieparaiicn
made for an operation if it should prove to be necessary. On
sepnriiting the folds of the anuB, n brond fissure was diacoTcred,
or rather iileefj with depressed centie and elevated edges,
which exiemlcd into the rectinn for some distimce. The anus
was now drawn well open by two itssistantj*, and the extenjal
portion of the ulcer firmly seized witli toiitlied foreepa, and a
careful dissection niFulo with pointed scissors; the ulcer beino-
gradually dra«,fged down w* tlie dissection progreaaed. In this
way, the entire diseased surface was thoroughly excised. Alter
FISSURE OF THE ANT'S-
IS9
tho opcmtioTi^ no evacuation was permitted for a Tvcck : tlic
iirst iU'jcction naa attcudcti with aomo [min ; but, r& the wound
healed, |!ic \mn bocrtnio loee^ and a goad recover^' toob plucc.
It is nijvr neiLrly nine jcore siaco tlio operation, aud Bhc has been
entirely vidl since.
Case CII, — Fii*siti'e of the AjiJts. — About tlie jcar
1850, I anw, in consultntian with Dra. Jamea Jn<^kai>n and J,
C- Wiirrcn, a Irtdy, about 40 ycare old, who for a. number of
ycftrs hfld aurtcred from symptoms of fif^anrc of tbc aaua. Sbe
wns very fccMe, and in nn anicmic etfitc* There waa very
violent spasmndic cuntrnction of the sphincter, whieb almost
prevcnttti the cinicuntion of the bowels. The pjiticnt being
etherized, I was requested to opcroite. Tbc iisaure hcirg of
Iting standing, and much lirm nmtcri^d oEluacd about it, it waa
eutirely exciacd, txa In the laat ciiae. A tenotomy knife was
then carefully workctl in under the aphincter, which was put on
the etrftoh by two iingera in the anu>'» and the muacle divided by
a aubcittaucoua eection. Tiie patient, aWcr the ordinary trcat-
uicnt, waa cUbctuaily cured.
Case CITl. — FUmre of the Anng. — Nov, 1862. Alady,
^'a yeara old, bc^rnn ahoxii a year and a half botl>re, and not
long ntler tbc bii'th of a child, to eulfcr (rom n pain in the
region of the rectum, after defecation. This pnin she referred,
not to the anua, but to a epot in die rectum opposite tlkc Jower
end of the eacrum. In the course of the day, n email collco-
tiun of pundcnt matter would take place in the rectum, and
the discharge of thia was attended with moel terrible suftering.
The pains gradually extended to the Bciatic and other ncrvos of
Ibe pclvia. She gcneniUy enjoyed pretty good hcnith ; wus mar-
rial, and bad one cliiid. The cnlanicnia were regular, and there
was no a^iparent trouble about tJie uterua. She was seen by a
dj^in^uished surgeon in tlie army, who exhausted Gvery avail-
able means of relief* but to no puipoee. I had no doubt, from
the deecriiition which she gave me wlien I iir^t aaw her, that
ehe bad a tia^ure of the onua ; atthou^'h she could nut beheve
that the pain which appeared to be ao high up within the rectum,
190
Ai^a.
nnd the pAins in ihe limba, coulJ be attributed to tlus cause.
On se[nmitmg the foJds uf the anus, H»i uk'eia^lcd fissure.
Opposite the coccyxt vro^ at once manifcBt; but an attempt
to explore It with the fiog^r vrns attended with aucli eutferiog
tLat it Wild DCCL'Fjsaiy to desist. I udvJsed Ler to tako n
private mora at the Hc«plbdf wliere the o[icnitLUii was per-
furmcd uoiler ethcr. Aa eoon as the irritability of the sphinc-
ter was overcome by the inHucoce of the aiiffifllhetic agent, the
finger could be pu^s«cd up into tlic rectum, whlehf so far as could
be aaeertnined by the eense of touch, waa in a perfectly lieidthy
eoaditien. The liastire exteiidcd from jii^t within the margin of
llie aQU3 into the rectuiu. The ulcer waa of moderate depth,
witli hard and elcvnted edgCfl. I iirmly grasped the whole ulcer
witli tiMjthed forceps, uud dissected it out with seissors. Tlie
night uftcr tJic opcnttioii, she wus free from pain, and in fact had
no pain for ^vg or &bL days, during which time she had no eiac-
uation of tlie bowela. At tlie end of thia period, she took &
laxative; and the evacuation which folbiweil wnfl attended with
a little pain, as might have been exper^ted while the wound r&*
mained unheided. During the ne?tt week she did well, so far as
reganis pain about the auus ; but she bad one or two severe
atljicks of sciatica, which rcj^iiired the use of remedies. At
tlie end of a fortnight a*\er the oi>erationT she left the Hoa-
pitnl, at her own requeiit, to go tu the house of a friend, appar-
ently well. A week later I w^as requested to ece her, and found
that all the old symptoms had returned. Her bowels, from tlie
want of proper manugeinent, had Ijecome quite costive, the did-
ehargps inking p]ii<ie in hanl lumps. On examination, the wound
WHS found to he nearly healed, and in a healthy state; it was
touched with nitrate of silver. This application, conjoined with
a laxative diet, gave relief for several days, when it li^ul to be
repeate*!. At this time she was compelled, by the illue»3 of her
huriband, to return homo.
In Mm^h, 18G3, flhe Came again to Boston, havirg a recur-
rence of all her troubles, with all their former seventy- I
advised lier again to enter the Hospital, and to stay there until
cured, if po^ttible. She was ethcrizcil, and a crack was found
in llie tiuiue place as before, but not i^tricLly In an ulcerated
FISTCl^A IN ANO.
Iftl
COTirJidon. A cut wns ntiw mnde direotlj tlirmigh it, jim! :iljoiit
n thinl purt tif ihe thi<:kness uf llie fibrva of ibe exlemiil
fipliincti-r included itt the inoiskm. Tills opemlion ngniti uf-
fi>ril«<l relief fur a wt^ck ur 1*^jj diLVH, wIil-ii [In? jitiackrt uf pMiti
hegnn to return at iiregiilnr imprvalB, often in the niiiMlc of t!ie
ri^lit, and ussumed a vrolenily hystencal chnraclpr. Cuiiteri-
ziLlinn iLgjiin guve prirtinl refi^^f. Durin*^ tliia time tlie cutainenia
IjiLil been irreguhir, thu discluLrge taking place tlin^ H-Ays ever;
wei'k-
She wna kept under trentnienl for her general health, and
mum entirely ret?uiered. I snw her n lon^ time nfterwarda,
wirhi>ut any reL^mrence uf her former tiTJuhlea.
This coae U ini[)ortniit, r»howti)g how ncccufiiiry it in to perse-
Tere in treatment, where tlie mind of the surgeon is confident of
the ciLuse of the nyinptoms. Here it was neccssnry t<J work
cijnshmily ngainsl the persuiLBiona of the palient, who pprsisltil
t^int her J4utleri]i<rs had ^me other ori^n. TWia idea whs 8till
farther eorlirme<l, when ehe did not get complete relief fiy a
rdtii^le opera.Lioii.
FIBTULA IK ANO,
The operation for fiatuk in nno is mo eonimon, and the treat-
ment so s^^ttled, that it is Rertrcoly worth while dweliinff on,
I would simply say, that, in those ea^^ea of fiHtida, running tnr
up into the rectum, it ia unneeessnry to follow the internal
cnl-tle-sac to its terminnlion^ wliich is often n hloody nnd dnn-
gerou^i proceeding. Generally, the incision should comprise
thnt portion which is included [letween tlic openings of tliG fis-
tula on the rectum and outside. The internal aperture of the
fistuhi I hnve nliuoat invarinldy found jii*t wirhin rhe amis, and
more cunnnonly on tlie nnierior fhiin the posierior side. The
treatment of injociionat na used hy empirics, is gererfllly inef-
fectual, and not only involves the I'tvs of niueli valunhle dmc,
but gives ujucli discojnrurt to the patient.
In regard to the ruTe for operiiting on phthisical patients, I
should SUV, that, if the fistnia causes no irritation, avoid inter-
ference. If inueb inflao mill ion, with numerous external ii&lulous
192
AKU8.
ofieiilnga. is prcffpnt, caiismg great sufTerino;, preventing excrGiBC,
aiii] ilevangiHg tlie system geaerallj, tiu opunaioii ufteu reatorea
almost new life to the patient.
Case CIV, — FiflTur-oira Ofentno xear tiir Hoot or
THE Coccyx, IK tiie Mbdia>" Lenb between tjie Nateb ;
THE Fistula containing Kair, — TLe following cnse wna
pn^ecLitcrd fur consultation ; and is similar to those which I have
frequently hnd imJcr observulion, but Lave nowhere seen dca-
cnhtd. ThemcKje of its origin hps not yet been clenrly mwle out.
Jan* 18<J4:, — A young niiin, 25 year* of a^, with very full
dcvelutuncnt of hair on the body, apj>hcd to mc on account of
a atnall fistuloLis opcnin^i %vhLch he hiid njion the sacrum, juat
between ihc foldj of tfie n-itcfln The first intimiit.ion which he
had of it wns from the exudation of moisture from this epot
about one year ago. At first the discharge was tliin, but nftcr'
wards assumed n pundcnt character. Recently the diacaec be-
came more ser^>uu, and the soreness and inconvenieucc resulting
from tlie di.iclii\ry;e led him to seek medicid aid. On examina-
tion, a amall cireuUr opening w-is aeen, just large enougl» easily
to admit i\ probe, looking aa if the skhi had become inverted at
fliat point, and tjuito unlike the raggedy iuHamcd orifice of a com-
mon ti^inla. A BCfo-purnlent matter oozed out from the interior-
Tlio probe penctrnted upwards between one and two inches, I
at once recoguiaed an oifcction which 1 had freijuenlly obacrvcd.
On opening thid Hrttula in eimilar caae^, a amall curl of hair has
generally been found occupying tbe bottom of tlic cul^dc-sac.
Thia hair aecma occnsionnll y to act as a foreign body* gLViag rise
tu inflammatlun, with the formation of abscess, rejiulting in
£stulotis openings c:itendin^ in various dircctiona, thus often
concealing the original difiicultyi By a card'jl exploratory op-
eration, however, the Utile widp of hair may be dliicovered in
ttomc part of tlie elnuat lying [icrfectly looae, and unattacbed to
the BLirroundiag tissues, I have once seen thia in a woman
wfiose hair was dark, and more tlian usually developed in that
region: all tbe other casca, uiimbcring jKirhnps eight or ten,
have been in men.
The origin of thia singular affection ia involved in obacurity-
FIBTULOUS OPEMyO NEAR COCCYX,
193
Tl would ecem [K)j?ftible» however, that it may Iiegin in thp atout
hnir or hairs arising from a single falhole hecoming in some
way diverted from their normal direction, and irverled upon
themHclves within the fiillfcle itHell": tfie oontiuued growth of
the liiiLr would then renidt in the formation of a tnugled knot or
brdi of hftir. which might readily gi\e rise, after a time, to irri-
ijinon, just as a similar aceumulalion of aebaceous matter in the
follicles of the faee may excite thnt form of inHarnmatory action
known aa acnc". Tlie occurrence of the diseflBc in the median
line between the folds of the nates mny perhaps be explained by
the constant pressure ftnd moisture of the part, j^ortening both
the newly formed hair and the epidemiic cells surrounding the
mouth of the follicle.
Tlie treatment of this affection consists in laying freely open
the cavity or cavities where the oocurrence of intiamniiition has
involved the akin nnd subcutaneous tissue; or, in case the skin
still remivins healthy, the eac may be laid opei^ and then dis-
sected out- The intcKumentp should be broup^ht together with
one or two sutures^ thus insuring a more speedy eure than if &
simple incision is practised.
This affection U interesting, in connection witt whnt has jnet
preceded it, from the fnct that the persons who apply for relief
almost always auppoae that they arc laboring under tha diaeaae
of fistula in ono.
Case CV, — Fistnlous Opening in the N^eifjhhoi'hood of
the Anaa^ rontttijiinfj Hair* — A man entered the Floapital,
July 31, iSGfi, to he operated on for what be supposed to be
fitituhi in uno. Ho had received a kick on the nates a year be-
forej and a emnll, hard lump Lad boon lof^, which hod recently
suf>pitrate{lt There wo^ nn opcniitg near the nniis. and an-
other near the coccyx^ neither of whkh communicated with the
rectum. A director passed freely from one to the otlier.
On laying the whole track of it frocJy open, a tuft of hair
was found between the two openings, quite free, and entirely
devoid of hidhs. The patient led the lloepitJil in about a
week, in a. fair way for recovery.
194
ANDfl.
PHOLAPaUfi ANT.
TliG disease which p^oea by thie Jiarne — ami it ia nBuaJJj eon-
fountW with an cveraion of tiic mucous membrane^ attendant
on extreme uriBCa af iuternjil hcmoiTUoiJs — h u very rnrc fltfoc-
tion. The pntienta in my pmctioe, in wliom the wholo calibre
of tlie int*?Ktine prola]>se[3 nt each evacuution of Iht* bowel*^,
\m\e p;enernJly been oliildren of a scrofulous habit, who hurc
suffered &oni ohetinate confltipation, irom irFcguJarity of tlie
bowels, from dysentery, or from awaridea of the roctuna. The
disease has nimoet always yielded to an invigorating' course of
treatment with iron, a noitriehiug- diet, whicL leaves but a little
residue, and aeCringent injections. Before an evacuution, an
eaemn of cold water or a polulion of tannin was adminia-
tered- I have also sgcu it in old pcreons, and in persons
sutfering froni^ Atone in the bladder, where the straining is
extreme.
Tbc records of the Massaehusetts General Hospital give the
following numbers, for a period of forty ye&rs ; and probably
one-half of these are misplaced, bein^r caaes of everted bemor-
rboidfl : — '
Total number of caMS 19
Cured n
Much relieved 4
Keliavoil *
The treatment generally seema to liave beeu by ligatures
applied to poitions of the tnucoii^ membrane nruund the anus,
ae for hemorrhoids. The following case I trcfited by i^uter*
ization wdth acid nitrate of mercury.
Cask CVT. — Prolapitua Ani. Cauterizaiion, Cure. —
A boy, aged 14, of English birth, entered the Hospital May
20, 185^- He [?iud that he had :t prolapsus when only two
years old, which dieappcjircd, and returned eight years after.
The whole calibre of tlie rectum whs ftirceil down for one or two
inches during every act of defecation »
POLYPfta OF THE RECTUM.
195
The boy bem^ etherized, die iatpatine waa everted, arid n
ring of it cauteriaed with the fteid uienlioucd above. The pro-
lipsua wfla then redueed. The bowela were kept quiet for n
nurober of days, but tjo recurrenee of ibe prolsipse oecjrred
when they itet(?d. He waa kept under observation until it was
certnin that the cure woa complete.
Where prolapsus ts compJicated with bemorrhoida, ibe trent-
menl wliich relieves the laiicr will also relieve the former; i,e.,
the hgature or ^eraseur.
POLYPUS OF THE RECTUM.
Polypus of the rcfMiuzn i^ a very rare iifieetion, and usually
of mild ehamcter, 1 do nol remeiaber having fleen more than
five or flix caHGS of it- The first of the following, operated on
by myself, is the only one recorded on ibc books of the Hos-
pital up to lJ^(iO: —
Case CVn. — Polypus of RBctvm. Usmoval. Cnre^ —
March 21, 1860, a boy, time years of age, entered the lloapkal,
for a Vftseular tumor, which oecasionally projected through the
Bphineter aui, it having been first discovered four ye^vs before.
It frave him great discomfort. With the finger, I could die-
imguish it about two incheB above the sphincter, of the size of a
ehcHTnutf attached by a broad base to the intestinal walls.
The patient being etherised, the tumor was draggeil down
outside, and removed by tbe fcraseur. He waa discharged well,
on the 26th.
Cabb CVllI- — Polj/pns of liectum. — AgBntlomnn, who
bail onre or twice HiifFered from fissure of the anus, ctmsulted me
nbrmt a tumor which occasionally came down while tho bowela
were being eva^^uatpd, and became pinched by the apbiticter.
By a distal examination, a hard tumor, the Bi3:e of a small
walnut, wan found hanging to the parictes of the rectum by a
niirroiY eiljdk, al)out two inches from the external orifice. I ad-
vised its removal by twisting, or with sciasors. His mind, bow-
ever, being relieved rts to tlie diaraeter of it, and being much
occii[iied, the operation wa8 deferred, and I beard nothing farther
from hiin In regard to the tumor-
196 A^■us. «
A ycnr after, hn^in^ fisfiurc of the a.r\%i6j which vroA Dpcratod
apOD, it woB tbutid that the tumor hud diaap|icurcd- In oU
prolralility, it hod been twisted o^ and ditiuhnrgcd by the action
oi' the bowcEfi-
Case CCX. — Polypi cf the HKctutn, Fiesvj^e of Anus,
Operation. Cure. — In April, 1(166, I wae roqueetcd to
operate on a ludy who had beta euflcring for n number f>f' yeora
fhrm a bad fiBsuro of the aaue, wliich, on examination by her i)hy-
eician, woe found to bo complicated with poij'poid tumora of the
rectum. The fieeure, whioh was found to bo in n very disc^ed
and thickened state from long ulceration, waa disaccted out with
the wi&sora. Three or lour polypoid tumota were then hooked
down from the roctum, and citlicr cut off, or Lied, wlicrc the
Toaculnrity seemed uiiusual. She had a dow recovery; but I
lieaid of her two mobtha afceru'orda in fine heiilth and ^[lirita.
Case CX- —l^olypue of Hectum. Jiemoval. — A woman,
about 35 yonra of ag;o, very nervoua and delicate, who had re-
ceive<l much treatment without avail, entered the Kofipilal in
April, 1SG6t — tJie eame week that I operated on the last ca*e<
The functions were goncrolly deranged, ond there wna scarcely
on organ in the body which was not complained of. She re-
mainedT for the moft jiart, in bed, earing that ^hc wjis too feebls
to ait up, and attributed her troublee .mainly to a tumor in the
rectum.
On examinatioti, & tumor wna discovered similar to tlioee de-
ficribed above- It woa dragged down and tied ; the li^ture
coming away about the fourth day after the operation,
IMPERFOHATE AlffDfl XSU RECTTDM,
It may not be congiderod inappropriate here to introduco the
subject of malformation of the anua and rectum, wluch ia one
of great latorost, aa involving the question of operation and
the life of the patient.
The following cases of imperforate anus, with malformation
of the rectum, present several points of interest in connection
IMPERFORATE ANUS ANU RR^TUM.
197
witli the question of nttempting to nffonl relief by a surgical
o|ieration- In simple occlusion of tbo Jtnus, tliere cnti be no
JouLt of the propriety of 0|veDing it, either by puncture or
crucinl Inrisionj mm'ntitining the passage afterwnrtla l>y the
use of bougies- The great nmjority of eases, however, aa
they oecur in practice, are by no meana so easily dispoeeil of;
being, as a genernl rule, pomplicated with an imperforate eon-
dition of the lower pnrt nf the rectum, and, in many ini^tnnces,
also with an abnormal opening communicating either with the
external surface of the body, or more commonly with the blad-
der or Vftgina- In a very conniderahlt: firoporrion, a1so» the
anua is perfectly f<rnne<l CKternaMy, but teruiinales within in it
eul-de-flac ; and a few inatimces have been rccordeil in which
there was a total nhaence of the reetum, and even of the whole
large intestine. Of thia latter malformation I have seen one
case, in which the large inteetine was absent, with the exception
of dIic cfficum ; and the specimen ha^ been preserved.
Upon the fliibject of operating fjr the relief of imperforate
rectum, surgecns are by no means unanimous. The grenC
fatality which attends these o]ier&tionB; the difficulty oiilen ex-
[lerienced, in the after-trejitraent, to prevent the closure of the
artifieial ikpemng ; »nd histly, and jicrhapB chiefly, tlio very
imperfect cliuracter of many of the so-called curcs^ resulting In
lifo-long diecimifort to the patient, — hjive induced many sur-
geons of experience altogctlier tu discountenance operative inter-
ference^ On the otlier hand, the certainty of death, if left to
nature ; the fact that tlie <iperation has sometirues liecn fully
Bucx'esflful ; the pronusc afTonled by improved operative inetfiods ;
and, finally, the natural relm^tance of the surgeon and friends
to leave any thing untried whieh may podtsihly save life, —
combine to justify any rational attempt at relief The tJioory
that the re^nlL^ are necessarily imjH'rfect, which allbnls the only
real argument against o^ierating, ib disproved by the very sue-
oeasfnl cases recorded by i3eigamiii Bell, Amusaat, Latta, and
others.
The operation whii^li promises the l>cst results, and which I
have several times performeil with succcas, consists in freely
dissecting through the tiasues whicli intervene between the cul*
198
ANU8.
de-eiic of tlie rectum anJ tlie external eurfece of tlio bod>', then
drawing down and puncturing the liowd, an<l finally securing it
by sutures to the ronrgiiiB of the dividetl inte^meut^ thus
£urniiiig a new cannl vrith a continuouB mucouB lining, instead
of the long fiatulous paaniigc which reftuha from a mere punct-
ure with the bistoury cr trocar.
During the year ending June, 1864, I mw four cases of
iiD;>erfomtc nnus and rectum. In two of them tliere wqa a
fistulous i>a&aagc, communicating in one Cfi^e with the vngino,
And* in the other, opening in the pcrinfeum hnlt'an Inch in front
of the normal poaition of tlic onus- In both of thc^ caacs, I
was nhle to re-estflbliah the natural paseoge by the operation
just deecribod. In a third oaee, upon which I operated by
punotaring the diatcndcd rectum, the child died; and, in a
fourth ease, i advised agninet any operative interference, Theec
four caece I propose to rclate-
Casr CXI. — Itnperforttle Anu3, toUk Abnonrval Op^n-
ittff of ihe Mectnm ^xtGniMy. Operation. Oure, — A female
child wiifl bom with a small fiatuious opening directly be-
hind the vagina, and half an inch in front of the normal
po&ition of the anu^, through wjiieh tiie fecal matter was die-
charged very slowly and with much difliculty. The child wna
therefore hrought to the llospita], w'herc liie opening wae en-
larged by one of the surgeons, who cnjoinal upon the parents
to hecp it from clofling up again by the doily employment of
tcDtfi. In epitc, however, of the attention which waa given
it, the aperture became gradually eontraclcdf so ac to CMise
much distrcsa whenever the bowcla were ovaeuatedf and to
lead the parents to bring the child again for operation, in tho
spring of 1865^ when it was about two years old, Tho
operation wtib performed by passing a curved Inetrumect into
the fifltuloua opening, turning it backwards, and pressing tho
intestine down upon its point where the ephincter-Qni muscle
should naturally be situateiL Here a dissection was made until
tlie aound was exposed, and the intestine freely opened by a
crucial incision. The intestine was now attached, by two or
three puinu of euture, to the skin, and a tent passed into the
IMPERFORATE ANUS ANI> liECTUM-
Id^
•
opening- The chUd bore tho operntion well. After n few
diiyn, the tent wjia removed; and the ilaily uhr of* bougies,
gr;Lduatly inirrvasmg m size, was coniDiencerL By the end of
the third week, it hecnme difficult to irmidnoe die hougie,
owing 10 the very powerful reaiAtanPC offered hy the Bpl»inoter
muwle : thls^ however^ always yielded to presaiire, nml the re-
moval of the bougie wna followed hy a frei? discharge of fecid
matter. At the end of a mouth, the diild lefl the Hoi^piliil ; the
mother beln^ rei^ueated to bring lier twice a week iu order to
have the bougie pa*ee<I, and the abnormid opening cauteriz&l
fur the piiqwse of closing h. Three mouthjs atlerwjird.'H» th«
cme waH h>F4t ^ight of^ a smnU fislidou!^ openin^r t^idl reniaiiiirig,
through wliic!i there waa occasionally a flight discliarge; tJie
new ftnua peHurming itfi fiinctiona perfectly.
Case CXJI. — Imperfornte Anus^ with Rsctitm ojitniuij
into ihf. Vmjhia. Operittioji. Rf^Uf^f, Death frmn Gas-
tric IrntaLiou tteo ■nimrlh^ aff^r. Mulpn^tlion of Iaf.e^tine.
— In June 1863, a fine, healthy irirl, six weeks old, wiw hron^ht
to me, with the rectum terminacing in the vagina- An infisiun
had Ijeen mnde by the attending physieian, at the jioinl where the
auus wtndJ lie naturdly siliLMted ; but he hud not succeeded in
establishing the pasaage. On account of the very early age of
clie child sind the small siie of the organs, it was verv difHuuIt to
determiue the ex:Lct eondition of the parts. The mother ^d tlut
the child was perfectly well, except that die dlscliarfree took place
through the vagina- A prohc parsed into the vaginji entered
^jcut two i[]ehe9 : in front of this, anolJier prcl>c eoulil he pasi^ed
into llie nrethnt, the^e two passages being entirely diftintt.
Alter considerable numipulaliim, it was found that tlie whole
jwsterior wall of the vagina* and the adjoining antenor wall
of the rectum, were wanting. The operation for the re^torit-
tioD of the natural pa>fsage was done us follows : A large Mlver
bunk, with a ball nt ibe end, was po/^^eil into the vagina, and
lun!i.-d dowa ug;jiji^t the spot at whieh it wiib pni[Ki'?eil tci
make the new opening. Here it could be inilistinelly felt tlirouga
the fiiielc mass of rhe s<»[V jwirts which iatervenwl, A crucial
incision wa<4 made through llie bkln, aud (he Noll [aiHn dist^cctcd
200
ANDS.
tij dthirr 8ii]e, nnlTl tlin HtTvnr bn.ll, presRiTig down the intpHlTne,
wjn felt in the wrutml, the wiill of the intestine only inter-
vening. A small aperture w»h now tmule m the giit^ And the
h(K>k iWHsnl Jhrim;rli ^o n^ In lioM tlic- ]KiHj*ni position. Tlie
(.>penin<r in tJie inte^i^Iine wiis then enlarge)], nnil its mar^^
etitcheiJ to the integiinient by four sutures, A jilij*; hus tlien
intniiluceJ into ilje *>|ieiiir^ to the ileptli of mi inHi nnd a half or
two inchef^. Afler the operation, a fi'pp Jisehargij tiwik pluce
from the viiglim, showing t\int the plug would not interftre with
the pafiHage of the i'ecea while the new anus vrns being efltab-
li shell.
A large anil wcll-fonneJ eannl was e^IaMUliei) in the iiomial
position, through whiuh well-f<>rire(l» solid ilischarge** took place,
from time Ui time, wlille the more liipiiil fecefi still mn*\e tht'ir
w»y through tb(? Tagina. The child wn» too yoimg anil tlic
vugiua too luaccesalble for any attcmjit to be made to elose llie
stbiionud [lOBsagc ; tliis it wna pro^x^ni to du at a luter i>erlud.
For a while, tlie i^liild eiyoyei! perfet^t heikh ; but fiuK^eijuently
waB atliLcked wkb gastric Liritationt and died Aug. 4, lH(ti.
Tlie t'oUowing eKtracIs from a letter from Dr- Cox, of Salem,
tlie atteEiding physician, give an aecount of the post-mortem
appearaiicea : —
'*Oa Tuealny, the 2d, I first saw her. She had constant natisfla.
and vomiLed almost every Ihincr she Look intii her sloraadi, and luul no
fllvitit! di rrhnrjrcs. Tho^c aymploraa toniinucil, more or leaa rirpoody,
till her dealh^ i>a tbo 4th, except th^t the bow(>1s \\vr& eUghtly mcv^d
J4e\-Qml limes. Tndfppinlf'iiily of ihe atnie or iltp aiinr^^pli^re of Eiite,
ih'a qutiditiou waa perhaps remotely caused by a mfillbrruaiion iioU
tran^poailion of the large irjtcslineT in coasoqucncc of wliich a free and
lh<»fr>ngli ei'ac!uation of ihu organ seldom, if ever, look piarv. . . .
TIm.' i^i'Lotti liACT'iultMl fi-oai the aiiua to the right iliac fuw^a, ilituee up
through the right lambar ro^on to the under surface of tho liver,
touching th«> ^IL-bUiddtir- Then it hcnt stinqdy don'nwvirdSf and da-
sepndcd, in eontaet and pamllcl wiLh the aflfenilhig porrion, to xho. right
iliuc fbasa. The colon thc[i cros^d the lower part uf the abdomen to
ll(t left iliac rcfrion, up throu^^h the Icfl lumbar region, almost to tie
E(omflch» tei'ininniing iit the ccecum, . . , Tlie [>i:ir[E*>H diseulored willi bilo,
fri>m it^ rniiturt witli the liver, iw wliiire ilit sudden uml abnijii bend of
the organ doivnwarda look pla(^c. This sharp flexure rauat have proved
IMPERFORATE ANUS AKD KECTDM.
Kl
acerioiJR obHtriK'lion to the evacuation of the howel. From this liirn To
ibrj imput colif the bowt^l wo^ rcry mucli dial^uded with ilatii^, and ooti-
tained more than rt quart of eoft FccaI matter of Eh<j coiiAiHtoDt^jr of
Ihin morfnr. Tlie only other mni^biil cluing^ found wad an injecri^d and
bulleiieJ atdtc of Ibi^ idul-ouji coal i>f iLe atoimiciL."
All incision being mude ;n the baclc part of the rectum^ near
the BnuBf diBpl&yed a very great contraction of that cuna] just
before itd ori<pnal terminaliiin in the vnrrina. la fjict, fidlowing
ihift contraction waa n, cul"de-sac which coiiimum rated with
the viLgina, about its middie^ iiy a delicate vaJvulor opening : the
H.r1in<'i]J anuB continuerl llie inteHtiiic down to its nntund exttit-
nuJ lonoiiintluu. It will be underj^tuMl, therefore, tliat, iimtend
of a free eoiomunieation between the inteblitie and vagina, tliere
nns a plnited condition of the nmcon? memhrane, au in tlia
oi'dinary terminiLtion of the ecinal.
The descending colon id this, ne in anotlier published case,
ivaa trun^juised; so thnt any o]>eration fcir nrtiiicial aaii«, aa
u^imllv practij^ed in the left lumbar region^ would necessarily
have failed of its object. I would advert to the very inLerestiug
fuct, exetnplified in the present case, and to which attention has
D]i;ny jeiira sirce been enllerl by lir, J. B. S. Jaekaon ; viz.,
(he very eousCa.iit terminaliiin of the interline in the vii^mi in
cases of imperforate aniw In the femnle. Dr. Jackson has also
remaiked, that, in all the irnsa^ of simple imperforate anus that he
has examined in the male subje^^t* a aniull opening has been
found betsveen the reciutn and ihe niembranoua portion of the
urethra ; and this opening in the male he reganis as analogous
to tfie one above referred to in the female. This is well depicted
in I'hite X, of Dr. "Willijun H<jdenhaiiitT*fi valuable wttrk euti-
iled, "Congenital Malforamtions of the Heetuiu and Anus.**
Case CXIII. — ImperforcUe Rectutti^ OperfUton. Death.
— April 9, 16G4- A very small child, three days old, wlJch
had not yet nursed, wan brought to me with the i"e<"tuin imper-
forate about tliree quarters of an tneh above the auus. Though
tlie child was tiuiescunt, the abdomen wa^ diHtended almost to
burst ingn A linger, being introduced into the anus, encountered
tlie ol^tiijction -, but there a^kpcareil to be no rounding out of the
202
AlCUS.
ttfUtm, indkstiTTg the
of ttw cftml abore- It
(kcMled to oiake an explorslory ptmcttm with the
irnctf- Wlwu the inatruuipnt vas dimtl in, ihe mcroDinm
began iAijw]y to fl»w oui, uniil &l ]ea^ half & pint faad cae^fd,
and, presnire bdng made upon the abdorT>eii, ftUofl foBowed.
The finder was tben paMed op above the ob^tmrrioTi, m as to
freely dilate it. Xo large cavity or depot of the fiuid con)d he
detei^ted. It itm advUeJ that the Goger should be pas^ up
once or twice a diy, wbif^h the medica] attendant promised to
do, and also to report the course of the case.
The {.'hild Untk TixmI irrifiuidiately afier the operatjon^ and, for
a time, teeiufd relieved^ It illei], however, the sarne nighi,
about twelve hoains after the operation. At the autopsy, a
fjoHDlity of blood waa found in the abdominal cavity, hot no
meconium^ A fibrous cord about an inch long intervened be-
tween the rertum below and the cul-de-«ac of the tmiierforate
intefidne al>n¥e- The great distention of tlie intestine by me-
conium bod forced II down into tlie pelvut, bringing it in contact
with the bottom of tbe anal cavity- On thrusting in tbc trocar,
the inieatinul contents Freely escuped ; but, on the with drawid
of tbe cajiula, the upper jiortion of interline retr^ccedT and the
npcrture in it closed so a« to be with difRculty distinguished.
The oozing of blood into the abdominal cavity probably took
p\nrs troni the lower aj>erture. The very unusual state of tlie
purtM dinclosed by ihc autopay ehowed that no openUion could
have been of service.
Case CXIV. — Imperforate Rectum. — May 12, 1864.
A female child, not quite 24 hours old, waa brought to me
with imperforate rectum. The alulomen was quite diatendwi.
v^inn and anu» iiatund ; the little finger could be parsed balf
an incli wjUuei tlic atuis. when it. was suddenly arrested. \Vlien
the cliild strained, a. ^enr^ation was felt of something prensing
down on tlie Gngtr; but it did not convey the impre^'sion of a
portion of intcHtinc diatendet] with fluid. On passing ihe little
linger of tbe other hand intn the vagina, the uterus could lie
distinctly felt aa in itji natural position. The finger could dien
l>c pmised over tbe iinger in the anus against tbe Bpiue, but
IMPEKFOKATE ANUS AKR RECTUM.
203
detected no tumor ; nor could any appearnnce of distended in-
te^dine be difttinguishefl elsewhere^ althoiigli the finger could Ije
turned round and felt through the parietea uf the abdomen. A
probe was pasM'd a little naj into the nretlirit^ hut did not pene-
trate the bladder, although urine, thick iind apparently gernl-
purulcnt* wfts discharged when the cTaminatioiT commenned.
It wiLs thought possible, hut not prabublE^, tbnt the intestine
might euinmuriciite with the hludder. Under the cireumstanceB,
no operation was ndviffeil. Dr. D. W. Cbeever, who had ex-
amined the patient the day before, had already given the saine
opinion.
The child lived nine days, tiLkin^,' littlo or ito nourir^huient,
the nl>dunien becoming gruduajly ttiore and mote diatendcil. On
posf-morteTn cTamination, the intestine wna found to terminate
In a eul-de-sac between one and two iucliea Jibove the imper-
forate anus : the sigmoid ilexiure, instead of being in ita pro|>er
place, was found tnineposed to the ri^ht iliac regiou, where it
lay in contact with the right side <if the vagina, from which
it Cijuld rcailily have been reached and puucturEsl, A probe
was easily psLssed to the fundus of the uterus, the ns and cer-
vii lieing very large. I wa;^ surpriaed to find with what ease
the little finger eould be passed wiihuut violem'e to the very
bottom of the vagina, a fact which may be of material impor-
tance in elucidating some of these very obscure cases.
The specimenB of this aaJ the previous case are now in my
private eolIeetiuQ-
CHAPl'EE Vn.
"GKNITO-FRINARY ORGANS-
8T0NR Ui THE UI^AliDEH,
Sr\rE the intriHliictioii of lilhotnty iiiid tlie use of ether, ttir
opemtiiin for Btime in llie blmVIer has umlergone a vpry ^Pflt
fLUifilioriition ; nnd, thougli once conHiderrd nf a ma^t fomiidjiMe
naUire, it is miw, in tniiny caaca, nlraust Btripped of its lcrrur8.
While jn Eurdpe, through ihe politencf^a of Sir Astley
CiMj;>er, T had an op^iortiinity of i<eeing some of the earlieat
instanw?a of litliutntj performed by the impr\»ved atone-hreRkrng
instnitnentf* of Heiiiteh^iip ; and iifttTAViird^, having witneanptl the
nnpiindleled alvill of Civiale in breaking the stoiip, and hnvmg
followed the. lessmifl of Armwflat, 1 was early led to adopt Utho-
triiy ni&tead of lithotomy. I pnr^iie*! this practice, though nut
tu tlie entire exclusion of lithotoitiyi for about thirty years, with-
out ihe lofla of a single life. During the spring of 186fi, bow-
ever, T hwt Uvo prJienla : both of them died after a single
operation of the niiMeJ^t character; and an investigation bhowed
that death would have resulted j whatever course might huve been
adopteil-
The cases ir whieh h may be well to employ lithotomy are,
in tlie first place, nhihiren ; flecondly, persons with large and
hard stones, or with organic changes in the bladder or proatate.
I have, however, frequently relieved old persona, even where
the prostate liaa been couciderubly enlarged^ by repealed, but
not prolonged, lithotrltic operations-
The euccesd of lithotrity, so far as my own observation goefli
depends upon tiie follov\LUg circa uistanceif : 1st, To Inject the
bladder modcralely with water; 2d. To use an inslnnnent of
moderate size, and so coiislnictcd as thoroughly to clear itaelf
of tlie fragmejita ; 3J, Not to move the inslriimcnt about too
STON^ IN THE BLADDKR.
205
freely. By not oli&erving lliia l:ist precaution, inflammAtion
may be cxcjiei!, aod even gnngrcne nnd deiUh ensue. By al
once gently sinking tlio beak of tlie m.^tnLincnt into the moat
depemlcnt pan of the bbnicler, opening and giving it n *liglit
oscillating niovenient, iho stone will^ in ahnost every inAtnnce,
fali reiwlily into ita grasp, ;ind may then he mised into tlie middle
of tlie Cftvity, itnd broken. The eame proceas nrny be repeated
upon one or two of the Inrger fmgments, taking enre, lniwevi?r,
not lo proiraoE the operntion beyond u few mtnutes. A Urge
catheter may then be introduced, and some of the finer purtielea
fillovvcd to eecflpe through it. Usuully two or fhree duys ela|jse
before the bla^itler recovers sufficient tone to expei the fragnier»t«
spon tan eonsEy .
In old persons. In whom the prostate is more or lesa en-
lai^otl, the Ktone la ofton coneenlod in n cavity behind it, and
requires that the beak of the instrument should be turned back-
wnrtls, and the stone puaheil out from its lodging-place, before it
can be properly seized.
Ether ia a most valuable adjuvant in a great proportion of
cases of lithotrity. When 1 first urged ita employment in fhia
operation, in a paper puhliahed in "The American Journrd of the
Medical iscicnces," in l'^48, many aurgeona objected (and some
Btill object) to itft use, upon die ground thnt the congciousneas
of the patient is necessary to give warning if the foM^ of the
bladder become entangled in the jnwa of the instrument. In
answer to this objection, it may be stated, that the mere contact
of the instrument, in an irHlated state of the organ, will give
rise to greater suffering than the actual engagement of the mu-
cous membrane in other cnees ; and, to a surgeon at nil in the
habit of performing this operation, the interpoflition of n fold of
Hoft tissue ia at once perceptible, although I have never known
any nnusuid pain manifested from ihia cLrt-umslJince. In eases
of extreme irritability of the bladder during un advanced atnge
of tlie disease, where there is an entire wiict of power to retain
the urine, I have been astonished at the great quantity of ether
which is re<tulred to produce |>erfect relaxation, so as to admit
of the injection <]f the Bmnjl amount of water necessary to pre-
pare it for the sjbseqxienc manipulations-
SOS
CEMTO-UBINARY OEGAS'S,
In i*cganl to the method to be preferred in lithotomy^ I have
generally fld£>ptcd, until Intcly, thut of Dupuytren, by the bi-
lateral incbion. This ie still a favorite vith some French and
mnny American Biirgeona. lie chief peculiarity coneiata, oe ia
well known, in the tranevcrae incision of tfic ekin, whieb j«
made directly in Itont of the imue ; and, eccondlyi in the dtiubk
divieioQ of the prostate by tho liiholomt cach^.
The absence of important ncrvce tu\d vcsficle in the median
niph6 affbrdfl a Etrong argument in favor of the median over the
common lateral incieion ; and tbc revival of perineal ecctimi
by &Ir. Syine has dcmonsirnlod the fact that the bladder may
bo Bafely and easily reached in thia mannorn Influenced by
these considerofione, I have eeveral times operated by a nie<lian
incision in the raphtf, dividing the prostate with the dciuhlc litho-
tomc or with a bistoury. The aiKanlagie of thiw method uver
the Iraasverfle incision of Dupuytren ie the greater room wliieK
it afTords for the widnlrawal of the et^ne through the cstornal
wound, while all ita peculiar oilvantagca arc securod by the
double incision of the prostate.
Lithotomy, notwithstanding the oxtmordinary eucecefl anid to
have boon attained in certain sccKoue of our own country, ia
ncvcithclca6» in tovni and hospital practice, an operation at-
tended with ccnaiderablc riek.
The opcrationfl for stone, in New England, may be eaid to
be very rai-e, but, in the limestone re-done of the South and
Wefit are quite common. Dr, J. C. Warren, in a paper pub-
lished in 1>^41, iatatcd, thut» in the course of forty years, he hod
been called on to [lerform all tlic operatioTU for etono which hod
been done in Boston. The whole number had not exceeded
twenty-five caeee, and the population had increased duriniif this
time from twenty-six thoueand to upwards of a hundred thou-
sand. Of the twenty-five coses, not more than three were in
persons natives of Boston or vicinity. During the succeeding
ten years, from 1844 to 1854, he operated for stone quite a
number of times- In the eourae of ubout ninety years one hun-
dred Cftsee were operated on by Dr, John Warren, John C»
Warren, and myself, and the flpeoimens are in my poeeeaaion.
In the lost thirty yeare^ I have operated on rather mora than
STONE rS THE BLAI>UER.
20T
thirty cases ; and the operation has also been performwl by other
aurgeonfl. Most of these cases were from a distance, hut four
or five of them belon^ng to Boston, Two-thirds of them were
opemted on by lithotrvtj-
The following onsee are selected as iJluetratiDg some particular
featurea either in the history or the operation ; —
Case CXV. — Vesical Oalctilus from the Introduction of
a Bit of Senling-ifjftx, Spaevi of Bffulder, relieved btf
Opium* Hepeated Operations, Recovertf. — A man, 24
years old, entered the Hospital April 11, 1^46, who, four months
before^ employed n piece of seitling-wai to remove a supposed
stricture in the urethra, A portion about an inch long, and a
fonrlh of an inch in diameter, slipped into the blndder. Soon
atler, he began Co have eymptoms indicnting the presence of a
stone.
With the straight sound, In the bladder I readily detected the
calculus ; »nd, pissing the finger into tlie rectum, reached it
witfiout much difliculty. It appeared to be on tite riglit aide of
the bladder.
April 12th, The patient being properly prepared, water was
injected into the bladder ; the lithotrile was iniroduced, and the
atone seized and eruahed. The water was then permitted to
escape from the bladder, brirging witli it pieces of the calculus.
Tlie bladder was allowed to rest for foui' days.
On the 16th, and aiibsequently several llmeq during the
month, the operation wan repeated- At length, however, the
presence of the litbotrite caused apa*tm of the binddcr, which
grasped the insti-ument so firmly as to interfere with its free use.
The patient stifTered so much from these tn'als, that he requested
the operation of li(lio(omy. At a consultation, in cnnscquence of
this request, I iniroduced a very large, long stafl', wuch as I pro-
posed to employ in the operntton, when, to my surprise, no
spasm ocL^iured.
On May 2d, all the preparations were made for lithotomy
and lithotrity ; and the patient took n hundred and fifty drops
of the tincture of opium, an hour before the time fixed for the
operution. The bladder wne injected with half a pint of warm
208
GENITQ-UItlSART ORGANS.
water; tlip lithcitrlte wns itWriHli^ceil. no ^Jjia^im omincfl ; ths
tJfK:rntii>n vnts perfitrmri-l ; nnd, in a (juaiUr iif nn Ijunr^ nWut
a teas[iooDful of fragments w&a Jiacliarged. Tic HuHcretl no
inconvcnltnce from the tincture of opluEu.
A coil s id emit on wliioh Imil inilueace in leading me t<t fall in
with tlie iwLtient*B wish for T4 culling operation waa thia: in
tliree iu£tanc<:a, tiAier repeated oi^eratiima of litlioErltj^, the alone
hnH ap[)ear^ to become e^LCi^iiIated ; owing, I BUpjio^ie, to
infljuDinatmn of tlic nun'ous coal [>f t.lie lilailder* Pcing appre-
heneive, from iJie difficulty of discovering the remaining fr»g-
mentT tliul (liiu proceaa was going on, I wished to prevent its
corapleLioit^
He e:iperienGcd bo much relief Ironi ihe use of the opium, that
T resolved to try its effect when injected intu the bladder. Two
di'acbiiia of tlie tincture were therefoi'e injected, on Alay 4tht
wiUk half a pint of WiU'tn water i from tliia he found much ease.
On May Cth* I Injected two dracliuts of tlie tincture of opium,
mixed witli two ounces of warm water, at 9^, A.M. In ao hour
aud u half afterwards, I injected aa much water as the bladder
would receive, not exceeding a gill and a half, and tlicn intrc^
dueed the lithotrite without much \i;ua. Tlie fra^iueut not
lieing felt, an additional pillow waj( placeil imder the pelvis.
It was then dlacovered in the upper part of the bladder, seized
twiee, and broken. Ko ^reat pain was cxpericticed, and a dis-
ehiu-ge of about a teaspoonful of broken calculus took place
soon after*
He nfierwards eubmitted to several similar operations, expe-
rieiicin^f qo incoavcnicnce ; and, by Juite 20tli, waa relieved,
and a week later was diachiirged.
Remarks, — The atone in tiiis case was very soft, and ai-
ways broken with great ease. There wna never any lodgment
of h in the urethra, and only on ojte or (wo oeea^sious any
difliculty ia withdrawing the lithotrite charged, through tl^e
meatus. A pcculianiy in the management of this case waa,
that, aPcer the npporeat introduction of the instrument, the atone
waa not reached until tlie handle wna earned downwards towards
the pcrinicum, fonniu^' an angle of 45° with a line i^rjjendicular
to the body in a horizontal posture. From tliia I concluded
200
tlrat tlic anterior part of llie bladder Iiad Lecome rontracU'd ;
or cIag that the Atone hud fornictl i'cir itself n injiich between fna-
Cicidi of the bliidder, an occurrence wljich I ihink frequently
takc6 place during the lithotritic treattucnt. Tlie introduction
of wfticr ixn a jirelimiuary step always brought on pain, and ren-
dered the patient aomcwhaC unmanageable, Oocnaionally, the
water was umittcd, and the operation waa performed with Icsa
pain find in Icfft lime than ueiial; while there whs no reason to
believe, tluit, under any ci/cumatances, the niucoua ^oat t>f the
bladder waa included between the jawa of the instrument.
Ailer the etone wa^ removed, the irritability of ihe bladder
yrn& at once diminished, so that tJic patient, who before wa»
vtry aeuflitive lo the alig^hteat motion of the iustrnmi;nt, allowed
tlie bkdder to be explored in every din^tion, almost without
shrinking. The physical flcnaibiUty of the patient waa much
increased by the tear of being cut, Thia case illustrates the
great advantage we have etncc derived from ether in overcom-
ing the contractions of the bladder.
Case CXVL — Caiatius of Oxalate of Limt* Stricture,
Jjitholrtlfj under Ether, PunthiU Af/forptton. l^ecovcry.
— A ntan W years of age entered the Hospital, Noven»ber,
1847, having auffered with urinary difficulties for nine ycara :
eighteen months before entrance, he contrncted a venereal affec-
tion, whifh left hiiji with an urethral discharge- On exami-
nation, the urcthru was found to be bo contracted as hardly to
admit the smallest sized bougie. The stricttirc was gra<Iually
dilatL'd by the introduction of bougies increasing In Hij:c; hut,
DOtwitifcatanding tlic enlarged paasago and the free egrcas of tlie
urixi€i he complained of muefi pain at the extremity of the
urethra, and was obliged to paas his water ten or twelve times
in the twenty-four hours.
In March, 1S48, he eamc under my core. Suspecting the
cxistencQ of some foreign substance in tlie bladder, and the
ethra being extremely sensitive, I plae^ him under the influ-
ee of ether, and, intro<lucing a dound, detected a stone.
Having waited a few days to allow the bladder to recover from
the effects of eoundingi on IVIarcb 11th the o]}cration of litbotrity
^7
310
GEMTO-UIUNAKT UltGA^8.
WAS done. The pntienr vtis first ethon^p^l, so thnt fhomiisciilor
B)'Stem was in n utate of complete relaxatiun; hnlf -.i pint of
vrarm water was chi^n injected mto the bliuliler. A small Ltho-
trite was in trmluccxl , mid the stone seized \ but it prot'ed to be
too hard. A krgei- iind more powerful instrcment wns substi-
tuted, by which the atone wna broken with repeated strokea
from llie hanimer. Sorae difficiilTy wna found, on withdraw-
ing thp inplrunient, in pnsf^ing the seat of the Htricture, on
account of it^ jaws being clogged with sand, and therefore
iroperlbctly closed. The patient was eniiTely inaenflible dnriug
the whule ojienttion, and not the siighie&t contraction of the
bladder iTn[>ei]cil tlitr ne("e»sary mnnipulntion.
The coDtlnuatiLwi of this history, as derived from die Hospit^
records, is in substance as follows: —
In an hour ufLer the operation^ he passed urine, with several
pieces of graveli and some fine g^nd« in alt nearly half a tea*
spoonful. The nrine contained a little Uoml, which wae npjiar-
ently frtJin the urethra. In the afternoon, he had a severe
rigor, la-Hting fifteen niinuics : phased urine once» a quiiriity of
gravel coming nwHy with it ; aome small piijci^s of the gravel,
which hud hiclged in the uretlim, were remove^l with ihe for^
ceps. The bladder ^^as washed out wiiJi cold water: cold
compresses were also applied to the uretlira, from which a little
blood bud been oozing. In the night, he complained of head-
aoije, pulse fnlj and hard. He was bled to 12 oz. with much,
relief; slept well-
March 12th. — Morning. Comfortable; pulse 06, Soi
Mmalt fragments came away. Alterntjon. Pulse 140; head-
ache, no tenderness of bowels, imd but little irritidnlity of uro*-
thra; passagt^ of urine free.
13th. The smarting and pain were very slight; hut tittle
detritus in the urine. Twelve leeches to perinwam, with a
warm bnth nnd enema, were ordered. In the nftemoonj hod
chill ; complained of uinLiise, pain in the shouhlers, kick i>f tJteJ
neck, and weakness of the riglit Ann ; pulse 130.
16th. Pulae 120- The countenance aoniewbat depTCssed.
Comphuneil of great pain in the right shoulder and arm, aa
well as between the shoulders; sdso in loins and left i^fde of'
SrONK IW TRE BLAE^ORR.
211
liarlc; tenderness jilon^ the course of the left ciinitid iirtery;
no Iroithle in jiiiHsin^ nrine, Htid liui little Huraneps of the
urethra.
From the XTlli to the 220, the febrile eymptome oontinuod,
the pulse heing eoniewhnt over 2LMJ, ijerfc<"tly diatirct ood reg-
ular. The patient being Tery feeble, a atiniulatmg treatment
wftfl pursued.
2id. I oponed nr abacoee over tlic tarao-metatftrsal articu-
Jntion of the left Jittle toe, ftiid found the bf>nc denuded.
23d. Pulse 190. From Ihia period the frequency of the
pttlfic hcgan to diminish, and he went on alowlv improving until
April !^d, when he was seised, during the Jtl'tetnoon, with n severe
piiin about the letl clavicle and' upper part of the left eido ox
tlie cheat. Great swelUng had taken place since noon, so as to
dmost hury the clavicle. It also extended up the neck. The
intog^umcnts over the clavicle were red and (edematous. He hod
^cat ditHculty of breathing, and the prc^anrc on the triLchea
dmost produced flutfocation* I humediatcly made a di^dcction
down to tlie clavicle, but no pus could be discovered. The bone
itaeif vrad evidently enlarged, end my impi^caalon from tlie eynip-
lome wtt3 that pus was forming in ita interior. The pain wns
le^ on the fallowing day.
Oa the 21st of April, the swelling about the cUvicle had
nearly dianppcnred, but the inner third of the bone was felt to
be cnhirgcd^ From this period be slowly recovered f mid left
the Hospital free of eomplaint,
M^marks. — The opcrntjon in thia cose wna ropidly done, with
no viiilenec to the hkddcr, a^ ahown by the symptoms nt the
time and atlcrwarda* none of which had reference to that organ.
The stone woa ^mall. Not being aware of the imrdneds of it,
] thought it would yield to a timall ini^truinent. The power
o\^ ihifl not proving euttident, it woa withdrawn, and another
introduced ; wbii^h, however, was so constructed as not to clear
itself of the dctritua or eand made by the crujthing proceed.
From thifl rea^n, the instrument which passed the obstruction
caused by the stricture with caae, on its introduction, was ar-
rested there on its withdrawal, from the jaws being imperfectly
dosed; and some tbrec was rctjuired, though not amounting to
violence i
ffU
OESnO-CKDEAKT OMCASft.
Ii wiB be |Kmt*ieJ thai dK fri^Boto «f tfone aH
swKj wtfUa s wcvk of the opcf^dav. %m 4n» iIat* s&fr itt
pam m the dbovUen bcc>^ ah^ w^iA aD
iBslflBt ahMtpckia woe
pofev far «a or arveQ dsj* after ibe 17ib,
tcry nfMdr rma^ag fro^ 190 to 312. There evened t4> be j
um^mj in r br forMaiionrf paa MdMumt pom of tbeboA^
kwaafaoDrl abosi ibe metHHml bane in tbe Ant, and TO
—itfj to exut m ibe davicie ; frvm the lAtier it vm [nUblj
ibaofbed widMOt anlriag any appearance ootwanfiv.
T^m eaaa will evidenttr cocoe tuMkr the category «r
placed by Velpeao and Civtale a4 ***^""** of paniknl
tkat. now called pvfeoua, BOfDetimea caused hv tbe «tiu|tle ld-;
trodoetloti i>r a OEheter, but laore frequenilv in lithotritr Uy Umt
irritBii'Jti of fragmenta lodged in die nnedini, mnd ab^it the neck
of Cbe Uadder.
The itone vu analrT^ hv Dr. Baron, wbo gavie xne the foW^
lowif^ nou <rr }t» <KD9tituents : "It conAietd chiedj of uuda
of lime; it aUo contains oonnderable unc aoid, and a
quantity of carbonate of Iim«. Tbe cDuc«ntno layers u*e very
numeroiu. In aome fragments under the ini'?ru£Ooper I eoimied
from ten to twenty, or even more lasers, la the »ptice of
fifiiedt of as inch. The radiated ^ouctare is also g«en underi
the name rircumat^ncc^, the radii bdng @till finer than tlie Uyeraj
which cro«4 diem at right angles."
Case CXVIL — Cifstic Oxidt Calcufue. Lithotrity,
Cure, — A man, aged 43, o resident of New York, aj>plJ<Hl tO;
TOG in July, lH'iS, ^vcn years before, he wtu seized with
virilent pain in hU vide, wbioh was attributed to the pauage
a caleulua throu^^h the ureter. Shortly afterwards, a calculi
of the 0ize of a pen was votdEtd with h\a urine* lie had a num-'
her of liiuo« since pu<^@cd calouli,
Ifi April, while en^'a^i.Hl in ploufrhitig, he felt a pam in hi*
iiliuliler, the cominencement of the tiuffermgM from which he
applied to he relieved-
I xo^udod him with a. ^mall lithotnte. and deteete<l a oal-
culu*, which inea«ure<t an inch and a half- Slij^ht irritation of
STONE IS THE DT-.\I>DER,
213
the blailtlcr followed this nxamjQation ; ami it was nf^e^tiary to
kee^] him quieL for a few dnys, and usu itJiiedit^f, before nu/
operaljoQ could be |ierfunned.
On July 13di, the bladder being injected with half a 'lint uf
wnnn wnter, (.]je atone yv&& immediately ^i/,etl witli the en shing-
lEfltniment* and broken* by meana of the screw, wilhout much
dil^cult^'
1/ith. He haxl suffered no inennvenieoce from the o^ier ition,
imd ill ffti^t felt rtlievtrl. A quantity of ejirid find fni^riii -nts af
9Ume ItJid pfuH^ed with tbe urine.
Tb(» ctperatiun wm rejieated on tlie 18th, 2Hil« 2lith, 29lh. wml
Any, 2d. Afler ent:h iiperntion he jnwaeil n mmilier of fra;^-
ments ; and once or twice it wa^ necessary to remove, by the for-
ce|W- porrkma which had become lodgeil in the fossa nav;cnbim>
Oil Aug. 3*1, !i fnc^uent whirh hiul been eni^^aged in tine wity,
and wliicb it wmh fomid iin^Kir^ible to extract entire, was geized
by n pcupverfnl jiair of dressing forceps, crushed, and thus ex-
tracteiJ piecemeal.
On the f>th he returned home well ', and on the 25lh I received
from him a letter, in which he informed me thnt he had expe-
rienced no dirticuhy in pusaing his water, and was otherwise in
gooci health-
T)t. Bacon kindly made an analyeia of the stone, which is
contained in the following note : —
'* The cftlcuJna, of which you sent rao fra^^rmcnie yestertlay for
analyst, proves to be of n rare and interesting kind. It is com-
posed of cifttint or ct/Jttic oxide. The yellow jxntions coneiat
of cyaiine in n stale of pnrlty, with the exception of a trace of
pbosplicile of linie. In the wintc friable parts, whifh appear to
be interspersed in the y<?Ili*w masses without forming regular
layers, the cystine u mixed with much phosphate f.if lime and a
little triple phosphate. Your speeimj?u^ H;;ree pretty closely in
physical ebaraeterfl with the description given by aniliort of
this very imcommon form of ealcuhis/'
Tliiji case of cystic oxide calculus U interesting fr<im llie ex-
treme rarity of thi* kind of stone. M, Civiale, whose ^jreat
experience \n well known, states in his work on the stim^ and
gravel, puhlish&l in 1840, that he has met with fair four cases
314
GEKITO-irRlNARy OHOANB.
of it. In the Jldntcrian Mu^^dum, out of eix huiidrcd and forty-
nine cnlculi, k appciirtr by the tn.taIo<fiic there arc but tliroc uf
the cy6tic <vxi(le.
It, hns bcpd tftftted that an lifTdlitsiry dieposition existed in
runny of these cases ; two of those und<;r the cure of M. CiviaJe
were brothefa. In Ihc present case this diseaac wn* not inhcr*
ilcd, accoi'ding to the account of the pftliert.
Cash CXVUl, — A vtry large Cystic Oxtdc Calculus-
/Sac in Biaddcr* Juitftotrity, Deaths three irGckff ajler-
lOfirtla, front In^ttiHTiintlon of tht Bladder, and Ih/(FJiiia,
Diseased Kidney. — May, ItiliS. Tlie following CQPe \s the
£rat iu^tnncc of dcnth, after the opcmtion for stone, which boB
oecurrcd to mc in a pnictiee of ovtr thJity ycitrrt. Tho pttH-
moftcni ajipenrmioca showed Umt this tcnuin^ttiou wiuj Almost
inevitable*
The patient was a ehoomnkcr^ of spare habit, and rather poor
Gondtitution ; and had been confined wiUi a severe attack of
pleurisy on the left aide about a year before, eoon after which
his troubJcs commenced. The first symptoms were n pain id
the urethra, and smarting on micturition ; the atream being
suddenly checked, and restored again on a cbangc of poailion-
All these symptoms were ag^avatcti, and h^d become insup-
portable whi^n I fir^t saw hitn,
1 introduced gently a sound, and, detecting the etone, ecnt
him to the HimpitaK
Being etherized, a email lithotritc waa introduced, May 5,
and the stone sought for. It was not at onc^ j^clzed, how-
ever, though apparently of very large size. Finding ef>me-
thing uncomcnon in the eaee, I withdrew the ini^trument, which
cont^^ined some iloeeidi of mucous membrane, and Boinc colea*
reoui fragments. The bladder was now injected with water
more fully» a liirge inatnimeut introduced, and the stone, meas-
uring between two and three inches, seized, Thia wna tarried
to the middle of the bliidder, and crut^hed witli some little Ibrcc.
The small fragments were then caught five or'six times, and
broken. The whole opcrotion lasted less than Svc minutea.
There was some fever on the following day, but tlie water
8TOHE IK TIIE SLADDEK.
215
WHS piwscd more freely than before. On the third day, there
woa tenderncaa over die bladder* During the next two necka,
many of the fragmcDts were [insfcdi though with diitioiilty. I
had decided that he could not undergo the rcpC4Xtcd opcratiena
for destroying so larj^c a stone, and thot, nd soon as he wan in
a proper condition, i would reniovc the remaining portions bj
lithotomy.
At the end of tJiroe weeks, when Kg hnd pas&ed a doy more
eonatbrtably than common, hod taken solid Kood, and ecemed to
be improving, he wa^ suddenly taken, in the night, with a foint-
nci59, and died.
The following appearanf^e^ wero prcecntod on examination.
The bladder was greaiJy thickened. On il^ poeterior and upper
part wraa a sac communicating with it, which was quite thin
towards the pei-itoncum, and in a etatc of high inHaDimotion.
There woa al^^o peritonitis, but no rupture could be detected. The
right kidney was about one-quarter its Datum] sixai its pclvia
and infundibuinm were greatly dilutedi and iiJlcd with purulent
laatler and ealenrcous deposit ; the cortical subatancc, in a great
measure, having diflappearcd. The ureter wna thickened- The
loft kidney wne about one-third Inrgcr than natural. Half of a
cystic oxide enlculus ^'n^ iound in the bladder, and weighed
480 grains; also a frugmcnt weighing *22 grains. AU the reat
of the ftone had been crushed, and \ui*l passed off by the urine.
The ^vllole Btonc must have wcigheil IHJO grains. The right
lung waa adherent at its apex. The loft lung had very eiten-
sirc pleuritic odhcsione ; and, on cutting into its substance, pu9
escape<l from various ixiiuts, showing purulent abaorplion.
It is probable, on the lirst explurntion with the small lithu-
trite, that tlie stone woe started from its bed in the eae, which
inHnracU, and gave rine to the aubecquent symptoms.
In addition to the preceding caaca of cyetie oxide cfllc»lus> 1
have had u, thiid, in a. mwi under my care for frneture of the
thigh- During his confinement to bed, he waa ecized with
violent symptoms referred to the kidneys, which subsided nfter
tlic expulsion, p^r ufethfrmi^ of sevcmJ minute calculi, which
prevctl on examinatton to be composed of pure cystine. Tho
urine also contaJned n deposit of cyetinOf in largo microsoopio
crygtola-
216
GExrTi>um\Atty oiioans.
Case CXIX. — OxithttG "f Lime CaJc^tJu^, LkholriUf.
Ovre. — An Irish boy, 15 years of oge, wiis brought to me
in October, 1848, with eymptom* of greai irrifjibility of the
bkdder» such as usually ari^omnflny the existence of a forei^
body in that organ. At tiiat time he declined all ex ami nation,
Hltbouifli I warned him of the proLtble nature of the dlacaae.
In November, nearly & month afterwards, finding that no
remedies bad any eflecc in relieviog bis sufferin^H, he finbmitted
to the operation of souuding, and (^uite a large calculus was
discovered.
Hia mother gnre the following history of Ida onse : He hud
been troubled in the urinary orgftna from infancy, "When three
years old, he had a violent attnck of pain in the region of the
right kidney, for which ho was leeched and blistered. He re-
covered for the time, but aftenvurds was seized with a paia lower
down on the same side, attended with difficulty in passing water,
and with bloody urine- From that time, he wao slmoHt con-
stantly troubled. He was obliged to pass his water every half
hour, and it escaped invL>luntnrily during sleep. He could not
walk fast wjihont pain, and passed blood oecaslonally.
On HL-eount of the size nnd hardness of the stone, and the age
of the patient, I advii^ed the operation of lithotomy; but tlie
parents would not listen to a cutting operation, where any other
method waa av:vilable, 1 therefore delermint^ to etherize the
patient, make an attempt with the erLiabing instruments, and, if
the atone was fount] to resist farther than waa thought safe, to
relinquish this operation and advise lithotomy, which his frienda
would probably consent to when the former was found to be im-*
praciicjible.
On Nov- 16th, the first operation was done ^ the bladder waa
injected ^ the crushing instrumpnt passed in, and the stone seized.
It meat^nred ore and a half inches. Attempts were madB to
crush it by means of the screw; but this waa found impossible
on account of it^ hardness. The hold was Therefore rtdaxed,
the stone seized in a new position, more on one side, and wh4
then broken down without any great violence. The fragraerle
were cnishe*! a sr<^oiid and a third time.
He suffered somewhat in the bladder after the operation, A
BTONf: IN THE QLADDER.
217
number of Jragmcnta of the caJcuIua were passed, wliichj on
bcins anftljicd, were found to consist of llic os^Ulc uf lime,
combined with the triple pLusphntc, which showed iteclf in
glittering tranfipai'ent cryatnle. The Jntter acemed to have been
deposited on the aurfocc, and were exceedingly ehorp and irri-
laling to the toiith.
20th. The operation wa^ repeated; the Btooe* when tirst
seized, seeming to resist the action both of (ho €ei^w iind
Uaromcr i but, atlcr u little pcracvci-ancc, It wfla finally cni±»hcd
by pcrcueeion.
The following; mornings a number of pieces were pBeeed, and,
among others, Jtppnrently the on<^mil cakuluu from the kidney :
it WHS of a li^^Ltidh-brown color, about the stiic of a emidl bean.
The operation waa repeated aix tiraca at intervals of a wcek-
The time devoted to the acizin^ of the sti>ne was generally about
five minuteS' l^roin the groat bardacss of ita conipoaitioD, it
eoiild not be crushed into Band, as is the cnse with the pho.^phatic
and urir>aGid ealeuli. The iragnienti^ were largo, and required
to be eeixed and enured separately.
Twice in the courec of this i>criod, portions became engaged
in the orifice of the urethra ; and it woa ncccaeary to adminiatcr
other, zind extract them, as the L'anal was so senf<itive that noth-
ing could be done without the aLa^istoncc of this agent. Finally,
the last frngment of the strme, wJiieh for some days had hcen
lodged in the neck of the bladder, and which I liad once pushed
bock, beeamo suildcnly fixed at the membranous part of the
uretiira, so aa to entirely obstruct the course of the urine, To
disengage thia. Hunter s forcepe were introduced : the stone was
at length caught, and drawn to the fosaa navieularls. From
this fipot it was found impimeible to extract it without laceration
of the urethra : the hoEd on it was therefore relinquished, and,
by the use of forceps, ^KJiti<ms were gradually broken away un-
til the whole was removed.
The patient, afler thisi fully recovered 5 no eymptoms remain-
ing to denote the existence of an irritation of thirteen yeara^
standing H *
S18
GKNlTO-Ultty.LKY ORGANS.
CaBE CXX. — Vcfficttl Ctdcftliin. /jithf>triti/. Itecovery.
- — A gentltfjuaa, SO yoBre of age, eoosultcU me in November,
1853. He Und the fir«t «ympti>iua uF the dUesee m 1843. He
had previously, (Uier a nephritic nttackf parted a staoh c^culus
from tEie urethm. The eymptomfl, at the tituo of tho upenLlicin,
were greut pain, a fre«]ueiit desire to piies water, Uoody urine,
and injtliility to bear tlie jolting of any vehicle- The water wai
paaeed tTerv halt-hour, both day aud iii-j^ht. The meiLSure of
the cal(^u]uj^, when firf^t seized by the hthotritCf was tourtccil
lines in diameter. It was easily crushed, with scarcely any
pain ; fropnienta pasflcd off, without difficulty^ in the course of
tweniy-four hour**. The operation waa re[jeated three time* in
a fortnight, without the ueo of other, giving scarcely any more
uaeasinesd ihnn an ordinarj- case of cathctcriem ; and the patient
was perfectly relieved in about Ihrec weehe.
Case CXXI. — Vt^cal Cahuluf,. A Pebhh foT NncUn*.
Bilateral Lithotomy. Heeovcnj. — On Nov. 7, 1847, I saw
in consultation a child four years ofa^e, aflected with eymp torn!
of some foreign substance in the bladder. The child was thtiii
ddicatCi aud tall for hij^ age. The history of tiis di^eaee was 9M
follows ; —
Two yeare and a half previously, as the chiJd was making
water in tho street, a boy, in attempting to wrcfit a knife from
hinuT pLille<I him over, and dragged him through a heap of
gravel- Wlkcn taken up by hla motlier, a quantity of this sub-
stance was found adherent to tho glans penis. For twonty-foor
hour^i he haJ an almost complete stoppage of water. At the
end of that lime, an examination being niadot diaclosod a small
bit of gravel lodged just within the orifice of the urethra,
was removed by a knitting-needle, and immediate relief obtained-
Some months after the preceding occurrouce» the child began
to complain of difficulty in passing his water, attended with fre-
quent desire to evaemitc the bladtier. Thcao symptoms, with
intcTTalfl of case, continued till within a few months of the time
when 1 saw him> Then they became much aggravidcd, bo as
to make it imperative to have active nicufurcs taken for his re-
lief ; tho sufferings both by day and night being almost copstont.
STONE [N THK RLAHJJEH-
219
and tlie cnlls for eviteufttin^ the blnddor inreasant. All nttecipts
ac an iniroduction of n aounJ lieing resisied, he was etberized,
and I dwcoi'ered a calculus.
On Nov- l(i, nn npcrntion having heen determined an, the
child W15 frdly etherized, find a sound plaeed in ihe blndder-
Lithotomy wuh jjerforiTiod by the bilriteral melh-xl; ihe incision
of the profltn-te being tnade ^vith a straight, prohe-poioted bis-
tonrv. The* atonp wJis removed by ti large polyjxie forcieps.
Ni> bud aynipiomB followed the operation.
On the lollowmg- day, the water paa^ed by the urethra : on
the third, by tho wound; and continued to do so tbr a week,
when It resumed its natural course.
On page 95 of the "Appendix to Etherization, with Surgical
Remarks," will be found a deacription of tlie stone, with aome
CDiaments upon its presumed method of introduction, by Dr.
J. C. Warren, in these words: —
"The Btonc waa ahont half an inch Jong, the fnuith of an
inch thick, and in form of a flattened oval. It was sawn by
Dr. J. B. S. Jackaon. The exterior layer conflisted of a whit-
ish deposit, the ebctecnth of an inch in thJekuesa, and composed
apparently of triple phosphate. The layers within this were of
a brownish color, like that of the phosphate of lime, and were
about half a line in thickness- In the midst of these was a
harder suhgtance, about a line in diameter, which appeared to
be silicious. Its outline could not exactly be distin^isbed from
the surrounding biyere of brown deposit.
" Tlie reti'ogrado paisage of the apparent Buclens into the
bladder may eicite Burpriae, unless we take into consideration
the inverted action of die urethra, by which bodies received into
it are ao often conveyed from without into this Drgan» where
they serve as the nuclei of stones. The introduction of this
nucleus may receive an additional explanation from the fact, that
the gravel-stone, removed by the mother, prevented the paasnge
of urine forced into the urethra by the strong contractions of the
bladder ; and this, not escaping^ was driven hack by the contrac-
tions of the urethra, carrying along the inner stone, which
formed the nucleus."
The first of the following cases illustrates the ordinary bi-
220
GBNlTOUUJNABr OKOAKS-
Inlernl rjprrafion of Diipiivtren ^ hihI may serve to compnre this
method with ihal ailopiei] in the ne_xt c;ibi% wh(»re the i>ritna[y
incifiione wera nuvel, but the fiaii] oneB identttral with tliose of
Dii|juytren : —
Case CXXIL — Vesicitl Cfrlcuhis. Siltiterttl Ltlhotontff.
Recovery- ^A. boy, 12 jcars okl, had been tTQubled for two
or three years with a want of power to retain his urine ; the
Hiifferirg h«il Ijeen excessive, both by <Tny and night. He wiia
in a very miserable and emacin.Ie<l (Mrdilion, but had recently,
however, for n. few weeks, hfen rmioh more conifGrtable ; n
fiiet wbieh was afterwards eiplaineil by finding the atonu fixed
in the upper part of the bladder. The preimce wda very long,
owing to the habit of conRtJintly pidlinjr at it. On sounding
bim, under ether, the stone was felt in the upper pari of the
bladder. It was decided to perform lithotomy, wliich waa done
by tbe bilaieral method of Dopuytren. A eound of good size
was introdneefi, making a great curve outward, so as to project
well in the perinaium. A semilunar ineiaion wna then iniide
ab<ive the nnua, and tlie etaff reached at the membranous por^
tion of tbe iiretbra. Dupuytren's double lithotome Wtts now
piihW into tbe bhidder, with its eoneavity upwnrdu ; and, tbe
Bound being removed, the inatriiment was revenged, its bladea
opened to the extent of seven-eiijhths of an ineh, and with-
drawn. Tbe forreps were now intnxluced ; the finger having
previously Ireen used to explore the stjjne, wliich was found
firmly adherent to the upper purt of the bladder- The stone
was seiie*1 with aome <liflieulty, nwing to the firm aiJhesiona
whith it hiul contraete*! with the folds of tbe muouuB metnbrune ;
but it was finuUy extracted without injury to the organ. It
proved to be a mulberry enleulus, very roiigli nnd irregular In
outline, iind weighing 180 grains. A piece of elaptio catheter
was kept In the wuund for twenty-four huurs, after which it wbb
diapeEBcd with. On the third day, a little water waa pnsaed by
the urethra ; and, on the tentli day, it had entirely resumed ita
DHtunil channel. All the distressing syniploms of stone were
imnLcdiiitely relieved by the o^iemtion ; and, at the end of three
weeks, the patient waa discharged well.
STOKE tfi THE BLADDEfi.
221
Cask CXXIII. — Vesical Cnlnthis, 3fedjan Li't/iotomy.
Hecoi^ery. — A boy, 13 yenra ok], entered the Hrjspitnl in
March, 1863, on account af great BufTcring in the regitm of tbe
bladder, jitvninjMinied by iTte<iiitmerce of urine. Two ycHrs
boJbre, he noiicetl an cKrcasionnl ditticidty in pausing wnter^ at
times a aiidden stoppage of thr> etream occiirrpil, and the urine
waa now and then a little hluody. The symptoms htniame more
urgent, nnd the pain eonfttant. so 118 to confine him to hie bed.
The urine dribWetl nwny, ond irritutcd the skin of tJie penia,
srrotnm, nnd thighs. The prepuce> as in tbe Inst case, waa
much elongated.
On intr<alui'ing a sound, the inslniment encountered much
reeiaiant^e at the neck of the bladder, but Snally pureed ia and
wime in contact with a stone. The bladder was quite empty
of urine; nud tbe cidrulun mecling die r^cjund at diflereiiC
points, while enveloi«?d in the mucoiis folds, gave the impres-
eion of the exisfenrc of two or more stones.
It was decided to perforin lithotomy, after relieving tlie
external irritation by cleatiline^s and 8uititble dres^ingB.
The operation which was perfonned eombined some of llie
more importaut Aalurer^ both of tiie riediim und bilateral
uietbodH, and eeenis to ufler eomc ndvantagea over either. A
Bound of medium site was pa^fled into the bladder ; tbe meatua
iiririftriue, ivlueh hud become \ery much conlnicted, being first
piiglitly enlarged by the Ituife- Tbe ekin was then divider! in
ihe ufcedlan raphf-, and the disfleeliiiiii continued in tlie same line
until the membranouM part of the urethra was exposed. Thiti
wai^ next opened, and tlie attempt made to introduce the double
iithotome ctic/ie of Dupuvtren, Owirg Ijj the uny ltd ding
comlitum of the neck of the bladder, the litbolome could not
rewdily bo passed in ; a prohe-pointed histunry was tlierefcfrc
eubatituted for it, aud the proetate divideil on bulb tides. Tbe
finger now entcrcil with ease, nnd n large stone wae felt very
high up in the bladder. Atlenipta were iiinde tn extract it
with a long pmr of polypus forceps, and then with the onli-
nary lithotomy forTCjw, but without Huceeas, owmg to ite great
bieb; the cut in the jtrontale was therefore enlarged, and
the attempts at extraction renewetl, but still unBiicceeefully-
2S3
OENITO-ORrNABT ORQAKB.
Ab \t waa not deemed safe to cnlftrgc the incisioii in the proatatc
further with the knife, the two forctingera were mtrodurcd, back
to back, nrd the aiibalance of the glnnd slightly torn. A larger
pnir of forceps waa then passed in i and, by ombrnting the whole
Btone within its jowa, it wue extracted without further difliculty-
A piece of catheter was placed in tlie wound, and the patient
sent bnck to bed.
Un the ninth dny, the urine began to paea through the urethra;
[ind» from the twelfth davi none escaped by the wound. At the
end of three weeks, the patient wne discharged, with the external
wound nearly healed, and free trom all fyaiptoma of etonc.
The ealcuJuG, w4iieh appeared to be composed of the triple
phosphate of magnesia and ammonia, was largo and very rough :
it measured 3J inchcB in ita longest circumference, and 2|^ in
the ehorteat; its weight waa 210 grains.
I was led to perform the operation in the manner related ;
viz., by making an incision through the skin in the caedian
taph^T instead of the cross cut employed by Dupuytrcn, ad
illuetmtcci in the first case, from having observed how easily
theac piirtd could be dilated in the inciaions praetiBod iu perineal
aection for the diYiaion of strictnrea, Irequently im|iaeBablG by
the Bmalleat sound. In these co^es, after cutting through a
deep pcrin;cum filled with inflammatory exudation, it ia oftcu
found necessary to citercise much pntienco, and to sjiend much
time in tracing the urethra beyond the stricture. Having had
oceaeion, during tho past few ycare, to do a number of theae
operatioufi, most of them entirely without any guide, I wjia led
to the reHcction, that it would be rery eaay ia this way to per-
form the operation of lithotomy when tJie operator i» guided by
the prcsoneo of a lar;ijc sUitf in the urctlira. When the mcdiaa
flection ia pertbrmed deliberately, the operator hua tlie parta
divided freely open to the view; which is not the case in
Diipuytren's o)>eration, which has to ba performed mainly by
the fiense of touch- By tins method, also, the vessels are
much lesa likely to be wounded than in the common operation.
Although different kinds of operations must of necessity be
praetiacd to suit different caece, the present method would seem
to be the moat direct and naturid one for arriving at the bhid-
STO^TE IW THE BLADDER.
223
dcr. Since performing it, 1 hnvc found tlia.1 a similnr opera-
tion hfid boon sujii^'oatctl by Mr, Eriehecn, who huJ not at thnt
lime, however, periurmcd it upon Iho living subject, Mr-
Allurton'a and Mr. Beaumont's opcrationH, altbou^b done in
tbc mcdiun Ime, arc csscntiallj clitlbniziti
I have in my pu&ace^ion a large calculus, removed from tbe
body of a gentleman after tieath, which had been lodgeil behind
ihc proaCatc. He bad suftered with it for many years; and,
finally, it wofl the cauec of his death. He had been sounded
by a number of distinguished surgeons, and by Bomo dccliirod
to have a etone, by other* not. From tide tcQBon, he had
deferred, for many years, submitting to an operation. By
sounding under ether, and turning tbc beak of tbc inetrumcnt
backwards, I dctecced a stone ; but an operation was tliougbt
inexpedient, on account of the great disease oxieting in ail
tbe urinary organs- After death, the kidneys were found
cxtennivoly ult'crnted, the nrctcra erlnrgod, and the blud'icr
greatly thickened and aaeculated, with a cavity or Joprostiion
behind the enlarged prostate, in which the calculus woa lodged
and partially concealed.
Case CXXIV* — - V^^sicai Galcuhis of Oxalate of Lime in
a Child three years old* ^ilatct'al Oper<tiion. Hecovoy^ —
March. l^'oT- The eymptoma appeared a ycnr and a half
bciore. The Buffcringe were iateneei preventing sleep, and
producing all the uBual Bym[itonia of atone in tbc most aggrn-
vatcd iorm^ The patient had been twice bounded, while under
tlio iniliiciice of etlicr, by experienced ^iurgcons ; but no dtono
wiia detected. After etherizing him, I introduced a common
sound, hul, with tlie most careful cxaaiinalion* asaistcJ by the
finger intnuiaecd into the rectum, failed to find nny calculus.
Tlic instrument was therefore withdrawn, and a sound with a
flight curve at its end, eoracwhat similar to the one describai
by Mcrcicr for exploring the priiatato glnnd, was used. Thi;?,
being passed in, and taking up Ices room than the conimuti
sound, at onee struck a atone, which lay very high up in tlie
bladder.
i94
GENITO-UItlXARV ORGAKS.
I ut firfit pro|kc»»et] to dej^troy the atone in this Case b^ the
crur^fiiii^ process, Imt soon found tlizLt tlie bLtdder waa too much
contracted to conuiiii tufficJent wnter to ullow the inatnmicnt to
be irionfcuvred safelv- The bilnteral operation wjis jierformcd,
and a Ini^e stoiie ruuioved- The coiita of llie bladder were
much thickened, and its cay'ity greatly cloug^itcd. so ihaX quite
B long [iciir of forceps wjia requifL-d to reach and dislodge tlie
stone. The patient slept soundly the night after the operation,
Lein^ the first ;rood night's sleep be had enjoyed for more than
a jear. At the end of a week, the urine [mased by the ure-
thra; iuid, in another neek, the child went hctine well,
Case CXXV. — Ve/itcal Calcylusofeitjhlcenmonihit^siaud'
till/* Mt:dian Lttfrrjtomtf, litcoven/. — A boy, 4J years
old, had always enjoyed good hejiJ:h, with the exception of the
frllowhig symptoras, which hid hiated about eighteen months.
At first, he was obliged to pass his wjiter more frequently
tlian usual, — as ofleu as twelve thnes during the twenty^-four
hoiir&. lie sooD had great difhculty in inducing the flow of
urine, making hearing-down Li^orta, and exhibiting Bigna of
pain. A correct diognosia was not made- Owing to conatftnt
pulling, to relicye the pain at the end of his penis, the prepuce
wne greatly culArged. H]8 health was much reduced ; his sleep
was iaterru[)ted by [jata» and desire to pass urine, which dribbled
away»
On entering the Ilospitn], he was etherized and sounded, when
a calculus, about the size af a filbert, cuuld he caaily felt. The
urethra was found unusually capacious-
Four days flfierw^irds, the patient was again etherized; tlie
bladder was filled Avith warn: water; an ordioary grooved staff
introduced; and an incision, about one and a quailer inches
in lengtli, made in the median hue of the perina.'uoi. Tlie
Blaff being re^iched, a probe-pointed knife was paaacd along the
groove, and a lateral incision wiia made through the prostate.
This incision waa made bilateral by the Uthotomc cackS. The
calculus was extracted with some difficulty* The dust from
ihc calculus coneistcd of oxalate of bnic, carbonate of lime, triple
phosphate of ammonLt and magnesia^ and urate of ammonuii
BTOVE TN TRE Bl^ADUEK.
225
ta
On the third day nftor the oporution, he pussed n little Trater
by the urothni; it then stopped, and for fuur dajs passed by the
wound ; after which, it passed entirely by the urethra,
Ahmit a fortnight aftpr the operation^ the patient. eThihiting
AOme ayniploms indienting the presence of ei\lculiis« a sound
waa introduced into tfie blndder; but nothing was dispovered,
A month later, the child waa seen again, after a visit of ten
dny» in the nnuntry. He was in a state of perfnni henUh, his
whole condition Laving been entirely ehanged by the reniovtd of
the stone >
Case CXXVT. — Vesicrtl Oftladrie, 3fedmn Lithotomy^
Recovery. — June 17, 1865. A boy, aged 3j yeora. The
symptoms were first noticed when the child wag but little more
than a yenr old, and were ns follows: water pasi^ed otl;en,
attended with diJliculty and pnin, at times dribbling away in
drops; sleep nnit^h disturbed; phimoats.
For over a year, he continued to grow worse. In the autumn
of 1864, according to medical advice, took cod^liver oil, which
improTed hfs general henJth. During the winter, micturition
waji invohintnry. Tlis sippetilc was good, and he slept well
when not disturbed by paJn-
On entering the Hotipital, an exAmination was made while
the patient was under the induence of ether. The prepuce was
found to he idmoBt impcrviou'^» admitting only a umall probe
through itH Aperture, It was slit up along the dorsum of the
glana, and the raw edges were brought together by a few sut-
ures. A sound was pnssed into the bladder, when the calculus
was easily detected. Analysts of urine showed it to l>e cloudy,
li^il^oolored, w^ith eonsidenible preoipitatc of a ropy character.
It was albuminous, corresponding to the dej>osic of pus corpus-
cles ; very faintly nlkidtrie. Under (lie mierosco|i€, a large
number of crystals of the triple phoHphates, interspersed with
puB and mucus corpuscles were ob*;erve<L
A few ihiyrt afterwards, the median operation was performed,
US detailed in the previous ease, and a very large calculufl re-
moved with much difficulty, notwithstanding the proatale was •
notched on both sides after the first section. The effect of tlie
3?
S26
GENlTO-maNART ORGANS,
Operation was nt (mt-e to entirely relieve the pntient from pain.
Tlie tlilrtl day Hfter» lie pawsuJ a few tlrojia of Tirine by the
urethra ; nt the end of a week, the water passed freely by the
DSLtiir&l po^ange ; at tlie end uf two weeks, he went home quite
well.
8TBICTUBE OF THE UBKTTniA, WTTB RETENTIOX OF
tnUXE.
T do not propose to enter into tlie treiilioeiit genenilly pur-
sued for strictures of the urethra, hut think it of great impor-
tance to allude to tliose cartes where, frotn aoine nccidental
cause, a sudden retention takes phice, attended with alarming
eyuiptoms. The surgeon's first impulse ie tc» relieve the jiaticnt
by the u«c of an inetniiQent- This is frequeuily found ijnpo&*
eible, ami it is ah[ui<ioned, leaving the patient in a wor»^ (xtudi*
tion than before: in fact, a pai^sage already eKcesairely smaU
has become almost nbliterat.ed by Hweliin^, and, of course, no
instniment ean lie made to penetrate it. Notlung, indeed,
needri greater forl>earaTiee on the part of the surgeon than to
Terrain hlnifldf froiu inKirumental interference, when the pulient
is (trying out in agony to be relieved from Jiis suffering. Tlie
oaur«e which I have gejkerally fonnd suecestifiiJ in suth cases 10
as follows : First, where it is pojHwible to temporize, to give aa
opiate eiitina. Second, to cover the ptrinffiutn and lower part
of the abdomen with ariodyne fonieutatiuns. By tlieec means^'
nleep is gencndly produced, attended with profuse pert^piration ;
and, when tlie patient awakes, he can empty the bladder.
SomelimeM, even during [sleep, tlie urine gmditally trickles
away* After this, by pursuing an nutiplilugistie course for a
day or two, n small iKiugie mny be pas^eil, and the stricture
treikted iu the ordmiu'y way by dilatation. Tliird, if the; sufiei-
mg id excesHLVet and the distention so great as ordinarily to
indicate puncture oftlje bladder by the rectum, the patient may
be etherized, when, by passitig down a fijifurm buu^e, auJ
msertlng it parlialJy into the stricture hy a twirling motion, I
have often aeen the urine at once begin to flow hy ita side ; and
in one or two in«tanccaT ou withJrawiug It, a vmall atitnin
BTHICTUEE OF THE imETHRA,
227
followed, which continued to flow until the bladder wm com-
pletely emptied.
In n patient who applied to me, not long eince, for the trent-
ment of a stn^tiire of long Mfinilin^* I found tbnt it wlls impos*
siblc to pit&a El filiform bougie. IIo wns, thcreforcT put undor
trc&tmentf jind inetrunienta abstained from- A fe^ days afler-
wurda, he wils seized with a chill, and sent for me to vifiit hini-
Not beiog able to attend, I requested a friend to ecu him. He
found n large, hard tumor over tlie puhea, and a retention of
■urine. The patient, however, complained of no pain, althouja^
the CiLfie Bcemcd almost to indit^aie tlic ue<}eHstty for some surgi-
cal interference. The condition of tlung« being reported to mo,
I advised the treatment by opiates and fomentation^T o^ above
suggested. It was followed, in the course of the night, by
rcliof to the bladder. On the succeeding da}-, the tumor fltill
existed, though not quite sa large aa on the preceding day; and
the patient atated that he had noticed it for the previous eigLt
months, tlioufrh amaUcT* than in this attack. I saw him some
weeks siLbaequcutly, with the tumor undiminished in aize, al-
though a good-aized bougie could bo passed through the strict-
ure, where, at first, none would penetrate- The tumor was
doubtle^B the bladder in a thickened condition, partially filled
with water^ and was the result of longKiontinued ohatruetion to
itfl delivery.
Case CXXVII, — lietentian of Urine reli&ved hy Iniro^
dueiion of CtipillaTy Bougie atid Opiate Enema. — A
young man, 28 yeai-a of age, on retiring at night, found that
he was nnable to urinate, and, in the morning folloudng, also
^ed to do fio. Five years before, he had gonorrhtra r this
vfttB followed, two years fnibHcquently, with complete stoppage
of urine, which was relieved by the use of a catheter, and «ince
he hod never made a full stream. He couatilted a physician,
who tried to introduce an instrument, but was unable to accom-
plish it. He was thea directed to me in a very suffering &tate,
with the bladder much distoudcd- I at once introduced a oa|nl-
lary bougie of the smallest aiae, which passed into, but not
through, the stricture. On withdrawing it, the urine began to
dribble away.
228
GENlTO-IIKraART OROAKS-
He waa then tlirpeled to go to the Hofijiital, wlnjrt lie liad a
wunn biidi given him, nnd an eneiiift of fitrly dmiis uf tini^ture
of opium in b. wineglass af Bta.rch. In about four houra tkher
this, lie wjis able to eni|it3" hin liladder, milking ijinte a fair
Htream, He rt^mmned in the Hospiml a. number of duys, until
ho could be safety discharged, declining any ayeleniatic treat*
ment for his Htriccore.
Case CXJ^VUl.— Stricture of Urethra. Betnitton of
Urtne^ Relieved by Capillary Boutfie. — A man, 33 years of
ngp, was brouglit lo me tm a Sunday morning in November,
iHfil, suffering greatly fn.im inal^ility to pass bi.H wnt<fr, bfijne
years before he HulI gonorrhoEa^ the effect of wliicb lasted for the
better part of a year. He indulge*! freely in ardent spirilfl-
On Satiirtlny, after getting wet m a storm, he was tnken witli
a stoppage of water. Krery means were tried by Ilia [jhjMician
to relieve bim. On Sunday, finding all ap[»li cations tail, he
sent bim to me for advice- I fount) the bladder distended.
]Vly Rrst disposition was to send bim to the Hospitid, mid tiy
the effect of antiphlogistic and narcotic remedves, before ut-
tempting the u^e of any instrument, as tbe catheter had beun
already tried withcmt effet-t, only producing a diKcliatge of
blood. Hij^ pain, however, was eo excessive, that I decided to
uttempt tlie use of n means which, tbree times before, I had|
found effectual in wises of retention attended witb very close,
etrlcture. Taking one of Chiirri^re'M smallest bougie», almost^
capillary^ T grfulually passed it down the passage, aufl carefully,
without pressure, worked it inut tbe stricture, wbieh took a firm
hold upon it> Tbe jmtient being cmttioned not to strain, it
waa now slowly withdrawn, when a small and irregular ntream.
of water followed. He was retpieated to stand up ; nod slowly,
by jets, some blood now und then pasBing out, the bladder;
was freed, aud almost entire relief from the excessive tor^j
ment obtained. Tbe patient wa^ sent to the Hospital, a
warm bath given^ and an eaemji of forty drops of tinciuTft
of opium ailer it.
He bad a good niglit; and cii the following morning passed
bis water easily. He was kejit on a lii^uid diet, and on the
13th left quite well.
axKicrruKK of tiie urethua.
229
Cask CXXTX. — Gnlta-prrclut lionifit; broken off iti the
Urttkni, Fr(if}mtnU ejei^ted xpontant^ouelif . ^ 185iJ. A
young man applied tu me ^IjileeuflGrLDg uadt;r an obstruction in
parsing vviittr. for which he hiwl Lretii subjected to much treftt-
nieut, withinjt relief. He luul co^iti-acted a gimijrrkcpa nine
uii>Dthj4 helbrCf aiid had a gleet ^ince. The symptoiufi Indiaitiug
fitricture, he was advij^ed to liave the urethra iixplorcd. A
Anirill wax bougie was Rmt selected irom a bundle, but rejected
from being a litlle injuivd. The uext tliat ofTei-etl w^ia one of
gutta percha ; nml, being of the requisite sir-e, it w&a softened in
the band, and pa^aed up readily tn the pruBtatlc purtlun of the
urcibra* Meeting bere with some ohsUuetloD, it wiu wltli-
drawn^ tlie point a little Hofliened and bent, and it then went
caaily Lntu the bladder, without ihe use of any force. On tak-
ing hold of the iuatiiinient to nithilraw it, at^cr it had remjuned
a uiiuute or two iii gitu, it br(»ke oH' abort at the orifice of the
urethra; or, rather, dropped ofT, as not the leattt violence was
applied to iL. \ reijuestetl the jiatient lo Bland perfeetly atill,
not having any (|ue8tiou at the time but limt, with a forcepa, it
could be seized, and readjiy withdrawn. This was found im-
practiunble. It Heenied to retract, and bury iLi^elf in the anterior
wall fif ibc urethra; and any attempt at seizing it only resulted
in laceration of the lining membrane. Various instriinieikta
were tried, whirh T had generally employed in wididmwing
ibreign cuhAtancca^ but, fmia the pecuharly aofl nature of the
muteriol iu the present iiL^tuncc, and \i& umall aize, it i:ould not
be detected or «eized. KffiJTis were made, by p^issing the finger
into the rectum and by manipulationi4 on tlie exterual [»art of tlie
uretbrn, to force the fragment forwards; hut* from the reasons
mentioDed above, viz., its softness, «mall si^e, and ite not die-
tending the canal ao as to make itj^elf [)crcex'tihle» nothing ci>tdd
be efl'ected iu this way- The patient was ^eut to the Jlospital;
ftnd as it wad found practicable to piisa a catheter by the ifide of
the bougie, and free ihe bladder, it was concluded not to cut
down for the purpose of removing it* hut for the present to leave
the caae, to long aa the aymptoms were not urgent^ and see
what nature would effect- He was ordered % warm bath, and
confined to his bed on a liijuid diet. The day foUowing, he was
»30
QENTTO- URINARY OROANa,
free from pain, niul lm<l pasaetl water wliile in Hie bath. On
tlie tliinl day-j lie abserveJ a. hani Htibstiiruie through tlif wnlU uf
the urctlira, making its waj towanla the unficu : thi^ he oasisted
& little, ]U](] extracted a bit uf boug^le jm inch m length, very
brittle, and shrivelled up- On the Rfl]k ilay a «tl1] hirger piooe
was plumed, and on the ^(ixth the reniaiiuler of the instrument,
niJiking in all ahout pcven inchfis. Tie BTiHere*! very little from
its presence in the urctlini, hia prlncipul coiupluint being the
BorenL'Bh of tlie urtilhra near the menlns, caused by ihe atlempls
made to extract it; which, however, had been conducted witb
the utmiitit care» and soon dlacuntlnuetl, as they were fuund to
be useless. Tlie pntic&t quiekly recovered, and waa couipletely
relieved from his previous troublesome disease-
I have often use<l the gutta-percha bougiea for taking Impres-
Bionf* of Htrictures, and, until tlie present case, had never expe-
rienced any iiccideiit from them. lu order to be employed vritb
Btifety, tbey ehoidd he made fresh ^vhen ref|uired for use, aa
tbey become exLremely brittle on espoaurc for any length of
tlum to the air.
PERDfEAL SECTION.
Mr* Syme, of Edinburgh, was the first to call the attention
of tlie jirofeHfion to this operation for the relief of stricture.
In the " American Journal of Medical Sciences for ISGl ," 1
puLli^hed a paper upou this subject, in which I advocated the
exten^inn of the operation to a ciat*s of cases not included bj
Mr. Syme; viz., to those strictures in which iiiatruments are
iiupracti cable, arising eitlier from injury or disease, Mr, Bryant
recommended for them, in Guy'a Xloapital licporta, puncture of
the hladJcr through the rectum. In a number of inAtaucett^ I
have iutrudjced a suiF as fu.r as the stricture ; and tlien, cutting
down upoa it, searched for the continuation of the urethm,
and, wfien found, divided It by careful touches of the knife.
If the urethra is found with difficulty, the patient may be
allowed to recover from the in^ucncc of the ether eu£Bciently
to make an elfort to puss water, and then die bulging portion
of the urethra near the bladder can be pierced, and the Btricture
PERI»KAL SECTION.
231
[TT^ed from bohtnd forward till the end of the stuff is reached ;
Dr, withuut ihie affietance, the uretlira amy be iounediately cut
Jown upon near tlie bladder-
A few cft^eft are scleciedj which show the advantages of peri-
neal section, even in the mo£t desperate cases.
Case CSXX, — Organic Stricture of the Urethra of ton
years' standing. The Urttie finfiU^ pa^Jied ia Drops. Re-
tsntion, P^nenl Section. Jjiviffion ofihe Strittttre. Com-
plete Hecovertj, — A man, about 30 years of age, entered the
Hospital on April 30, ldf>0, with a stricture of the urethra
of ten years' dtiratioa. The water, when he entered^ passed
in a very small etream ; and it wae constantly dribbling during
the night, accompanied witli a purulent discharge. He com-
plained of pain in the renal rcpon^ thou;rh not of a severe
character. After very careftil attempta to paas a bougie of the
amalleet de^ription. It was finally decided to incise the stric-
ture from within, wliicb was done oa May 15th with temporary
relief.
On May 2*Itb, the urine became leea free; there was conaider-
able Julnces in the pubic re^on ; and the patient complained of
pajn about the bltidderf with gt^crol uncu^inCEs.
On the next day, I found he had a complete retention of
urine, and proceeded at once to perform perineal section. He
waa plflcod on a tabic on his back ; and after being thoroughly
etherized, so that hia joints were ftilly relaxed, he was tied, as
in the operation for lithotomy, I have found it much bettor to
contitie the limbs in this way, than to intrust them to the care of
aseij^iantflf who are apt to be worn out during an operation bo
likely to he long and tedious. A small staA' was introduced;
and it seemed to penetrate the first Etriciurc. which was incised
about a couple of weeks before, and brought up against a second,
apparently ju^t behind the root of the scrotum- The fore-
finger of the left hand was then introduced into the rectum,
and the situation of the prostate ascertained. The pcriua^um
was then divided, and a careful dissection made to nj^ccrtain (he
site of the urethra. This wa* rendered very tedious by tlio hem-
orrhage from the Ijulh at the bottom of the deep wound ^ which
232
QENITO-ITRINARY OROAXP.
in this case waa ini>re tlum urdmarily trouUesome. The urethra,
however, was fiiLtllj' mieiied ilirtttly in tVoni; of the proslale,
BJid a large giirn-eCa.'^tJC c^thelcr paefied through the wuunti Ltito
tbe bliidder, giving exit to a very krge quantity of urine. The
csnal WHS now opened forwardfl, and the eallositips freely diiided,
until the fiticffwMP reiichtKl. A sef*ond gum-elaslic estheier whs
now jmssed downwards, thruui^h the [>eni!4, until iC Jippenred in
the wound ; the i^oiy end of tlie fin<t having been cut off, tlie
point of the wcord was insinuated into it, and firmly fixed- In
this manner it was dragged up through the whole extent of tJie
nretlira^ Tn similar rases, whore it la difficult to find tlie iire-
thrii, and where other meant: have failed, the oourse might be
pursued which w»h adopted in tlte jireaeut cajie. I nllowed tlie
patient partially to recover from the elhor; stinmlatrd him to
make nn efTort to urinate; and when the urethra, behind [he
atrieture, became dila-ted, a minute strenm of unne lasued^ indi-
cating tlie s[Kit for the introduciiuu of a probe, and llie urethra
was found.
No unpleasant symptoms followed the operation : the p&tient
was eomfortflble, and relieved from the sense *if fuloesa caused
by the distended bladdnr and ureters. At the end of a week,
the first catheter, being removed, wiia found to have been pur-
tiidly acted upon by the urine, ntid its calibre somewhat
obstructed ; it was replaced by nnnther.
At the end of a month, he was ahle to introduce the instni*
ment himself; and, at the end of two months, [he wound in the
perimeum having healed^ he ke|Tt it in at nighty leaving it out
during tho day.
He shortly after left the Hospital entirely well-
Cabe CXXXI. — Stricture of th^. Urethrn of ivetity^Jtv*
years^ duration, yumerous Urinary I^iHiflie in thB Serotmn
and Perint^\tm. Perineal Secfton. Curt, — A man entered
the Massnrhn setts freneral Hosjiital on April 24, 1860, and
gave the following history of himself. He had siiffered from
gonorrhea twenty-five years previously : he then had a slight
stricture, which, after fifteen or sixteen years, became so tight
fls to give liim a great deal of inconvenience, for which he
I'EEtlWEAl, SKf.TlON.
S33
entered the Hnsjjifal iimler my nnre, nnd waa lrecit<]d by irlornHl
iniiisior. Thi.'i relievwl hiui tor a time. In 185^, a fistulous
ojteaing appeared in tlie periiusum, followed by two in tlie
BcruhiTo : throiigii these opt^nings, purulent miktter, with iirinej
was fredy discharged. The wliole of the scrotum wiis tense,
indurated, and biiirowed by sinuses. Two monlhe previous Ut
his admission, n No- 1 bougie was passed into the bladder after
much efthrt, by whirh his syniplonis were aggravated.
I pulsed a No. 1 bougio down to the Btricture, and kept it
applied for two or three houra diiily, eieriing a gentle pressure
against the stricture. After treatment for iihout a week in this
way, i\\Q stricture gave way, and the instniment passed into the
bbulder.
No I with standing the passage of the bougie, the disease of the
Bcrotum increased ; and towards the Ist of June, the atriciure
having Again closed, so that it was quite impcsalble to patis any
itistruraent, perineal section was done at his rcqueut, on June
4th.
He was etherized, and confined in the position for Utliotomy.
Syme'e floiind was passed through one stricture, and encountered
& second. An incision was niado in the median line of the peri-
na>iim, untd the point of the ^taff wa^ reached. The dleseelion
was tediouB, front the hardening of the tissues by in61trationi
and on account of the hemorrhage, which was very free: tho
porina^um also was uncommonly deep. In order to see more
clearly the continuation of the urethra beyond the stricture, the
endof thestalTwaB turned out through tho incision, and served to
hook up, and thus brin^ tho deeper parts mure fully into view.
The wound being freely sponged with iced water, a puncture was
made into the urethra, in the neighborhood of the neck of the
bladder^ into whiclj a probe was passed, an<l the uriTie allowed
to eecnpc. A large gum-clastic catheter was substituted for the
pi^be. A ebarp-pointwl knife was passed up by the aide of a
Ginall Syme's gound ; and tho Erst stricture, which lay behind
the middle of the scrotum, was freely divided. The catheter
was drawn up through the urethra, ue in the last cu&e>
The first catheter was left in place a week; then, bcooming
obatructcd, it was replaced by another, and this waa done weekly
234
GENTTO-URDiAlir OKGAlffi.
through the nmrHe of iIk- trentrnGiil. The wnnnd in the pen-
napum^ on accotiiit of the (lisujusnl »iate of the liriauos, wan very
■low En henling; and the patient remained in the Hospital for
two unmllin Hflerwanla.
A communication was received from him in Ntiveniher, I860,
in which he HtateiJ t}iat he was entirely well.
CA8fc CXXXn. — Trajonatic Sirictttre of thf. Urethra
of Jive years* duration. V^et^co-rectal PiRtulo. — A teiimster,
36 years of age, came into the Hospital under my care in the
early piirt of the »[irini^ of IKGO- He piaid th^t, five yeara
hefore, hts had heen jammed against ft wall hy the huffier c»f
a freight-car, vritli such force oa to produce a rupture of the
urethra. He remained in a mtical fiitiiatiDn for a time« and had
never since been able to pasa his water except in a very Bmall
fltream.
On examination by the rectum, T found that tlie bladder,
intestine, and surrounding parts, were glued together, and
involveil in an indurated mass, and the calibre of the intestine
was very much diminished. Fistuhc had formed by the side of
the rectum, and there was communication between the bladder
and ihe recium. A probe being introduced inlo the fij^tida by
the side of the rectum, pnssed up by the side of the intestiiie,
througli the induruted tiasues, and appntently entered the inte-
rior of the bladder. No ordinary menna afforded relief; and I
advised him, unless willing to have perineal aeetion performed,
to desist from any further efforts, for fear of producing imtation
and complete retention, especially aa he did not sufler much
from his disease-
In June, baring heard of the success of perineal aection in
other casefl^ he came hack to the Hoapital for the purpose of
having it performed upon himself-
The operation was performed, and a catheter introduced, riB
in the Urst caae.
Not the slightest unfavorable symptom followed ; but at the
end of the week, when it was neceeaary to replace tJie catheter,
the end of the instrument escaped into the rectum. This was
prevented by hooking the beak of the instrument against the
PEltrNEAL aEonoN-
235
pubea ; and then, inateaJ of trying to force it forwards, the han-
dle WHS suddeaiy <\e\ir(;ssed, und it clipped uito the blndder-
Carried foi-warde in the ordmary way, it always wont into the
rectum.
Before the end of the month, tho urine was paeeed by the
oatheter, althou^^^h there vras purulent discharge through the fis-
tuloua opeDing near the rectum, and occaatoTiaJly from the
rectum itself. The patient remained in the Hoapltid rather more
tbao two monthS) when he Ictl, and haa since been bceu well.
Cam CXSXm. — Urethral Fistula from BuUet^t^otmff,
PerxTieal Sectimi. Hecovert/. — A yoimg man, 20 years of
fljfe, entered the HoBpitalr June 3, 1865, h&vin<^ hoen wuiinded
in the attack on Fort Stendraan in the preceding March- Tlie
ball grazed the fiide of the penij^, taking out a piece of the pre-
puce, and, pttssinijp through the eerotum, carried away tlie right
testicle- It ihea penetrated the deep muHclee of the periniDum,
fbllowinir the course of the urethra, nnd cume out just below
the margin of the onus. When wounded, he was in an orctt
posture ; he fell iusensihlc, and was at once carried to the rear.
On entering the HoHpital, the entire wound was found to
have healed, with tbe exception of the fistulous opening below
the anus- He was obliged to urinate once in two or tliree
hours, anrl the greater portion of the wnter eacapod through the
wound near the nniis. lie had previously been repeatedly
informed that nolhinj? could be done to relieve him. On on*
anunation, a stricture was found near tho prostatic portion of the
urethra ; and a bou^ic^ intr<xlurcd into ihc meatus, emerged at
the anni opening of the wound. I directed that a bouj^ie jihouid
be inserted daily down to the ai:ricturc- On June Si!^th, the usua!
operation for perineal section was performed. The end of the
Bound being reached, the posterior portion of tiie urethra was
found involved in a nmss of cicati'iciaJ tissue; and great difli-
eolty was eipericnccd, after the wound was enlarged, in tinding
the orifice of the urethra which led to tlic bladder.
This, being found, was freely divided, and a large gum-olaetic
catheter introduced tlu'ough the whole course of the uretbm.
On the followiug day, he was qiiite comfortable. On the Sth
g36
GEMTO-UmSARY OR0AN8.
of July, the t^Eitheter wna reinoveil, and the wound in the peri-
□a^uni wan ln^iiliiig ra^iidlv* No urine ei^iijicd froLii the old
"nound, near the anus, after the operation. A few daja after
this, he passed a fijll etreani, a few dn>p3 onlj eacapbg through
the periiijpum, wliich was rapidly graimlating.
He shortly aftenviirda left tlie Htjspita!, hut returned from
time to time, during tlie fullowiug Sve or ai.x niontlis, to have
an inetruiueut pufiited> Ilis recovery, eo fax as I know, waa
compIeLe.
Case CXXXTV. — Traumatic Stricture of Urethra.
Perineal Section, Recovery, — July, 113G3» A tall, thin,
delicate boy, Ifl years of age, tripped, while walking on the top
of a fence, and cjuiie Juwo astride uf it, striking the pcri-
nreuui, and produulag a rupture of the ui\:thra. At firet, there
was a bloody dlschjtrge fxoiu tlie urethra, and retention of urine,
\vhicli was relieved, al tlie time, by the use of a catheter. The
nfit four months were passed in great i-ullering, and with fr^
qucnt uttacka of retention cf urine. lu January, 1$C4, six
months after the occurrence of the accidcut, the retention b»-;
cDiiie coiapleLe ; and an operutiLjEi waa found necessary to
relieve him- A distinguished practitioner was sent for from a
diBtance, who cut down upon the urctlira in the pcriiiu^unia
having first introduced a tatheter into the penis as far fu
po^siltle. Tlie urethra wax reached at die point ivlicre thfi
o]>striietiou eommeneed, hut could not he traced farther; and^J
although an elastic catheter was introduced into a passagaj
which Becnied to couimunicate with the bladder, it wiia after-l
wards found not to reach that orgaii. From diut tiuie until^'
1 saw binif sis weeka niler, he had periodical returns of reten-
tion about once a week, which were relieved by the escape of
ft email portion of solid matter, followed by a jet of urine-
Improvenicnt for about a week fi»llowed i but, at the end of
tliat tiine, tlic retention again oLJCurred. The urjne Fihowed a
constant tendency to eacjipo hy the perineum, unleas prevented
by chming tlie oHBce by the iiiij^r.
After watching the case for a week, during which lime he
hfld an attack of ccniplcte retention fcr eight or ten liours.
FERTNE.iL SECTION.
237
wmen wiis only relieved by opium und ctlicr, I finnlly o]>eratcd
on him on the ^th of March, 18C4.
He was placed in a etroug light, and fully etherized ; ft capil-
lary bougie W0S pneacnl into the urethral and the end of it
appeared at once through the opening in the perinipunip The
direction was dow made upwards towards tlio spot nl which
the bou^e cecapcd from the urethra, in hopes of finding a con-
tiniifttion of the pasBa^c in its vicinity. On diede(?ting to thia
spot, which was underneath the sorotum, near ita root, no trace
of the inferior portion of the urethra could be (^seovercd.
After exploring lor a time with n hooked prulic, a small opening
wafl detected at the tiidc of the other, but not in a direct line
with it. Into thia, a accond-capillary bougie whs pasecd, which
evidently penetrated to the bladder. The whole length of thia
paesagc was now gradually laid open, hcirg through a Bolid ad-
ventitious deposit. Tlicre was no possibility of passing a
prcbe, even at the side of the bougie, until arriving nearly at
the ncek of the bladdery the urethra being, in fact, constricted
throughout the whole perineal portion. A probe waa now
passed into the bladder ; and a catheter of medium size, being
firet passed into the meatus, waa carried by the eide of the
prcbe into the bliiddcr. On witljdrawiug the probe, a quantity
of caleareoTifi matter escaped- In the c^mrsc i»f the night, a
stoppage took place, which could not be relieved cither by using
the Btylet of the catheter or l>y injections; and the urine began
again to escape by the opening in iho pcriiiwjum. On pneeing the
finger into the rectum, the bladder was found to be half full of
semi-solid matter, feeling like a bag of putty. This proved to
be a phuHjiJialic deposit, which hrui probably been for a long
time collooting, owing to the extreme narroH'uoaa of the paaeage
through which tlie water trickled. The elastic inetrumcnt wne
therefurc removed, being dragged away with some slight difli-
eulty, owing to the cjiJeareons substance wliich adhcreil In il-
This WU3 replaced, foTlumitcly without much difficulty, by an
S-ehapod eilvcr catheter. The bladder M'aa ayringcd out t^ice
a day with water, and some of the pboaplmtic eubatance
brought away at each injection. This catlictcr became eloppcd
on the following day, and hatl to be taken out and rcphiccd,
238
(jENlTO-tTRINAKr ORGANfl-
ivlikli wa» efT&'leil under ether. lie iiltiniiilel^ reoovereil, re-
qiiinng tlie ^jocu.Hjiina] u^g of tLe instrument ti> iiiiuntiun the
free pAdsage nf tlie canal.
Case CXXXV. — Slricfure of Urethra of ticenf-if yearn'
aliiiding. Flslnioi in Pcriii^o. I^eiLnenl Section. — A man,
5li years of uge, ihin, ]>ali!. wnd of miaemblG jiw[>ect, entered tlie
Huspitiil in Maivh, 18fi.1, with stricturef^ Liflhe uredini of Iwen*
ty yearfl* Htjiiiding. Tlie urim* trieklwl nwny in drupa or n fine
btream, and no Infilrument could be parsed uito tJie bladder.
Some years bcForCf be Jiad a pcriuual £i^tid^, wlik'b, af^r
Ireiitmeiit, r.luhfd ; the urine resuming \ts natural cbuiind- His
strictures bad, however, oontinued to grow worse. After a
triiil of [ii^vera] weeks, a. CHplllary bougie waa pasHcd without
violeucu du"ougb the first atriclure, which was jutit lu froat of
thu BcrotuDi* It wa» left Jbr half an hour every daj in the
alrictnre, gradually dilating it. A second fltriciuw was soon dis-
covert^ o^poaile the middle of the pcn.ua.'uiu, whL^re a cidluMty
could be felt of tlie size of a marble, Tlie bougie was llnally
p]u:fed tltrougli this obstruction alao iijtu the bladder. Despair'
ing of getting iu any larger instrument as a guide, as the inlro-
djction of this amall oue had already occupied aeveral weeka, I
determined to operate, A free iuci&ion was made^ iu the usual
manner, in the periuteoui ; aud a long and patient dissection
performed before the urethra could bo discovered, the bougie,
from its smallncse and flejclbility, acjircely serving as a guide Co
the touch. The urethra waa found to have been pushed to one
side \jC the median line by iuHamuiatory cxudatioa. It was
opened at the sttictured pEu^t for the length of about half an
inch, after wLleh it admitted a No. 8 elastic catheter from iLe
wound into the bhidder* To divide the other stricture behind
the bcrotum, a director was carried up from the wound to the
stricture, and on it a eonceale<l knife wod passed, and the con-
striction with flome difficulty divided ; tliere being a disposition
to push the stricture in front of tlic knife, owing Ut Jt^ CAtreme
toughness. A No, G elastic catheter was now introduced intu
the meatus, and passed into the bladder, though with difficnlty ;
for the external stricture grasped it with some force. The
PERINEAL SECTION.
239
f>aticnt was placed in bed, and an el^cic tul>e ftttacbwl to t!ie
catheter to convey the urine into a receptacle placed for it be-
ncatli the bed. For the first time for miuiy years, tlie wntef
flowed freely frora the bladder. On the folJowing day, the
itricture had nlready, frf>m absorption, bo far relajted lU hold
upon the instniment. as to admit of ita ensy withdrawal, nod
the introduction of a larger one; a proceeding rendered necea*
aary nleo from the obatruolion of the eyea of the firet one by tlie
ffiucua of the bladder. For the samo reason* it was ullinaately
necessary to gubstitnte an. S-shapod silver catheter for the eiia"
tic one ; af^er which the obstruetion did not recur, and the man
made a good recovery.
Case CXXXVI. — Traitmattc Striciitre. Perinsrjl Sec-
iicn. Recovejy. — June, 1*^65, a man, aged 49, entered the
Hoapital. Three years previously, he fell a distance of eight
feet, coming down astride of a beam. This was soon followed
by abscessed, which resulted in orinary ftstulfC' On eutrance^
the scrotum and Integuiucnt of penia were* greatly s^vollen and
cedematous* At the middle portion of ureUira, thrcu<^h the
scrotum, a hard tun^or, the size of a goose's e^p;, could be
detected. The urine paaacd only in drops, A capillary bougie
could be made to enter with diflieulty into the bladder.
Perineal section and the operation for j>hymoai8 were per-
formed about two weei^ atler coming to tho Hospital ; nnd, in
a little mure than throe weeks ofler the operation, the patient
woe discharged well^ the ecrotum and peuia having re^nmed
their natural dimensions, and the urethra being thoroughly per-
yious.
Case CXSXVTI- — Tmnmatie Slrietnre^ Penneal Sec-
tion. Hecofcrif. — April, 18li5, A laborer, two years before,
TCceived an injury to the perinacumi which was enceeeded by a
elriciure of the urethra. Subeequontly^ fistulous openings ap-
peared in the perinieum, which communicated with the urethra r
tliese, however, healed. On entering the Hospital, it was found
that the urine escaped from the meatus in drops, while the
greater portion made its way through fistulm ou the under aspevt
240
OENiTO-lJRINART" ORGANS.
of the pi?nU, nnd tlint there were several strichires i oni? near
the meatus, am\ the others in the tnctuhmnoiia portion of the
urethra. The penis wns flwlemntoua.
Perinesil sei^.tion aiid the operation for phj-moflb were per-
formed, aud the patient discharged, neruly well, one month
after the operation, and two tuontli** after being admitted.
Case CXXXVm. — Traumatic StTicture. Perine.trl
Section. Recovery. — March 13, 1861. A laborer, aged 53,
received, shout three raootlis before, a blow in the periiucuiii,
where an ah>;cesa formed, and, twentv-fonr hours niYer mjdry,
broke, discharging hlood and urine j lejiviug a fistulouH ojien-
ing, t]irougb which i>aLjent voided )iih water for two months
prior tu hia coming to the HospitnJ.
On examination, iin iinpcrnieable stricture wa^ faund about
one inch anterior to ihe trianguliir ligaineui. TIte fi^tuloufi open-
ing in the perinicum admitted a probe for the didtJtnre of an inch,
March 23d. Perineal flection was performed, and the Htriolure
divided. In mx weekiif the urine was pjtH^etl through meatus,
the wound henled, and the patient discharged well. The oon-
valescenee in this cuse was prutracted, tlie patient having re-
peated attacio* of erywjpelatouj* inflammation and hemorrhage.
DrSEASES or TITE rHOETATE GLANB.
The affections of tJie prostate gland are of great importance,
and require ijuite as much delieney in their treatment U8 do Htrii>
tnreB of the urethra. Stealing on gradually in peraona about
sixty years of age, they do not often ret^uire the a^ij^istanoe
of a fcurjTGon until almof^t euraplete Bte]>[in^ of water baa taken
pinee- Ii will then be found, that the patient, for some time
previously, has passed hin wat^rvery frerjuently^ and that finally
it has begun to dribble away from him in^neibly : on pitising
tlie catlieter, a large qnanlity of fetid urine ib evacuated ; and it
w^ill at once be fieen, that, for a long time, the Uatlder bad lieen
but partially emptied. In most instances, the ])rostatic catheter
can^ with great care, be made to enter the bladder: in otliers,
however, the passage has been renilered tortuous by Uie eu-
WOUVD OF THB BLADOKK,
241
Inr^ment of tlie tliinl IiiIm* of the pnwtntB, n.n(l grpnt wire is
rijcjiiii-eil, or mitichief will he ilnne with the iii^lrument. In
tbeM! CRS^es, I Imve niutiaired beat with a French [mtn-el]L»ttc
cailipter, tenninnttHi wiili nn iilmonf. ciipillury point, mid Imvhig
the eye, ur aperlHre in it, ut iibtiut two inrheB Jistsince from
the terminntion. TfiiB mjty be introduwd ta* Car as the olifilnic-
tion, wkli a stylet within it : by a sudden motion, it may then
be shot off froMi tlio atylet, and carried into iJic bbidder- Tf
carefully witbdniwn, after rcmainin^r in phme fur tn)inti honrfl,
it will generally retaiti the eurvjiture of the lorttioiiB passage.
Where tliore is much [lain or Jrrifjilion frmn tlie uitnKluctiun
of the instrument, it luul better be left in the hUdiler for ilie
greater part of the twenty-four hours. If these causea do not
exist, the water may be drawn off iwo or tliree tinica a dny.
j\r™»t pjilientj*, after having a poro^tyi^ni like the above, arc
relieved, and things go on for a time as tibuqI : In others,
where the patn and suffertTLg ban been very great, secondary
syniptonm come on ; and, juBt ha ihc patient schema to have got
through his dcffieulties, a cerebral affeftion *in[>ervenes, and
he dies with alt tlie aymptonttt iif unemia. Where bloixl Is
thrown out into the bladder, and no urine |j)w»eB on the intro-
duction of ihe c;ijhe1er, nri injeclion of water may be made ; and,
sfler a day or two, the congula beoome dissolved, and paj^s off
witbonl ditfieulty. Cases, which at firnt louk very formidable,
ofien tarn out favombly, even in persona of quite an advanced
WOUND OF rxiB nLADDEn.
Case CXXXIX. — R^-marhnhh Case of a Wound of the
BladdpT. — A young, vigorous, and brave officer was btrtick
by a liall, which passed directly llirikugh the pelvis, just be-
hind the hip joint, penetrating the bladder, ilie mine escaping
&om both openings of the wound. An examination by the
rectum, h»s reported by the [latienti revealed the fact that the
left lol^e of the proJttnle hnd been carried away. A catheter
was introduced and kept in the bladder, and the urine allowed
to pnsH tliroii^rh it during the treatment. InHammntion took
place in the ooursc of the uretlira ; and an abscess fnrniefl in
31
54S
GE\lTO-IJKL\AKr ORGANS-
front (if the scrotum, breiilcing there, lenving the nrothm open
fi>r a ttpnce of nearly two jnches. At the time of The recepuon
of the wouTLil, there wilb a eenaa oF numbneaa prniliirod in bolfa
lower extremitiea. After n long anJ lediona ff^nfinement, he
regninwl fair health, having an a|x^rtiire In front of the flcrotum,
through which the iirina passed when the bla*Mer was evaca-
ated ; the recovery being in other respects g^od, conaidering
the g^ravily of the lEJurj. He returned to his poal, and took
part in an engagement, five or sisr monihs nfterwarJs. Shortly
after this, he conaultei] me; being nerroua on account of ft
ivant of power which he felt in the lower rstremi tics , and which
he feared might leail to pandysTs. These symploma I atiribnted.
to bin riding on horseback. On cxiuninatiun of the wound
made hy the hall, I found the sear^ on either side of the pdvia
in R healthy condition; and, on cinmining the neck of tha
blEuldcr, a bridle c^niU Le felt in the reL-tuiu agninet the lefb lobe
of the prostate, where the injitry hml apparently been. The
aperture in front of the Heroluni wrjs largo, and a great part of
the urine escaped through it during micturition ; but there was
perfect control over the neck of the bladder.
Thia case ia a very intcrcBting one, from the fact of there
being so serious au injury of the pelvic nnd bladder, urine paas-
ing out from both opeiunga of the wound, followed by good
recovery.
TESrCO-RBCTAL FISTULA,
Cabe CXL. — Commujiieaiion i/elv^een the Bladder and
Reatitrn, resnltinff probably from Ulceration. — Dec, 12,
1864, a mon ahoul 35 years of age conaulioJ me oti account of
the following diseased condition of the bladder, which I put on
recoi^l on account of its rarily. lie said, that, for a month, he
had passed no urine, but only a white, milky fluid, per nnuni,
in quantity of about a tablc-spooniul, when he etmined at 9tooL
On farther questioning, however, I found that, throe times &
day, he was in the habit of going to the water-closet^ and dis-
charijiug from tlie rectum a large ctuantity of tiuid, followed by
ft eolid operation. He said that he had suffered for the past two
years from inflammation of the bladder, caused, as he supposed,
CANCER OF RECTUM,
243
bj assisting at tTie o.onftiiomeiit uf I119 wifi^, nburii he held dur-
lag tbe whulu ijij;lit, wlill4; she \fiis struggling whh the pains of
labor. This Jie did much agaiast hib incliuutJoiL. Ever alnce
tliAt time, he had difRciLlty Id poashig Wis "^vnter. which vas dls-
charged ijuite fi'eijiieiiLly, und niiKcd with mucus.
I ]>a[4«ed an elBstit: cftdietcr Into the hluddcr, and drew uff
about hitlf nu ounce of tbtid urlnt^f mixed with piia : Eome hlood
folJuwed llie wltlidnLwu] uf the iii^ti^uijiciit. A rocul exaiulnu-
tlon dIstlowMl nothing iLbnortiml ; hut the finger cdjiIiI not rtjieh
liigli enuiigli to deteot the oppning Into the bliutder. Tt was very
evident, however, that tlie case was one of lon^-iTintimiwI in-
flammation, with ulceration of the bladder, ending In |>erf^iratiaii
into tho rectum. I forbear glving^ the trentmentf as there w«s
evidpndy hut lilllc to be done,
Tltc patient was eieesdively pale and emaciated, aiid liad the
aspect of a map whose case would be likely to terniitiate un-
favorably .
Cancrk or Rectum. — Ca.sk CXLT. — Scirrfious Tnwor
of ike Reciuta mid BUuhler, — A gentlemau, 5G years old,
confiulleil »ic, in 1849, on aeirount of retention of urine. He
was ojicraled ujxin for the jiilea nineteen yenrs befure ; and, at
ihnt time, a small hard tumor wna diseovered n^nr the aoua,
which he declined having interfereil with. Al^erwanls, he oeco-
ALonally had nttacks of |)uln iu the buwels, and ladige^ion, but
never any ecnona Hymptoma in the rectum^ He always bnd
diarrhea a.
An examination was attempted per imum ; and it was found
that the reetuin wn» obstructed by a «cirriiauti tnasr^, which pre-
vented the intrtHiuction even of the little finger, Tlie retention
was gradually overcome by the use of the catheter, nnl the pa-
tient had moderately good health during the annimer. The
next fall, I was called to htm on account of a second retention,
which gave way to remedies, without the use of the catheter.
It was, however, ahordy followed by general anasarca ; and he
gradually Hank, exhiiusted-
At the autopsy, the Inat four inches of the rectum were found
pervaded by a ficirrhoud mais9, leaving in the centre u narrow
244
GEMTO-UlrlNAKT OltG.^S-
j>iill»rtay fur tlie fe«3a. Tljc iliwiwe liinl eTtenJed to the blad-
der nnJ urethra, iind apps-rently impticiited the midiUe lobe of
lh(^ |iroNt]ite gland, which projected intu the bludder, and occu-
pied ahmit \i third of iti-^ cuvily.
Owing to the loose state of thft howelfl, the patient had heen
able to live nineieen vonr^ wirh this tiinior, am] had euffer^l but
little inconvenience from It ; and, in i'jict, was not made aware
of its exiatenee bv aay pain vt other sensation, except aii ncca*
eional irrilatian of the skiu id tJie ncighborliood, the result of
the iinperfet't manner in which the evat-uatiuns were contrijlled.
The left kidney was in a bi^^h Htale of indamiiiatiun, uiid there
was some purulent deposit in liti pelvis : the ureter was not
extraordiiuirrly disteiide*!.
It might be titated, that, during the lust week of bis life, he
refused food entirely, on aeeuunt of the difficulty and iMiiii in
swallowing, caused by an iaflnnimation in llie faucea. Very
flevere hiccough tnsned, wbicb wjls mitigated* and the Ijtst part
uf his life made easy, by the oecoaiunal inhalation of ether.
Case (TXLIT. — EiwrTJiouit Canc^rovm Dinpnire of Ester^
ntil Genilal Ort^ans^ Memoval. ^ A laborer, aged 36 years,
entered the Hospital in May, 1865. Three years previously be
had an ulcer en the penis, which was soon followed by inflnm-
mation of the left testicle. He received no treatment until
October, 1864, when the diseaseJ testiele having attained great
eize, w&a removed by aume surgeon in the sonthem portion of
the country.
In about a month after this operation, a hard, gray-colored
tumor formed within the lips of the wound. This was cauter-
i:iwl, bnl oj;ntimied to inereaji^e in size rapidly. It presented the
appearanee of an irregular injisa^ about the size of a very large
tomato, being at least teu inches in circumference, having &
granular, fungous appearance. It envelope'^ the loft side of the
(icrotuni and the puhes, and implicat^^d the penis. There was
a fetid discharge, and ocea?«ionally hemorrhage, hut never mucli
pain. His mother hud, at the time of her death, a "rotio
cancer." He desireil an operation, although Informed that it
would be only palliative.
IVDDEATEn TUMOK OF PRNIS.
545
Miiy 10, 19C5, he was etherized. A ligature was first pfi-53o<l
throiij^h ihnt portioD of the ttimor Eitunted above the pubea, und
drawn up firmly^ The remainder of the tiimor waa then die-
eocted ami torn from ita ndhesioTia, nnd caustic potash ap|)lied
to the hanG. SevcrsJ hli^^iQg vessels were tied, and the cdgoa
of the wound were brought together with suturea.
This was a most desperate case of disease, in which hardly nny
operation seemed fivnilflhle : the disenw*] maae was ahnost n foot
in circum fere nee, nnd the intej^'unionts of two-thirds of tlio penia
implicnleii. The snuas m the grojn, in the course of the spcr-
iniirie cord, descended so deeply that the only fidr way of con-
trolling the hemorrhage seemed to be to enclose the whole base
of the growth in a ligature- The patient left the Hospital in
nhout four weeks after the operation with a wound of the size
of u dollar, and able to move a.boui freely ^nd to pursue his or-
dinary avocations. The relief from the dreadful stench of the
ulcerated miiJ*s, even if but temporary, was enough to repay hhn
for the operftiion. Before it he was completely di*abW. The
diueaae returned subae<iuently internally, and destroyed hiia.
INTUBATED TUMOR OF TENIS.
hid«T-ated Tttmor of J^enis. — I have four or five times
met with n very [>ecultar disease of ihe cavernotis foKtiire of the
|>enifi, which I have not seen dei^crihod in any book until re-
oentJy. It has genemllv nppenreil in the up[)er part of tlie
fihron^ covering of the corpora cavernosa at the root of the
penia, and so perfectly defined, flat, and firm, na to seem like
H foreign body implanted in the substance of the organ. Its
edges were quite regidnr, with Hbarply defined corners, like a
bit of broken crockery. The disease haw usually appeared
slowly^ increased gradually till the induration baa arrived at
aboQti the size of a ten^^ent piece or somewhat Inrger, and
then remained stitionary. It ha^ not been pnxluctive of much
pidn ; and the pnneipal efTVct bain been to produce an increased
carve of the penis towanls tlie puhea, with a degree of tension
and uuensiuess during erection. In one insbince, — ihnL of n
gentleman about to rty years of age, — the iEduration wbs Inn-
u%
Gi::4lTO-URINjUtY OKQAKe.
iteil to (ine side, ami caused a deTmtioQ of tlie organ in that
direction, u greater source o(" mconvemcQCe than in tlie position
fitated above.
The tumor ia entirelj free from acute inHiuumatory nctioQf
and ia uiillke tLe induration caused hy Hiq nipturc of tlia
Cilvernous tiasue, which occurs in the course of venereal dlwjise.
This ia particitlorlj the case in the lufiammatiDn from gonoirho^a,
wlucJi is lijiiited to the under part or one of the sides of tho
[icnis, and douictimcs tenuinates in eu]j|airation.
The treatutent adopted cousisted pnncipallj in management
of the diet, alittinence from nil excitement of tho sciu-J i>rg;nna,
&nd in the local application of mercurial ointment by inunction ;
■loo in tke use of an olntraent of the iodide of poLish, imd
occasionally of leeches. These remedies. es[)ecially the mei^
curial ointment, have ficcmed to have the eflect of arrcflting tlie
disease, or producing a slight diminutioa of it, but in only one
instance causing the entire diaappearnncc of the tumor i so that
1 have almost been led to the conclusion that there may be a
sliglkt dcjHjsit of calcareous matter in it. In none of the cosea
met witli has an oi>eration seemed to be neoessaiy.
Having made a statement of the above facts to the BoBton
Society for Medical ImprovenicDl, about ten or fifteen years
since, for tlie purpose of eliciting information, my attention was
dran-n^ by a medical gentleman, to a i;iaper published in the
" London Lancet," nbont that time, giving a number of casee^
but attributing the origin of the disease to former venereal affec-
tions ; at least, in most of the ca^cs adduceil. tlie patients had
been more Or less addicted, m the course of thctr lives, to sexual
irrcfi^arities.
This disease is ulao noticed by Dr. Groas in hifl "Surgery,"
published ill 1S53, Avhere he refiirs to a case of indurated tumor,
in the pcctinifurm septuiUj removed by an operation.
Case CXLIII, — Indurated Ttimor of Pcntg. — A gentle-
man 5^ years of age, well-formed and in good healtli, with the
exception of a prolapsus of tlie anus, applied to me on accotmt
of a trouble in the penis. He said that* during ereciion, the
glans crooked backwards on the doreum; alao, that the sexual
nroUKATED TUMOR OF FESIS.
247
powers were much iJiminialied. On exauiliiuLlon, I founcl at the
back flnd rui>t of llie jiemB, partly liiJilcn hy tlie t\dn^ &d indu-
ration aituatt^d in the corpora cnvemo&ft, e^ten^ling quite ricroas,
ant] of a de[itEi uf about an inch. It fbit aimoEt like a bit of
wood under lUe £broLis ahc:at}i of the peni». He nmd (iiat it
had ejciatcd about two j^ears, gradually extending from behind
torwardfi. There wae no pain in it* nor sensation on handling
il- I could not dlflcorcr any symptom of trouble in the ure-
thra, p]-08tfltc, bladder, or kidncya.
1 advised him to uae a cold enema daily for the prolapsua, to
rub the tumni' with an ointment of the eubmunalc of mercury
and tlje iodide of potnasium, to avoid excitement of the organs,
to uae no stimulant, and re&trict himaelf principally to a vege-
table diet ; also to take internally the iodide of potassiunii three
graiua, twice a day. Under this treatment, the tunior alowly
decreased in ai2e, but did not disappear entirely.
Case CXLTV- — fmlaraled Tiuiioi- in iJtt Peni^, — In the
previous cose, the induration was situated on the doraura of the
pCDis, near ita root, and in the immediate vicinity of the puW.
lu the present instance, it was aituntcd near the extremity of
the organ, aitd in close proximity to the ghtns. The gcntleuiaa
wa£ advanced in life, fiomewlmt gouty or rheumatic of habit,
had been troubled with acialica, and fit one time dysjjeptic.
He had nCYcr suHered (rom any form of venereal diacase.
When 1 flaw him» he was in a very good atate of health*
His attentiou waa Erst drawn to thia itfTection* from hh penis
becoming distorted during erection, being turned a litile to
one side- This was attended with a slight degree of uacnsi-
neds, and with an unnatural hardness of the organ at the point
indicated- Ou exitEiiiEiation, 1 found on the back of the penis,
near the glans, and somewhat to the left tide, a distinctly
marked induration, which felt almost like a foroigu body,
flituatcd beneath the skin, in the Gl^rous tissue of the coqma
cavemoBUm. It was quite angular; and» when seized with the
filers, wa« found to be partially movable In the surrounding
partJ9. Tlierc was no appearauce of inflammation, nor any
tenderueas on pressure- I advised him to apply, twice a day.
»8
CE?mO-CKlKAST OSOASd,
wtuiki MiDtiwgirt omr ihe indnndon, fir^ Whtng Uk pnrt
w^ wvmvaler. TIbs ODitf«eme fblknred for about a month,
wWs tht DBC of tbc oinbneni wȣ GUSfiCiided on anxnuit of a
■S^lit imUtioB qT the skm. This soon Mifaeided, and an omt^
BOA oC kxlide of poCaesum vas subetkotcd fiv the mercuruil
oACiBeitt. He «B» al$o adTiscd to take do wine, ami noC to
ait oa horacback, bulli of wltkh be n&s in tbc hahil of doing.
Il m»j ht stateil tlial lliere was im> dis<mf« of die unnaiy or-
gaBf. Tbe pabcal fulloned thi» course far about a vvsr* sm^
pcB^Bg, frDm time lo time, Uie use of remedies, for eiglit or
Icn Aa^ loguker. He nMd, f<>r tbe most pait* the olntmeat
of Bodidc of potKaniD, ntrdr tbc mcfraraL The diMftse
giadaallr Tvlded Ed a certain extent, tbe ^Larp oatUite of the
indaniioM diiappeani^, leaving ouIt an arale£ned lunlneas,
irU^ wu imtLer diffiroJt U> detect. At this period. I adviaod
Inm to eospend trratniait, but to fellow oat tbe precuitiooA
vrlucfa I had planted out. Tbe unpJeasttiLt eriLptoma whkli ml
firet atleaded tbe di^iease had difapprared.
The hu-ioTT of this ca^ if Ttrj smilar to that of otber^, — -
tbe mitigalioa of tbe mnpCoiiu under treatment ; but m neailj
bD tboK WMS still a per^iftesce of »xae iDdoxatkin. in ^pite of
leaKdwsi. I have never f^:^u it atA^ume a m^iiiauit fi.>mi,
the fear of wluch patkirts gmeraUr have in their miode, nor
coqU anj ai tbe c^Sf» be Irac^l to a venereal ori^n.
&aot wTiti^ the above, the patioit cousulled me for ■■*^*"*
and I found that the induratiOD bad cuoipleteJT di»-
:
Traovs w Sfekmatic Cord. — C^k CXLV. — Adijnac
Twmmn of £k Spermtattc CWif. Annorai. fliffcorery. —
Nawafacva 1843. A Bamed maut M jtar* %M^ iwentv jv^m
bdne iBodw.pJ an i^oiiHl henna oa tlv r^bt ^nle, bv a ftrmiu.
It wt^ of the aze of cbe&tnui, and ^ifilv irdonbie. He bad
^vajs faecB IbUc lo the renirm>ce of the hernia fitoce, and
wore a tran*
la 1037, be |ietcei*vd a foaW swelling, or tumor, at tbe lower
part of the sooCinn. of a globular fum, haid. movable, not
riiiii IW tatkle, be ihou^t, ctJuM be ^t bdow- lUs
TUVOBA OF SPenMA^nC COKD.
249
tuTQar increased until it had acfoined the sizG of an orang^e.
and ttien ceased to enUr<^.
Nine years after the appearanoe of the first tumor, a ^ecood
one was detected above It; and three others have since been
di^overed. He had bc«n examined by & number of surgeons,
and the tumor vanoaelr pronounced to be a hydrocele, disease
of the testicle, ouientid hernia, &c.
On ejLiminalionf it presented the following appenrances ? The
scrotum was the size of a child's head at birth, the increase
being evidently on the nghl side. It contained^ apparently,
Beveral tumors, more or less connwti?d- One, at the lower
part, of the size of the testicle, and in which pressure caused
the peculiar pain pTodiieed by injury lo that organ ; above this,
a tumor of the size of an orange, qutie hard and in^iensihle;
BtiJl lusher, two large and two small tumors, the latter I>eing in
the vicinity of the inguinal ring. An Ludistlnct feoling of fluc-
tuation pervaded the whole of the mass, which was pressed up
against the orifice of the inguinal canal, and c<»mpletely cov-
ereil it.
On dragging it down, and cmbraCLng the inieguinents b^s-
tweeu the thumb and forefinger^ the spermatic eord could be
distinctly perceived paasing out from the ring ; but, on the most
careful examination, no prolongation of the tumor into the ab-
domen was diseoTored. On causing the patient lo cough, a por^
tion of intestine waa felt to force itself down into the scrotum,
and immetlifltely recede. The queslion of diagno»^is seemed to
regard : 1st, An omental hernia ; 2d, A disease of the testicle ;
3d, ^omo tumor of rare oocurrence.
The objection to the former wne» that there seemed to be no
connection between the tumor and the aUlomen ; and, although
it is known, thnt, in some eases, from the efTecfs of pressure, tlie
connection in old omenlal hernia with the abdominid cavity JA cut
off, this u not of very frequent occurrence. To tlie supposition
of its being a di.^eiiaed testicle, the smnll tiimor at the lower
pnrt of the scrotum, of the apparent size and sensibility of that
organ, could be objected- My own impressions were in fiivor
of the third view of the case, and tbercJore 1 advhei) him lo
have an exploratory incision made ; and, if it was found that
32
250
OENTTO-tmiNAET 0ROAN8.
the operation could not be terra innted without great risk tc life,
llial the wound should be cloaL'J without procccdiog further.
Thifl being consented to, tlio patient wa£ etherkcd, and an
incisioii maJo through the integiinicnts of the eerotum, exposing
the middle lube of the tumor; but the diagno^ia wae not cluci-
dOitcd by euttin^r into this. The Jower lobo was then removed ;
the teflttele bniii;; ineoqioroted in il, apparentiv heallhv, though
smfLlIer than natural. In the diaacetion of the rernaLuing tu-
mors, uearcr the inguintd ring, the hernial bao was unavoidnbljf
cut into^ hcm;2; iutimutcly connected with them, Xo intcatino
appeared, cnrefid compression being niadoou the inguinal canal
duriag this latter part of the operation.
The lecoTcry woa perfect, after a amarl attack of consti-
tutional irritation ; the inguinal ring being plugged by tbe rc-
mnius of tbe inflnnied and thickened gjic.
Tbe tumors, on careful examination, were found to bnvd a
fntty Btructure, and cmbrnced the spermatic cord, — the vaa
deferens being trnced. in its whole Jcngth, pai^sin^ throu^b the
centre of the mass.
One or two mstanccg of similar tumors arc given by authori-
tieSf but none apparently of so large a size*
PHIMOSIS.
The operation for phimosis has been variously performed.
The common method is to pull forward the skin, pre^s back tbe
glana, and then remove a circular piece Irom the end of the pre-
puce. On letting go the port, tlie skin recedes, leaving tbe
mucous membrane etill conetriotcd, and often with a ring of in-
tcgunient attached to it. This ia slit up longitudinally on the
upper side, and the edges of the skin and mueou:) membrane
brought together by a aeries of eutures pineed around the whole
ctrcumfcrenco of the organ. The old method con&istcd in sim-
ply slitting up the prepuce upon its dorsal aspect, and allou'ing
the integument to roccde on either side. Tliia operation, iu
many coses, onawera the purpose, although it leaves a rather
unseemly Hap of loose akin. The operation first describedi in
some coses, does perfectly well ; but, almost always, there is
aTDROCCLE.
251
an cxccssirclr »^rc spot At the point where the fhtnam u divi-
ded, taking a Ion;; lime to heal, aud attended by muetk imtAtioQ.
All the benefits of the operatioQ may be isecured by the foUovr-
ing procedure. The front or dorsaJ part of the prepuee is
fleizi;it by forccfi^t placed obliquely upon it, 5o aa ti> take up a
triangular p*>rtion of the tissues, covering' the gtan^ ; the skin
behind, or that continuoud with the trEenum, being lelt im-
grafipcd by the jaw^ of the jn^tTument. The portion protmdir^
beyond tlie torccps i:^ cut away with sciaaor^. The same end
may be attained by making tbc fikin tense, by introducing one
blade oF the forceps iaaide the prepuce and the other outride,
and removing nr apron-ltkc portion in front; care being taken
to divide tJic mucous membrane well down towanla the baae {>f
the gloos, od a failure in thid pArt of the opcrution is one
of the most fertile eourceiS of etmngulation. The edged of the
wound arc then nicely adju^stcd by means of many sutures
taken Tery near the margin- It will be underetood, that, in
thifl latter operation, the akin behind la not inlerferfd with.
The ertcct of pbimo&ia ia to act a^ a place of deposit for eon-
tagious Accretions, In many cases which I have seen, in young
persona,' it haa ap|>eured alao to have retarded tlie growth of
the organ. In eljJdrcn* wc often find the prepuce adlicrcnt to
the gians, aometiinca so firmly aa t(J render it imposBiblc to de-
Glroy the adheeiona ; in which coaCi there is nothing to be done
but to cut the skin, and draw it boekwardsn Generally, how-
ever, after slitting up the (ircpucc in front, the raueoua flurface«
can be caaily separated from each other by means of a prube.
HYDROCELE.
I shall atludc to thia common Uiscnsc very brieHy, The
favorite treatment of late years ha* been by the injection of
Tincture of iodine* A drachm of the tincture, or, what is per-
haps better, the eom^>ound tineture, of ioduie, tm it does not
predpitate, diluted with three parte of wator, \a throvm into the
one, and left there. Tine treatment is, however, very uncci'tain.
I have tried tbo setou, but have seen much inHummntion pro-
duced by it; and in one case, hemorrhage, from the ulccraEion
S53
GENITO-LItlSIAitV ORtiANS.
cau&od hv it, (rnttirg off a good-si^ed \ess«?l- Tnc-iaion is apt to
be foUowwi by eiippiirative iTirtfimmntion and n letiious conva-
lescCDGe- Tn one or two iData.ncea in wliitrh I have lately pmi^
tiaed it after other nieuutf had isiileJ, I fouiKl, :ittnoht*d to the
tpstide, numerous cystic ^ou-ths containing Bpcrmntozon, which
Mr. Curling destTilMzs aa hnving found tn an encysted hydrcn^le
attadied to the ejiididymis. Aa u general rule, I have fuiind
that the wcaltliier chissca in life |irefcr the jmlliutive openUion
of tapping- The laboring classes, who are more ineonvenienced
by it ID Lheir vocjitions, prefer the radicrd cure. Before operat-
ing, it i« nlwaya nt*.ejjsttry hi look i\tr the trnnaljceucy of the
tutnor, (jy suuliglit if posHihle. The <ipf*ration of tripping ia
best done witli a auiidl trociu', thrust in quioLly ; Lhe point being
direcltd oldiipicly upwards, b^ the testicle is usually at tlic back
part of the scrulum.
H-jEMATOCELK-
Case CXLVT. — Hmmatocele. Ext\i*pnfion of TfMicte,
— This patient hful carried a tumor, of uuknovrn origin, for
nineteen yeahs. Wlien seen, it w:u of the size ttC a ciiaiu-iiuli
finu, widiout fliKtUHtion, and presenting an indiimfd t^pot u|K>ai
its anterior aspect. Being considered a tumor of the testicle, itaJ
extirjjalum was a^lviseil and priictiaed. The sac, whieb waft not^
puni;tiLred dnriiig the opcratioa, was subaeipiently laid open,
and gave ihsue to a dirty-colored fluid. The le/-ticlc, after tho
removal^ was found finttenetl and waalcd on the posterior fat
of the sac. The tunica vaginalis was thiL'koned to nearly
quarter of an inch, its interior lined with troagulatod lyinphJ
aud iliflteudcd so much aa to hold a pint. The rci^ovcry w&s'
perfect in two weeks ; and^ ahhou^jli there waa a mistake in th»
diagnosis, the oijeniiion pei-fornied was tlic best ibr the paiient^
aa the process of granuhition, in so duckened a sact must iiecea-|
aarily have been very tardy, and tJie teaticle waa do longer
any cffieiency.
The diffindty of diagnoflis was inerea^cd by the enlargemi
of tlie other testicle, which had within a year attaiaed doubl
its natural size, was much datteued, and evidently had m
H^::3IATOrELE,
253
wflter pstemnl to it. Bath the piitiont nml hjs physipmn in-
siat^ thut the disense of the other le^iicle commenced iu tlie
same mnnner ; and the latter Btateil thnt he had often e:iamined
it with the view of deiec<ting fluid in die tunica vaginalis, but
□ever could discGm uny.
Cask CXLVTT. — Case of U/p^mfitocelef res^nthUnfj Dlti-
ea*H of tfiP. T't'.nd/i. H/itnoi-aL —^In Miiy^ IflJij^ the following
case of difficult dmgnosi^ came under my cure nt the IIo$|iiraL
T^e patient wne a colored man, aUout 35 years old, of large
powerful hiiilfl, Mongintf to the navy- Seventeen years be-
fore, he lind rR<jcived a bluw upon the te^itide from the fall
of n powder box. The testicle swelled until it wue twice wi largo
Ji9 naturaK and afterwanls 'lid not diinrnish in e\ze. In Mjirrfi,
18^5, he had an attack of intermittent fever, attended with
great swelling of the testicle, and excessive pidn in it. The jiain
was so great when he entered the Hospital, tliat lie Lij[ietl to
have the testicle removed the same day- For the farther inves-
tigation of the cafle, howf^ver, I decided to place htm under treat-
ment for ft short time- He was put in bed, on a light diet, and
large lauilannm poultices were kept coii<itantly np]jlied to the
scrotum : opialea wctc giv(*n at night, Uoder this treatment,
in three daya, great improvement took place ; the pain was
much relievwl ; and it wng possible tu hanille the organ. On
examination of the parts' the cord was found cpate healthy;
the tumor of the scrotum was nearly globular in form, smooth
and elastic, such as might he presented by a greatly enlarged
testicle; no feeling of fluid raiuld he detected. The skin moved
fireely over all the tumor, eicept ut the back part» where there
seemed to be a projection from the main imwH of a different
character ; the skin h[>re being a^Iberent, and the snbjncect tissue
giving ft pasty sensation to ihc finger.
Being in doubt as to the nature of tbe diaeafle, I informed
him, that, after exposing the Burface of the tumor, I should ex-
plore it bel'ore [kroceeiliug to exlirpaiion- He was therefore
etherised, and an incision made in the sci-otum, over the front
port of the tumor. A second incision, nt the lower p.irt of the
scrolumj exported a small portion of the healtliy structiux; of the
254
GENITO-UaiNAHY OBGAITS.
tcaticlc* An incisum was then mtwle deep iuto the tumor oboje,
hy which a eoc, ncnrly three-quarters of an inch in thkkucdSt
was openciii giving vent to s, little bloody Hukl* A fibrinuuH
inaas waa found in the sac. Ttic aiae waa at once shown lo he
one of old htcrantotclc, and its rcniovol wiw proceeded with.
The projection behind waa a cyst filled with fiuld, wliich had
been the sent of Tcccnt inftnmmulflrv action. The akin of the
fiurotum was here eo adhercnti tJinC it was removed with the
tumori The testicle, us in the preceding cosCi waa much diniin-
iehcd in blzCi and so dL^placed and compressed that ltd fuDcticnd
miiat have been entirely snajKnded. The Ictt scrotal cavity
was the Beat' of a hydrocele, whit: h, however, was of recent
dcvelo[>mcnt, and probably dependent upon the acute attack of
the other side.
T.UIICOCEIB.
Many methods have been su^geeted for the cure of rartcoccle,
or enlargement of the spermatic reins. Brcechet'd methodi
with the screw-damp, is olmoat inaupportably painful; while
that of Kicord, which is now perhaps the faroritc oae, eoneiaU
fiimply in cuttings across the packet of veins with a ligature. I
have tried both these plans, as well as that by reDsoTing a por^
tion of the ecrotum : or, in caeee where it has been much elon-
gateil, by producing adiieeiona of its eidcs by mcana of auturca.
The folluwing operation for the relief of varicocfUf which I
Lave successfully jicrformcd in from sixty to seventy caace, and
wliich is I believe pecullari seems to me to be the eimplcst and
most etfoetual- Tiie vas deferens is firet separated Irom the
Tiaoular part of the curd, imd is kept out of the way by an
asBistant. A longitudinal inciaion of about two inches in
Icn^h is neict made in the scrotum down upon the bundle of
Teins, which ia then ceizcd with the ibrccpsi drawn out, and, by
a few touches of the knife, aeparated from the adhering tissues*
Two strong ligatures arc now passed above and below the ma^
cf enlarged veina, and ^rmly tied, eo ua to include between them
as much of the diseased tieeue as poc^ible^ The etrangulated
Teins, which at once shrink into a very amall compass, are now
VAKICXKTELE,
255
alloTred to reocde into the wound, which, W the corlra<^tion of
the wfoEuni, becomes reduced to a compnrnliveiy enmll «iz€.
The patient ia confined to his b«l, and wntcr-drcf^itJfK npplicd
dunog: the separation of the sJou^h, which takes pl&e« >□ from ten
tc fourteen ditvs. In several co^ee, where the acrotum had been
clonpitwl to double its natural length, and filial with large
maffee of veina, which would almost seem to defy any modo of
treatment, I have operated by this method with perfect sucecfla,
and have aeen llic scrotum eoniract within a few weeka, or at
most a fe^ months, to its normal ^izc.
1 hare never fieen varieoccJc cxeept on the lett side of the
eerotum.
Case CXLVUI. — Varicoceh of Grirat Stsc. OperatiQn*
Hetovet'if* — A young man, 22 years of age, for ten yeare
had more cr lees of a tumor in tho eerotum. Finally, it
became bo large and cumbersome, and attcndeil with eo much
pain in the loins, that he eont^ulted me for relief. The scrotum,
when the veins were fully di^^tcndcd, hun^ half way down the
thigh. The left testicle was atrophied; and its vaa deferens,
when ecparated ftom the re&t of the Epermatic coril, woa but
half the size of the other. The testicle was so enveloped in
the enlarged and thickened veins, that 1 feared it would be diffi-
cult to remove the latter, without the former being dragged out
with them. 1 therefore informed the patient tljat tliie might
take place, aa it had once before oceurrcd to mo in a eimilar
inetnnee, which mndc it necessary to remove the whole mass.
Ho agreed to hove done what woe thought expedient* Being
elherized, and the vaa deferens held out of the way by an oasidt-
ant, iiie veins were exposed a« high up as possible, for fear of
encroaching on the tunica vaginalis ; and a loop of them being
drawn out, assisted by a few strokes of the bistoury, a double
ligature was past^ed under, and tied above and below. The
ficrotum being loo long, a large piece of it wns e^tciacd. The
whole wonnd, with the esecption of where the ligatures aud
tumor formed by tho ticd-up veins protruded, wae closed by
fiuture», A cold-water compress wa» placed over tho wound.
A considerable amount of infiammation Ibllowed this com-
jd.
plicated Operation. At the end of four day?, the sutures wefe
wiEhiirawD, and titftst of the plough of ths vtjins cue oC
Tlio wound waa dressed witJi u poultiee. An nb^e«fl formed
low duwn at the htu-k i>f iKl' scrotum, ord re<|aired the bUtourv.
After this, he gratlimlly recovered ; and left the Hosptal in ihre^
weeks, with a small, hciUthy, graauliting wound* The scratum,
from tlio ftize of an orange, wfw redueed to tlial of an egg-
I £HW bim, dome riiontha nflerw&rds, entirely free from dift-
eaae, &nd relieved of pain.
Case CXLIX. — Varicocele tind I/i^drorelt, Optrottm
Her^overtj. — June^ IS^iO, — A man i5(J yenre of age bad, for
n long time, been nfflieted with a varicocele and hydrocele of
the left side of the scrotum- II causwl him pnin in hU baek.
from the dragging on the oord. Being eiheriye*!, an inciuon
was mmlc over the cord ; die veina were drawn out, and tied in
ihc ui^ual manner. At the same time, a alight opening wis
miide info the toniea vaginalis, and the serum evacuated^ The
parient did well for two or tliree dayw, when he was attacked hv
gangrene, which then, fi>r the first time since the organiiaiion
of the Hospital, jx-rvarled tiie hoiise^ on acctinni of the filling-up,
with bad material, of tlio ilata in the neighhorhood. A large
bit of the RcrotLim sloughed, and nJi ahacess formed behind,
whieh re*]ijirc;d evaluation. A yeaat poultice waa appliM, nnd
the patient put upon rjninine and stimidanta- At the end of a
month, he waif well enough to leave the Hi>Apital ; nnd, & month
aftortt-ard*, he ca.]led on me perfectly well, the varicocele and
hydrocele being both cured.
Cash CL- — Varicocele, Operation. Recovefif. — A Bol-
dier, 3(1 years of ago, entered the Hospital, Oet. li>, 18(>4, ri>r
a large varicocelo in the le^t side of die scrotum, whieh luiii
troubled hira for mEuiy years, but had been nggravated by tiffi
performance of military duty, during fuur months, and finally
caused his di^chiirge froni the jinny.
On the 12th of October, tlie veins being exposed by an in-
cision, in the manner iJcwriljed above, a longj curved nee<lle,
armed with it double ligature, wn:^ pah^ between tlicm aikd the
Ml
RETAILED TESTrCLK-
257
vatf deferens, TJie loop uf tlie ligiitiire beini; cut, and t)ie veins
[lulled i>uL mi f;ir m^ [Kr^H^ible. llie li^itiin^ were tl<^cl ubiive :iiid
below, 80 as 1« iikclude a large niasA of vewelrt. The wliaJe
wnj4 ihen puslied liiu-k into the seititiim, ami water-dreftsiiigB
applies!. On the 27th of October, purl of the ligniurea were
removed with the roreej>8 ; and, on die SSth^ iJie rest came away,
Oct, 31at, he lefl the Hospital well.
RETAINED TESTICLE,
Case CLT. — TenCiele r^taiut^l in the (rroiii. If^tnoval.
Stt^^ueiit D*tath of l/u; Piifitnt from hiteniftl Disease,
appare^itlif Mftll^mint. — A gentleman, 38 yeara uf age, con-
»iiilfe<f me in Fehnmrj, ]85fi, on account of his right testicle,
whieL had never descended into the scn^tuiUt but Eiud been
retained in the tn^inal canaL For Tnan v veant^ ihitn waa no
inconvenience to him; but. just before Le saw mci it liat] been
quite tender, giving him extreme pain on tlie slightest pres-
sure, eAieudtnii npwiirdit into the abdomen, auil down tlic thi^h-
Aa no treatment gave relief, I pertbmied the operation of re-
mo vhI.
lie wju in poor health, and quite nervoua, hut with nu appar-
ent malignant dlseade. He wai4 etlierJzed with eldorie etlier, and
the dlBBectioii wjndiictLil with the utmost caution, ibr fear of in-
fiinging on the alidomiQal cavity- The tenticle wa^ removed,
with tlie tunica vaginalis, which closely embracetl, and in aomc
places Htrongly adhered to it.
On cutting into the tcsucle, the flCrneture wa« found to be
completely dif^jrganized : the up|)er [wirt of 114 Ux]y prewenting
tlie iL^pect of an uni^ijie apple ; in the lower waa a cf tft filled
witli a jelly-like nialerfal, Uruler the micrn3CO|)e, some nucle-
ated tx^Is wexe aeen.
This gentleman recovered from the opemtioQ ; but died
Guddeuly a yeai^ aflcrwards, having aufTered fur some time
previuusly witli obscure symptoma (jf internal diiteaae.
lu two other cjisea of testicle retauied in the groin, which
X hare wltueescd, the organ wa£ Invaded by encephaloid ilis-
eaae.
S3
U8
FEMjOS OENlTO-URQfArtT OBQANS^
FEMALE CENITO-TJaiNARY ORGANS.
iiUPTcmE OF rcBiy^uu.
Case CLLL. — liuptiti^ of tk^ Perinmum* Operation*
Cure. — I waa requeated, in October, 185E), to see a latly, 35
yeai-fl of age, who, five vears before, had received a severe
laeemtion of the pcrina^um, implicating the rectum about an
inch and a \mW. The effect was complete iocoatinence of ihe
feces, causing confltant annoyance and anfl'ering.
The pntient, being fuDy cthcriicd, waa operated upon on
Monday, Oct, I8tli, in the following manner, the position
being the same aa for Hthototny ; The lacerated edges of the
rectuin were firat miwlo raw, and a quadrargular bit of integu-
ment removed en each side of the fie^^urc, about thrce-fburthd
of an inch wide^ and an inch and a half long. The edges of
the rectum ivcre then brought together by three sutures, which
were cut off close* Three deep auturCB were inHCrted, with
etrong double thread, commencing about half an inch from
tlic borders of the wound, and travcraing its entire depth-
Theec threads* being secure<i over bits of bougie, were made
tight, and brought the edges of tlio woiiad well up togetlier.
Five auptrficiiU stilchca were now paascd, to adapt more per-
fectly the edges of the eldn ; and one within the vagina, to bring
together the deep part of the wound- Thia being done, the
finger was introduced into tlic rectum, to aaccrtain what reaial-
ancc was likely to be made by the ephinctcr ani. Thie» which
before the operation could not be diatinguiehcd, waa now quite
prominent, and could be hooked up by the finger* like a broad
cord or ribbon. An ineiaion was therctbrc made through the
integument at the margin of the anoe, the mu^ele c:tpoeed,
and freely and carefully divided on the finger, by the BCiBBora,
without cutting through the n)ucoue membrane of the rectunj.
Tlic anus, which before thie division was eloscd, now remained
loose and <i[iou, A hit of lint waa placed over the wound of
the periniuum, and lixcd in place by collodioo, ao aa to serve as
RUPTUEE OF FEIUN-EUM.
259
fl prote^^rion from the eonlncl oi' the urino. The patient waa
then plnc^d on her jiide, »iid a kr^re cathetor with n Me]d to it
introduced into the uretlira, the end of which fifterwards wus
attached to a bit of ^utta-percba tube, which conducted the
urine into a niak urinal provided for tJie purpose. On recov*
orin^r from the ether, ehe had thirt}' dropa of laudanum admin-
istered to her, chiefly for the p»jrj)ose of checking the action of
the hou'eld. Tlie opcrittion lasted no hour and a half, not-
with^^Nindiag nil expedition vviia employed.
She pasAed a quieC night, and felt no pain in the wound- The
catheter, causing some irritation, was withdrawn, and nfterwardB
was introduced twice a day, with the gutta-perchn tube attached,
to prevent any coniaci of the urine with the edges of the wound ;
and eubeefjuently an ordinary female caUieter of much smaller
mze, with a gutta-percha tube aitachetl, was employed. Her
nouriflhmeni was priucipally a hit of oraeker, with a little
brandy and water, two or three times a day, which she preferred
to tlie juice of meat.
On the fifth day after the operation, the wound becoming
sore, and the sutures more or less loose, the quill stittirea were
removed, leaving the superficial ones. She had had no evacua-
tion, but had been somewhat troubled with flatus. The water
was drawn off twice a day with the catheter, and the wound kept
clean by constant bathing with warm water, and subHcquent
protection by a little cerate, rubbed on wJlh the finger.
By the tenth day, all the autures of the rectum, skin, and
vagina were removed; and ihtre seemed to be a good solid
union, with the exception of a very small aperture between
the rectum and vagina, which fitUl remained o[ien, hut gnuiu-
lating.
On the twelfth day from the operation, she had a very large
evacuation from the bowels, aided by an enema of warm water,
Thi* was efTcefed without doing any damage to the union of tlie
wound ; and, on the following day, she began to paas her water
without the use of the catheter, sat up, took fooJ more freely,
and w»s considered convalescent.
On Not. 5ih, I made a final examination of her caee.
The aperture in the rectum was cJosed, so far aj* ixjuld be de-
260
FEMALE GEMTO-UBlNAKr OKGANS.
tpmiin&l fnim IniipeJ-tJon nf the [mrt hy llie «i3eciiliim nni, ami
diflr!<isffll no HiimI |iflj*ftirg frurii iln^ rpiiMiin into iIht vngiiia.
The perinffium wbs t*trong, thick, anil finii, longer th»n is uau-
a!ly perreiveil in ei woniiui whr* h;is Ixirne children. The union
wii.H sft gnod thill triu:ee tif the DiJera^tic*!) wero !*cjircelj' per-
ceptihle- The patient hiul AJl control of her evacuations for
the firpt time in five years: and her atdmach, though a little
dyajjuptic, wiis in better condition than it had heen ihr a good
pmt of that lime.
The division of the sphincter niii, und the use of rollndicm to
protect the eitenial wnund from tl»e atrfjon of the nrine, uere.
I ihiak, of ^eat advaiLUige in prodiidng a favitnible ret^uh.
The removal of the urine twice ilail/, hy the cntheter, witli
a p^Lim-elaatic iidie att.at'htil, wa?i also of ^eat utiUtyn A little
urine only imce a^srideiitally iranie in contact with the wound,
unJ wad immediately followed hy much irrit^ition. This can be
prevented, when the catheter is removed, hy pinching' up the
gum-elaeiit:, retaining the urine in tlui instnimcnt until ii is
carried to the uteneiL
I have gone into some detail in this caae, as T have felt better
dati^Bed with the mimagement uf it than of auy that had come
under my oljservalism. The u»t of a small ^das* or ivory rod,
in place of a hou^e, woidd, T think, be of advantJige, a* lew
likely to retniit irritntini^ matter. In using the quilled suture,
J took great paiss not tu dr^w tbu stltehcs tighter tliaii wa8 ab-
fiohilcly nccctit^ary to bring together tlje deep part of the wound,
from fear of prodncjng partial aErEmgulalton, and oonsequent
unhealthy inflammation in the intermediate Integument, — an
accident uf nut uncommou occurrence, as appears hy rectirded
cafleA. The jntroductiou of a atltcb witliin the vagiua was of
much uHe in faeilitating the union.
CAflE CLin. — -Ifupiure of the PertntEum. Operalion.
Cart. — This caae iflcundenfced from die Ilof^pital I'ccords. In the
spring of iy<i+» a young u'omiin, £0 years of age, wfim admitted
to the Iloppilal, on account of rupture of the perinieiiin- 8he
stated thiit, four years before, the had been delivereil of a male
child, by u miJwiie, after a labor of forty-eight hours. When
EUPTUfiE OF PERIN-^XM-
361
she left her bed, it was discovered that the perinfl>iitn wn« rup*
tured. She \vns able to retain her feces, exce])t when tliey were
very liquid. She always had pain nt ev^icuntjons.
She was etherized, sind phii'csl m ihe position for litholomy-
There waa found to he Ji partial prokpee of the uterus. The
rupture cif the perin^oaoi involved only & part of the sphincter
aui, lenvinn; the recto-vaginal septum entire- A. V-shnped in-
eisioti WAS made through the mtegument along the furrows just
outside of the extermd labia. That portion of skin which lay
near the nnns was dissected up. and tiie dissection carried back-
wards fijr .1 distance of three-quarters cf un inch upon the up-
per surface of the sphincter. The dissertion was continued
inward.s, in the line of the V'-sha^ied incision, so as to olitaiu a
riw surface. Thus> flnps were obtained, ibe edges sind raw
surfa<<es of which could be eiisily ftpproxi muted. Silk fiutiires
were passed tlirough tJicse flaps, about half an inch from the
free wiges, and Hepiiw?(l over pieces of bougie, acenrntely ad-
justed on each side of the wound. The pressure thus ejcerted
was in a line with the pnnots where the sutures were inlrothiced.
The edges of the flups were held together by means of inter-
rupted silt sutures. The laceration was thus closed without any
tendency towards outward traction, since no portion of the in-
tegument of the nates was involved in the operation.
Direction was given to pass the catheter as often as should he
necessary, and not to allow any urine to lUII upon the wound.
A simple cold-water dressing was applied.
On the sixth day after the operation, an examination was
mode, and it was found that there was the usual suppuration
abotit the sutures. All the sutures, except one near the nuLLs,
were removed. There wna firm union without any tension-
Subaeqiienily, cicatricial ion was complete; and, on the eigli-
teenth day, she was discharged from the Hospital, cured.
Case CTjTV. — I^r/phire of the T^erintRum nnd J^**cto-vafji~
nai Septum^ Opfrttfioji. Recnvery. — A lady 30 yeurs old,
of ordinary good health, who applied to me, was confined, two
years before, with her first child, having been forty-eight hours
in labor. The head of the child was dropsical, and nearly
2fi2
FEIMAI^E GEMITO-ITEINART ORGANS.
doublo the naCtinil size- As it pasaed ibe external organs,
the rupture owurrerl, whk-b. however, wa& not detected imcil
the next da.y- Her phyginian, suspecting a laceration, mftde
an eiamination^ and introduced two stiloliesT wliicK were inef-
feetunJ in producing iiuion. From thai time, she had not been
able to retain the contents of the bowels, wliiob, unlike tlie
previone case, were constipated insfend of being relnsed. About
9ix monlba before T t-nw her, having stood a lon^ time in a
crowd, occasionally on tiptoe, she was tskt-n with a sense of
difltresa and weight in tiie pelvis ; and it wa* found that n pro-
lapBiw of tiie iitenjs lind taken place. Thi* was aa additional
source t>f trouble to her, obliging her to wear a sponge tor sii|>
port, and to n»e astringent injcetiona.
Tlie operation was done much as described in the previous
ease. The haJr being shaved, a surface thrcoquarters of an
inch wide was exposed on eauh side of the laceration. The
sides of the deep lisftiire in the recto-vaginal septiiui wtre dis-
sected up (separating the rectum from the vagina), their efiges
freshened and brought toijether hy Htitehce. The perini'Uin was
brought togetlier by the cjnilled suture* three atitdiea being
ueecT, nn<l the edges of the skin nppniximated tiieely by melius
of four Hutiii-cr* with fine tbrejid. The sphincter nni was di-
vided on tlie left side as follows : The finger was introdneed
into the rectum, and the mus<rle hooted up upon it. A Hmal]
aperture wil^ mside oo the nmr^n of the mucous oiecnbrane,
distinctly exposing the muacular fibres; these were divided
with a small prtir of blunt-pointed HcisBors, down to the mU'-
coiia meiulmiue of the rectiiir, held oa the finger. Tliu uuub
now remuitied perlectly open and relaxed, and without the
slightest traction on the fititchea holding it In front- Tlie
operation IzLsted h:df an hour, the patient bemg fully under
ether. She was placed in bed, on her side, and the nurse di-
rected to draw off tlie water with a catheter having on elafitic
tube attruOieil to it, tliree times in the twenty-fonr hours, u.ud on
DO account to allow any urine to touch the wound.
Four days after the operation, I removed the back-stitch
wiiich held the quill, as auppurutlon liad tiiken place around it,
causing some pain and irritation about the anus. In other
VESICOVAGINAL FKTDia.
263
tf^Bperb, ev^ry thiii^ il!J wi:!!, and tlie putient experienced no
ttnwtituLiojiiLl (lit^turbance. The atitches iu die akin were aUn
cat And w^ithdrawD, and the union appeared goodi She took
iiread. lea, iind brotli for nouiiahment. ller recoTCiy was per-
fect.
YESICO-VAOINAL riSTCLA.
The treniment of this afTeotinn, whicli hud, until vcrv rerert-
\j, been almost wbolly confinefl to ihe simplest ca^eg, lnu* been
Intel? revived m this country with remnrkable SMCcese, espennlly
sinee the puWieaiion, by Dr. Sims of Npw York, of n number
of very flui^c&^sful cases, in which lie itltributed the good result
to the cTDpioymant of sutures of (Silver wire; but a more ex-
tended trial ba* failed to demonstrate tliat sitperiority wl»eh wns
datmc<l for them over silk or linen threads, and tl»e greiirer
inofinvpnience which attends their employment has iilrendy led
to their abandoninent by some r^nrgeons.
In <|uite a large nrnnber of operational which I have per-
fhrmed for vfciico and iirethro vaipnnl lifilulii, 1 have always
used Bittures of coinmnn surgeons Bilk, and have had every
reason to be salisfiei] with the rc#<iilts.
The reid imprtneinent in ibis o]>enitionj and that which has
been the meana of bringing it into so general ufie» is the very
free dif<secrion \tf the vai^nal muroiifi membrane from the old
cicatricLal ti^ue^ and frtim the wallji of the bladder i bv tWia
plan, the »ti[i:hej^ are i.*ffecliially relieved from tension, and the
re8ii]ls are generally favorable.
In many ca^^e-f of this digeaHCf we Rnd c1ic as uteri, and some-
times tlie upfter pirt of tfie vagina, completely obliterated ;
causing retention of the menstruul Siiid. I have watched a
numljcr of caae^ of this kind^ and have always ob^ervejl that
relitjf is ultimately obtained, often after great siift'ering, bv the
formation of u fisiuhtus opening eommunicaling with the
vagina, or, very rarely, with the bladder.
Few surgical diaejise^ are mare distressing to the piUient llum
ve?(ie<i-VAgiTnd Rstuln. and no operation better rewards the skill
uf the eurgeon- It reacne?* die uuflTerer from a state in which
eustpmre has become a burden, and restores her once more to
llie world iLnd to the enjoyments of aocioL life*
264
FEMALE QENlTO-URINAKr OEGANS.
Ca.sk CLV. — Vrsiro'i'i/ginal Ftfihilit. OpVTfUion. lif-
coverij, — A wuiiuu 2^1 yfurn lA' ag<^. mother of thr'ev- diil-
dren, was in labor four days with her liiHt cliiid. All her
rhililren were horn dead. She did not pereeive the injnry done
to die hliLfliler uU ahe b^^g^in ti> g^t itp from her CDiiUnement,
twelve days aftcrwanU, whoii) on examination, it was di^-
coiercii that neiirly all die urine escaped throii^rh a laige open-
ing in die vagina,, I iirst saw her iii November, Ifl^lO, The
aperture iii the bladder extended fnuii an inth bcldnd ihe
pnbea to the oa uteri, which was ragged and irregular, having
been Involved in die injury. She had nienstruatEjd twice since
die aitideut, and w^:^ ratht:r ft^ble. Tlie akin of the inside of
the tliighs was irritated by the conatant jjOisaage of urine over it-
The ciper:ilioii wad jierfjrmed in Nuveinljer i die ii^nry wjia rt?-
Ceived in the pretedinj^ February. Slie waa plaLied on an
elevated [jJutfurm, constructed for diiti purpuc^e, on her abdo-
men; the limbs being jilaced at right anglea with die trunk-
The mucous inemlirane having been freely diaaecteil in the
usual way, six auturea wert intruduCE^, and the whole wound
broiigiit merely together: the button-euture, accordingto Bo^e-
matfri Tuelhod, was not o^eil on aecouiit of the great extent
of the opening, odierwiee it woulil Imve been employed. She
WBJi laid on her aide^ and a catheter with a gum-elaj^tie tube
ftttttclied to it introduced every four hdura. to draw ofT the
water, the tube being added to prevent any contact of urine
witli the external organs. Thia pkn J have found preferable
to leaving the ealLeter coimtontly iu place, b;^ it allows much
mure freedi>m to the patient. Every thing went oa wcQ imtil
die end of a week, when, ou account of the attend:int'e omit-
ting to dmw off the water, she paeeed the whole night with
the bladder distended. This waa followed by a lojikage from
tliL' woujid tlie next niorniug, Iu the couLEe of the following
week, all the euturea were removed ; and, about the iirat of
December, ehc left the Hoapiln]» as fihe said, well, being able to
retain her wuter about two lioiird. I aaw her before ahe left
town, on th« 14th December, She had not menatruated aince
die operntion ; and I found it dil£eiiU to decide whether the
opening i'rom tiic uterue wm into the bladder or vagina. lier
VESICO-VACDfAL FISTCLA.
2G5
>jenUb, hnwever, wiid goiJ, ami luis remalnra! ho since- Tn a
fljiiiiliir inRtiini"e» tlie incn^tnuJ fluid jia^sed into tbe bladder,
and escfiped from tlie urethra without iDcoavenicnce.
Case CLVI, — Vesic*>^affinal J^iatula, Cauterization^
Relief. Pho»phatic CnlcytJtu. Litk&trity. Rdief. — A wo-
□OAD, aged 32, entered the Hospital March 9, 184S, Fourteen
weetfl before, she wna delivereil, hv forceps, oF a dead child,
after a kbor of four days. During this period, she was for
the greater part of ihe time insensible, from the eflwts of nar-
C'ulioe.
Tw'j days after delivery, there was incontinence of urine,
which flowed constantly from the vagina, never pa*Bii:g by ihe
urethra, or collecting in the bladder.
She did not meoHtruate after lier labor, nor did she have any
difficulty at the period when the raenstrriHl secretion should
appear. TJiere was, however, much milk in the hreaats, but
varying in amount : she bad not noticed any relation between
tbe (]UBn[lty i^ecretL-d and the catamenial period.
The external organs were found excoriate*! by the -urine,
which i^as constintly dribbling away. The vagina wae eome-
wlmt contracted throughout its entire length, hut more e.^pe-
oioUy at aboat three inches from the vulva, where there was a
vcrv marked constriction. Behind this was a loniritudinal alit,
with ealloua edges, on the anterior wall of the vagina, through
whiclk water was seen issning fi'otn the hlncider. A sinall ii-regu-
lar opening eiisted irt tho posterior part of the vagina near the
Bihmtion or in the place of the oa uteri, which had entirely
disappeared in the cicatrix.
She wa« thoroughly etherize*! with chloric ether, aa it was
found almost impossible to mnke the slightest examination, on
account of the extreiae sensibility of the parts. The epeculnm
of Ricord was naed both for the examination and the ojjcration.
Tlie edges of the fiiitida were cauterized, so ns to produce a
elougb, with ihe potiisM umn cjiIcc, and ii cndieter introduced.
Thia instrument, which ha<l been made fir the puqjose, was
half an inch in diimieter, Ave inube^ l^ng, with a shield an inch
from its exiernal erifiee.
u
ws
TEtiMjE aEKlTO-UBINA£Y ORGANS.
The patient suffered but little from the eauatic, and no urine
passed through lliG liistula for several <]aja> It vniB touehod
oDooflionally with creosote ; and, nino days atlcr the opcrntion,
nn urine havinp pitJ^sed throiip;h it for eomo timo» the cnlheter
wns omitted, and she wtm allowed to walk about.
A month later, ehe reported that no urino pEta&cd bj tbe
vttn;ina» When the crtthctcp wns first omitted, tho water
dribbled away from the urethra, whieh from long disuse had
upparcntly last its power of retention. Thia power, howe\'er,
was by dcrrrccs restored,
Ou JMay 7th nn examination woe ii>adc both by the vagina
with a epeeulum, und by the hlEidder with a catheter. The
fifitulouB opening vas hardly perceptible. In the bladder was
found n iralculuflt QpparcTitly ahoitt tlie aiae of a eheetuul. With
d lithoti-itc, the Btouc was easily oaught and crushed. On the
fallowing day, the fragments of the alone eatne away with the
urine. They were found to be composed of the phosphate of
lime.
Thie patient remained in the Hospital until the latter part of
May, when she liad full command over the urine. During
the whole of this time, tliere was no appearance of the men-
Btrunl ijecretion ? but at Btoted period^T ^-t an interval of four
weeks, an increaeed tieeretion <if milk took place in tlie breasta.
A year later, she cidled on me, and euid that she had been
well ainee lojivint^ the Hospital, About three nionthe before,
nearly a year after her dehvety, the ealamcnial function was
restored, and remained regidar. This muat have had ila exit
at the orifice whiel] took the place of the oa uteri, and which
undoubtedly when I first saw her waa partially oeeli]d4>d.
On over distention of the bladder, a small quantiCy of urine
wae found to escape from the vagina. An examination with
the apeetthnu proved tliat the old Hstula had elosedf and tliat
the urine must eecape from the same fiasure in the nterua aa the
catamenia, showing tJiat a veBieo-uierine fistula existed,
Li quite a uumber of tbe eases of indammation and toughing
of the vLigina al^r tedious labor, which have occurred in my
practiee, the ob uteri has become olJitemted. The menstrual
fixnction, however, ha^ not been suspended : having, in «ome
VESICO-VAGIVAL FISTULA-
267
uietnncee, fonad an exit through tJie bladder ; in otherB^ forcing
its way into the vagimt.
Case CLVU, — Vesica -va^ttml 7*V.fl/n/a- Operation,
Citj-e. Jietention of Men&trnat Fluid for Nine Year*,
Spontaneous liupinre into Vifjina, — About the year 184fi,
1 woe cfdlel to sGG a wooi^Ln, 2o years old^ who had been de-
livered of a dead child, some weeks before, after n txjdioiis liLbor.
I fouod that the whole va^niU portion of the bl;tdder hod
sloughed away, leaving but the aiiporior, and a suieJJ portion of
the htteral walls- There were bci^idea large abseessca running
into each groin from the v.igina. After a prepiratory treatment
to restore her strength, eho was operated on- Tlie bladder
was dissected away from tlie vagina as for aa possible, oad the
wJges of il, being pared^ were brought together in the usual
manner with Bilk sutures. The organ was then not more thnn
one-half of its original size. The operation was followed by
complete suecess-
By the previous iaflanimation, the os uteri bad been entirely
obliterated; and, at each subsequent menstrual period, she
surtered dreadfully for a. number of years. No uterine tumor
could be detected, either by the abdomen or rectum- Nine
yeara aftcrwarda, during one of these monthlyattaelcs, a rupture
look place in the vagioH, foUowcd by the discbarge of nearly
two qiiaita of menairual fluid. This was the only appcarjince
of this aocretiou, [ saw her in 1866, eleven years after the
nipmre, and finiad there had been no return of the discharge.
There had been, however, until within three years, the usual
preimmitory flymptomfl of diecatamenial flow, but nothiag more.
She was in good flesh and strength, but bad suffered fnim
disturbance in the stomncb and bead nearly all the time. She
CTmaulted me, when I Inst saw her, on account of profiine vom-
itin|r of a colorless fluid- The bladdex bail performed its iimc-
lioiifl normally *iince the operation. The de^iruction of tissue
was more extensive, and the result of the i>[>enttion more suc-
cessful, than in any other case of this kind that I liave had.
In ant^llior case, where the whole lower half of the hlad-
dor Wfis lost by slou^rliiug, the siune symptoins were miinifested
FEMALB GENITO-UTUKABY OROANS,
at the cafcwneruai pcrlocla. At one of theae perioiU, a year
ftcm tbeir tomuiencemcntT tlie paiaa became violent Jintl forcing,
OS in labor. A rupture of some part of tbe utcrua into the
vagin;i took place; and the patient was, as #lie atatea» at once
dt'iugeil with blooJ, so that long-conrinucd fainting took plncCi
from which slie was with difficully recoTered, The rQenetniftl
ftiDCtion baa since gone on regularly.
PROLAPSE OP THE WALLS OF VAGtNA-
Tbc follow4njr cAsei illustrate the jiroinpsc, or hernia, of the
bladder into the vngma, not a very common Jiffcction. It is
UBUnU^ caused by a ^training; effort, acting upon tlie relaxed
wallfl of the vagina, and must be Jiatinguishcd from prolapse
of the mucous membrane of that passage, and from cyatic
tumors arising in ite w^Ia* When the tumor formed by the
bladder is of large size, it is the source of great iocouvemencc
in walking, and interferes with mlcturitioD-
CasE CLVIII. — Prolapsus of the Bladder and Antdit^r
WaUs of the YagiTiti, simulatii\ff tt 'fianor. — In September,
18(!3, a young woman, 25 yearfi of age, consulted me lu regard
to a protruBioQ from die external organs, which interiered with
locciuotion. She hnd been married at seventeen, and waa the
mother of five clUldrcQ. The tumor was not noticed until alter
the birth of her last cliilJ, Her general health waa good,
A large fold of iLc anterior wall of the vagina was found
banging down just within the labia. The os uteri was slightly
enlarged; otherwise the uterua was normal. Elevating tliat
organ had no effect upon the tumor. A catheter, passed into
the bladder, could be made to enter the tumor, by reversing its
beak.
I introduced a horseshoe pessary, with immediate relief, ao
that she was enabled to walk home* a greater distance than she
had previously walked since her confinement. This exertion,
however, caused a aligLt hemorrhage, ao that I thought it best
to remove the pessary after tAvo days. Subsequently she
IcEimcd to introduce it herself, aud wore it with relief.
TUMOR OF moss VENERIS-
269
Case CLTS. — Prolapsus of the Bl^dder^ shiinltitinif
Otf»iic Tumor. I'^ormalion of a I*'istula. — Iti September,
1861^ I wna reijiieatefl to see a lady, about 50 years cf nge,
who wna effected with a tumor in iJie xagina, rGaonibling cystic
tumor. It wns first nollL-ed several years before, after ^trainiDg
while lifUng ; recentJy it bad caused uiccuirenieiice by ils weight
and the pain felt during luicturition, which was frequent and
tliffietdl, I perceived, on eviiniiniition, a Ini^e tumi:>r, i^ttuatcd
m front of the oa uteri, wliidi retranted on pressure, waa
flabby, and projected bet^'een the labia. Half an inch below
the iirethrn. was an ulceration, tbrtiu^h wbieli n frittbeter waa
[Missed iiiio tlie eavicy uf tbo tumor, wliich proved lo be the
bJadder, A sound could only be introduced through die ure-
thra into the bladder when die latter was rodueed to the normal
postlion, not when proJapaed. Evidently, the obslruetioo lo
the paeenge of tbe urine through tbe urethra waa the cause of
the formiition of a fiaiidn. She was advised to wear a ring
pesaarv, to keep tbe bladder in position.
Cask CLX. — Uncommon Tumor of thk Mo\s Vene-
ris, RemuVaj„ Clke. — A Ijidy, 42 years of age, nolice(l,
*oon aftor coufineineni, a tumor in the left groin. It gr:ulu-
■Jly made ita way into the labium of that side ; and, as it en-
lnrgcd» iiivolTed the niona veneris, dragjriDg it down, togetlier
with the iiiteyumenia of tbe abdomen, and finally formed a
large pendulous tumor, hinging between the limb^, cox-ering
the external organs of generation, and causing much pain and
inconvenience.
It waa removed, and found to be fibro-celliilar, of very firm
consistence % the cellular tissue surroumling St, and entering into
its eoinpoeition. being infiltnited with serum. Its weight was
two pounds and two ounces,
I leame^I, subseqiicnily, that she na^ well, and bad been safe-
ly delivered of a hejdtliy child.
270
FEMALE GEfnTO-CRUTARY ORGANS,
VASCl3LAfi AND SENSmVE TUMOU OF THE FEMAJ-E
UKETH RA-
A vascular tumor la not infrequently met with, junt nt tlic
entrance to the nreTbra, in the female, having nrounrl \ts haw,
uriimllyf jt hnght ei^the mat 0119 hluah. It ia comput^ed of en-
Inrgwl veinB) nrd is trliiHsed by Paget nmang erec file growths.
Mr. liutcluneon eompftrea it to lieroorrhoid*. It m generally
Teiy eenflitive, and ia the sonrt^e of ^reat irrifntion, t^using
piiin, ilrlimg, ami smarting dnring micturition, often rkggra*
Viilf^l at night: Dt'eiwionully it is the seat of henntrrhf^e.
Extirpation ia die only remedy ; and care muat he tiiken
to excise tho whole morbid growth, and even then it la liable lo
recur. A vnhmhtc monograph has been written on this subject
by Dr. Alexander E. Husiick of New York-
The followincr eases are illustrative of tliis aflecdon ; —
Cask CLXT. — Sen/ntive Tumor of the I^cmnlc Urtihra,
Excision-'— TVe patient wna a marrip*l woman, (i4 yearn of
age, never pregnant- She had harl good health iloriiig early
life, with the exeeplion of dyainenorrhcm. Her cataiiienia
ceased suddttnly, when she waa ftfty-«x years old; and four
years 9nb«c*qiiently she putFereJ from dypuria, attendeil with
severe tsenlding : at night there waa atinging |>mn in the region
of the iiretbni, and priirituH during rhe day^ The external
genital organs, especially in the vicinity of the uretlim, were
exeesaively tender. These aymptora^ inereaj*ed in severity up to
Jujic, 1^63, when I first saw her,
I found a vascular excrescence, about the atze of a pea, pro-
truding from the nrcthni- On ihc 1st of July, the tumor wa«
exciseil, with a dreiilar portion of the mucous metnbrane around
tlie orifice of the urethra, and the wound cauteri:£cd widi ni-
trate of silver, A flexible catheter was then introdiii^ Into the
bladtlcr, and allLJwed to reutain. She soon recovereil, and was
disoharged well. The tumor, however, recurred some months
after tlie operation, but gave nmcli leas tmuble. It was re-
moved nh before, and I have out ^ince heard that it returned.
TUMOR OF THE FEMALE mETHBA-
271
Case CLXQ- — ScupUit-e Tumor of Female Ufethta.
Ejc^isimi. Complete tleUef. -^ A youngs womiin, 26 jears
oIJ, of dark hair and eomplexiun, hai3 for four veara been
troubled in micturition. The affection, however, had not
ftsfiumed a very aevere form u»tiJ a month before ber first
viait lo mc. Kvcry pfLtiaag^ of water, at thie time, was
attended by a burring, slinging aensntian, which was almor^t
Ineupiiortiihlc. anil finnlly became so severe as to affect her
health. With the neiial delicacy which women feel in com-
plaintfi of lbi3 nature, she had avoided consulting her physi-
cian ; and it waa only t>y the advieo of her sister, wlio had been
a nurse, that ehe waa tnally persuaded to apply to me. At
this lime, the mere contact of the clothes was inBupportablc,
and alic had Imd one or two ottaeke of rather profneo bleeding
from the neigliborhood of the urethra. On examination, a
vnsonhir tumor waa found, of the size of a very email pea,
projecting from the urethra , the mueoua membraQe at its
ba^c iKiinfjj hi^jlily injocfcd- The tumor, and the surrounding
pnrtB, were exquisitely painful to tho toudi. The patient being
fully etherized, tho tumor waa seized with fbrcepe, dragged out,
and as Jarge a ptirtion na poHpJblo of tho mucoua membrane
excised- The operation was followed by eoropletc relief; being
the first case thiit 1 hnyc mot with where a cure has roaulted
from a atnglo operation ; most of the coaee having been attjicked
by caustics or the knife before coming under my obacrvatioc.
Case CLXIII. — Sensitive Tn^mor <if Feviaie l/relAra,
Extininn. Heiief. Hccnyf^nce of Tumor at the Had of Ten
Yt^tira^ Exfitfion. Relief — A lady, rJS years of age, had
been trimbled for nine j-enra with great dyeuria, and oxceasive
Ben*iitivene3Ji of the parta in the ncighboihood of the urethra, so
that she could not Ircar even tho cc>ntacl of her clothed. Before
C*maulting me, cauterization had been employed ; without giving
her any relief, however,
I found a small vascular tumor projecting from the orifioc of
the urethra, bleeding on the slightest touch, and eo painful aa
to elicit loud outcriee from the patient on the moet delicate
examination. She was etherized, and the mucous metubrane of
272
FEMALP^ OENrrO-UBTVART OBGAKS-
ihe urethra everted lo ae great an extent as [>osdb1e with die
forocpa, Tind excised. The hemorrhage inuring the operation
w^ quite profuse.
Relief followc<! for nearly ten years, when the tumor re-
apfieured, but with less violent eympiom^ than J>efure. It was
trt^ifed in the same icanner us at tirst, and with as goixl result.
1 have not heard of ita recurrence.
OAIfCER OF VTXYA.
I have been much struck with
lave Deen mucii struck with the great relief afforded lo
patients wilh extensive and painful cancerous affectioaa of the
vulva by a surgical operation. Femalea are very apt to con-
ecal the disease until lis ravages have made great progrces,
when, frora the amount of discharge, the difficulty of locomo*
lion, and often a painful secondary tumor, they are obliged to
make it known. In a number of cases^ I have removed a can-
cer occupying the entire Inbititn, extending u|> into the Hoor of
the vaginiL. and penetrating the iiretbr;i ^bove. The wound
healed nipidJy uftcr ihe operation ; and the patienESf so &r as I
know, have dnne well. The cancer i:* without doubt epitheliid,
and in my opinion amenable to operation^ In the inatiucee in
which I havG practised remuvQl, there haa been no recurrence of
the discasCf although eome of tbera were of tlie most formidable
chniracte^'H
In the coac of an old lady, who waa auffering esceasively
from a very extensive cancer of the labia and a large aecondary
tumor of the groin, ^ — -in whom loi7omotion was entirely pre-
vented, and the discharge so acrid as to excoriate the surroumliug
parts over which in addition the urine jraseod, — I perfortned
nn operation, i-cnioving tlie whole di,=eased portion of the pu-
denda 1 and the patient recovered the uee of her limbs. The
tumor of the groin was not interiered with.
Cask CLXIV. — Cancer of VnJva. OpetfUion^ lie-
cofj^rVn An unmarried woman, 36 years old, entered the
Iloepitai in March, ISG5, for an ulcerated cancer, o<'cupying
the whole extent of the left exiemal labinm, also the upper por-
TUMOE OF VAGINA-
273
aon of ri^ht Inbium, impltcntiiif^ the vulva, and extending quile
deeply beneath the sui'i'jw.'e. Ii begsin, it y*;!ii' bel'>re, hy a hard
nodulat^l swellinir on the left lubium, causing, at firet, no m-
coEiveni^nce. Jaan.iry, 1805, it dischnr^ed JVeelVi and also
wfla quite pninfuL Soon utter tliisT hard globular swellin^'a ap-
peareJ in the left ^oin. On the 30lh of Mnrch, nn opomlion
woe performed, Cr> remove (ho cnlu'e disease of labiu and vulva,
II wai» thmjght ui^desd to attempt to ramove the gl^inda m tke
groin, the induration at their bn*ea being very indefinite. IVben
the ereotiie ttasue was cut into, the hemorrhjip;e waa pretty fre«j
ftnd many largo veasels required to be tied,— wliich is generally
the eaJf^e in tliia operation. A few days rdlcrwanla, an erysipe*
latiiUH intljimnkution occnrrofi in the tnmora ia the groin, re-
quirin^j free inci&iona. Sloughing took place, ternunatin^ in
the t'omplete destruction of tliese secondary tumors. The pa-
tient was difloliargcd ivell on the 24tL of April-
TUUOR OF VAGINA -
Case CLXV. — CyHic ISimor of Vagina. liemovaL —
A lady, 2*i yenrs of ag*^, well-form«l tmd lieiilthy, two tnonllis
before her conlinement percoivt-d a round and clastic tumur in
the bock part of tlic vivgina> At the time of her eonEucment,
it Wft6 forced down outride the vagina, and fiubacquentJy pro-
Irnded on anv motion, or on her fie^uining the npri<;ht poeture.
When she col]^^ulled rac nftevwurds, ahe was in the fourth
month of her second pregnancy, and the tumor caused ^cat
uneauinesB. On examination, an elastic tumor tlic size of
an oran;^e wne tlamd arising from the posterior wall of the
van;ina, and extending from the ob uteii to the extemnl organsn
The finger, being paa^ed into the rectum, could detect the tu-
mor pressing book and aomowhat obstructing the passage of
the canal. By a little manipulation, it eouJd be gnuluaUy
bi'oiiglit down oitteide t)io external organs, and was seen to bo
A rounded, elastic mass, covered with tiic mueeus membrane of
the vagina* Tlie oa uteri wna quite large, soft, and patulous,
and pret^ented the nppearunee of a much fartlicr advance in
pregnancy tbnn adtnittcd by the patient.
S74
FHUALE OEMTO-rBlKABT OBOAXS-
She wae etherized ; the tumor was ^racped by the hnnd so
&A to make it tcn^e ; and nn inciaioD Iwci iochea Jong made iii
the mediim line, and a deJicntc snc exposed. Tiiie wa6 now
partially unccvcrcd, when it ^ave woy, ood about a giU of
cream-colored fluid wns evacuated. Tbe «ic vras corapieiely
aepamtcd from iu aiu^'bmeiit by the knife and director. The
wound was lefi to take c&re of itsoif, do slilchea beinif used,
tihe hod no had Bvmptotnf , and soarccly any «ctifatioDa to ia-
dicftt« that an operation had been done. She woe kept quiet
for a week, from iear of the po^ibility of a miscarriage, a4id to
prevent tbe mucous membrane of tJie vnginn from bo^^ing down
and forming an incoDvecient escrcdcence- Tbe recovery was
oomplete, and did not interfere with her pregnoncvi which went
on to a We termiDfttion.
POLYPtS CTEM-
Case CLXVL — Polypus of Ut^nts. J^cmova! ^ Liga-
ture, — During 1847, ft lady fell, while entering her house in
tbe evening, and received a ee^-erc blow on the lower part of ibc
abdomen Irom the atone &tcp. She was carried into the bouse
autfenng grcallyf and a profuse uterine hemorrhage followed.
For some months she waa confined to her bcd« scarcely able ti>
turn from pain, and euffcriDg from occasional returns of the
bleeduig. Coming under tbe core of lui experieneeil pmcli-
tioner, a vaginal examination wof made, which disclosed the
existence of a polypoid tumor cilmdeJ from the os uteri.
Being called in consultationt I od^-iJ^ed an operation. At thu
period !^be was suHering from amemiat and ^o cxbauctcd a^ to
moke it unsafe for her to a^ume the upright position, a^ tho
attempt was always attended by fainting. A ligature wa*
applied to the ^>olypua, and tbe tumor separated on tbe fourth
or fifth day. the subse^iuent recovery being rapid.
The patient remained well until l?^51, when the recurrence
of liemorrhage at tlic menstrual periods, severe pains and bear*
ilftl^own dCnsatioDs in Uie back nnd li>in^, indicated the exialenco
of uterine di&ea^e. Added to the aborc symptoms was the
discharge of a gill of watery tluld from the va^na once in £vc
or ^ days.
POLTPra tTEHl,
275
A tutror vtas discovered occupying ihe whole fundus of the
«t€ruB, ami projecting into the Ta^rina, With some difii-
culty, the fin^r could be passed into the ciLvity of the utertis
through the oa^ which tightly eitihrno«<l the central part of the
polypus; with the speculum it could be distinctly seen, its
parjcles presenting a white, gligtenirp appenranee, A strong
ItgnCure, made of whip-cord, was applied to iu base in the
following manner : Two porte-nreuds, threaded with the hifK-
ture, were carried up throu*^h the os uteri to tlie base of the
tumor; then, by taking on? in each hand, they were made
to deacrihe a semicircle around the polypus. The ends of
the lin'ftture were now en^foged in the aerre-nceud of Graefe,
which beiDfi carried up to the root of the polvpuH, (he threada
were diBenjrngod from the porte-na?ud, and the ends drawn as
licht as possible and secured. By means of a screw, the pres-
sure was increased daily and the tumor destroyed, bo that the
instrument separated at the eml of a week, no ci>nstitutional
symptoms of eoneefjuence hnyin^ occurred.
This patient has since menstruated, and enjoys good health.
C.ifiE CLXVTTh — Pcfrfjmn nf Uf^run. RtimouaL — A
woninn, 40 years of Jtg*^» "hcj had bnme a number of chil-
dren, entered tlie Hospitnl in May, 1860, for men<irrha^na.
She at1rihijte<l It to hard wurk, and for a year bad eirnstantly
bled more or le?'^ daily. A vascular polypUH waa found pro-
jectmg fnrm the oa uteri : It was datf and about the si£e of a
cherry. The jwitient said the tinuor would oct^sionally fill up to
^i kr^re size, ao ns to project through the extermd organs. The
OA iHeri was niueli enlarged and very hard » and the body oi the
uleriid WU8 lt[iped bac^k, and could be felt of the frize of & large
orange in the rectum. I twi&ted off the polypus with a force[js,
but Cduld get no inslrunient into the us. Thy bleeding at once
ceased. Ergot in die form of troehes, at the rate of fifteen
graifis three times a day, wu^ then g:iven, and on the sec^ond day
brought un expultiive pains ; but no tuuurr np[>eared. At the
end of n week, the ua uteri had diminished to half its prevtOEia
al£e ; and. a ^jrluight aller the openition, there had been no fur-
tlter hemorrhage, although she e<in4taiit1y hud the eenbation of Its
276
FEMALE GEMTO-URIPiARr OKOA>~Si
returning. Thp onlv resisoTi to wliWi T ran jiMcrihe thr large
si7e of the uicrus ia the cunslant imtation of the bleeding polj-
pua and the eiRui of blood for its giippJy.
Case CLXVUI. — Polypus of Utcmn. Iie)»r»val. — A
heoltby, iinmnrried woman, 30 yenrfl old, of regidnr nienatniJi-
lion, whilo making some effort wns Heized with n pnin m ttia
liac'k and a sfinsalion of somediin^ fp^'i'^g" ^'*y ^^ '^'^ jjelvis.
SltortJy afterwnrdrf, she bad liemorrhogc^j — probnMy uterine ;
Kid, in a few daySj noticed a substance projecting Iictween the
Inbift. At &vf>ry sid>&eqnpnt nieiiPtrunl [leriod hIiq was flid»j(!ct
to iiR'norrhagia, anri r&^cnily tliri ble&bng rwiirred in the inter-
vals. Her Htreni^th was much reduced, and she euflfefed con-
Mantly from pain in tbe loina. There vfsts a.Uo a leucorrhwftl
discharge.
On examination iindor ether, n red, granulated body, the size
of a pigeon*n eg^, was discovered proiruiljng between the labia.
On passing the finger up ihe vagina, the Tumor was found to be
attached by a long net'lc to tbe inside of tfje uterus. The oh
wae open and everted, so that the finger passed readily into llie
cavity of the womb.
The tumor was grasped with a pair of broad forceps (such
flfl are used for drawuig out the tongue), and twUted around
five or fliy times, when it came away without resistance. I pre-
fpiTwl this metliod to tbe more tedious one of ligature. Titers
was no bleeding, and the following day she was ([uite well.
FORn:ia*j body usr vagina.
Cahk CLXTX. — Ltrrje Hair-pin e^ctrncted from the Fa-
ginft of a ChUtf tlnrfei^n i/enrs ohl. — \ wns reijiiesteil l>y a
physician to see a child whom he biid visiffd in the muming,
in whose vagina he had discovered a hair-pin firmly impacted.
Fur ii number of years, she had been trouiJed with a jiiirulcnt
dirtcbjirge jj-iiiI ctthei' symptoms, fur which many physicians luwl
been consulted, and many npplications bad been made withont
avail. Ah her symptoms were becoming; more urgent, her phy-
sician was consulted, who advised an exaniicaiion. The girl,
FOREir.y BODY IN VAOINA.
277
finilinff that tbia wna to tnko pince, confcsflcd to her nootlicr,
that, 50vcn yotira before, while In ciropony witli otiior cbiklren,
flhc huJ introiiui^eJ pomcthing into the vn^inn, ami tbnt ebc bed
ELlwnye been nwnre tiint its presence was the CDuee of hor
troubles, and hnd determined never to diseloae the fact, and
was now induced to do so only by tbc fear of the tbrcotcnctl
emminaticn. One pron*r of '^ hair-pin was dctcctcdjual within
the vnginit, wbieb eoiild be druwn down a abort dietance, expoa-
irg tbe end of it CKtcrniilij; but the other end, hc\u^ firmly
itnpdctcd in the aide of tbc poefiiipe, prevented farther movement.
In rh:; ai'ternoon, I wjie reqiicslcd to see tbc enee. The pdCient
wiis a Jarpe, heal thy -looking ^^^U thirteen vears old, of rather
wore intellect than ia Udual for une of her a^. Slie was ctlicr-
ized, rift tbc parts were swollen, and too sore to odniit of ttU
eiploraliun without giving; great pain. On pneainff the finger
into the vagina, the whole pasaa^ wftB found thickened and of
ftlniost a callous barflneaa. The upper part, or benJ, of tlie
hair-pin waa in contact with the cul-dc-sne i»f the vagina.
Half of one pron:; was dee|ily imphintcd in the wjill of [lie
vagina to the extent of about two-thirds of its lonfftli. It
wag incrustod, to a thiekncaa equal to abnut a third of lis di-
ameter, witJi calciireoua mutter. Uy careful iiianipLihttion, the
iron was produally bent to an an;»lc at the point whore it pene-
trated tbe parietca of the vagina. Two-thirds of it eouM now
be drawn outside the pnaea;^e. Before proceeding farcherj the
finger was passed into the rectum to n'lscertain if tbe pin eould
be felt on that aide; but it eecmed to have poeaed more tow-
ards the tuberotity of the ieehium. By exerting eonsiderjLble
force, und twisting it in various directions, it tvae loosened and
drawn out. Before bending; it, an attempt was mode to pu^h
it up into ihe vagina ; but the passage hnd become loo narrow,
from the e^leeta of the inllammattojt, to admit of this munu^uvre.
She soon entirely recovered.
278
FEStALE QESrrO-rRlNART OROAKS-
OOCLUWON OF THE YAQiflA.
At the time when the first of the following eaecs cnnio under
my care, litlJe hnd been piibljalicd in rcD;ard to occlueion of" the
vngiiia> and 8ome eiul>nrraa?ment yrn.s felt as to tho proper
courae to be adopted. Latterly, however, more attention hna
been paid to the eubjeet.
The subjoine<i cnecs ^vc Bomo detaiJs in regard to the diag-
nosis in retention of the menstrual eeeretioD, and the mode of
giving exit to it, when the nnatomicol relalionp of the f>artfl are
nbnormal either from disease, con^nital malformatien, or diffi-
cult parturition, and may be of usq in future cDsea of a eimil&r
character ; —
Case CLXX, — Occlusion of Vcffina following « Te-
dious Labor. Vesico-vaffinal Fistnln. Retention of CatOr-
menia. Operation* Ii''coi>Gry* — 1S50. A marricti wt>man,
20 years of a;^, a year before had been delivered, by nieEine
of inHtrumentfl, of a doud child, after a labor of four daye, Tery
severe inflammation followed, ntttsndwi with slonghino; of a
portion of the veai'io-vagjonl ije|»tiim, eo thnt the remnins of the
bladder, falling clown, became adherent to the posterior wall of
the va*riiia, and obliterated the paesnfro. There wae also a val-
vular opening from the neck of the bladder into the lower part
of the vagina.
The menstrual eccretion hod been retained since her confino-
ment. At first ehc Buffered at the rcfjiiliir periodical returns of
the catamenin from pain and distention of the abdomen, with a
aenee of bearing down in the rectum- Afterwards, the pwa
became almoet con-^lanl, and so acute as only tu bo relieved by
large dosee of narcotics. From thcae cauaea ehc was olmoflt
bedridden, and very much emaciated.
The constant dribbling of nrino had rendere<l the orifice of
the vagina so extremely sensitive that it wna impracticable to
make any examination until the patient had been placed under
the influence of other* Tlws cul-de-sac at the commencement
of the vagina wafi just BufHeient to admit the end of the fore-
OCCI^USION OF VAGINA-
279
finger. From lis up|ier jxirt, tlie urine esoapod through the
vaK'uIar opening, so situated thut a probe crould not be made to
enter the bbdder- On passing the forefinger mto the reotum,
^ hnnl Hnd sli^rhtly elnstic liimor cou!d be felt about two ineJies
from the exEernnl oritice, pre^.^ing backwards and partially
obstructing tlie bowel. The other hand, pUeed on th? abdo-
men, dwtinguUlied n large giobuJar inasa rising nbove the brim
of the pelvis, jiressure on wbioh communicated a. distinct
impul^ to the finger in the rectum.
The nbove exaiuination led to the conclusion, that the tumor
fek in the itbdnmen and rectinn was the uterus and upper part
of the vajrina distended by the menstrual fluid.
The pihtient, being fully etlterized, wna placed on the edge of
the bed» with the liinba supported as in the operation for lith-
otomy, and the labia hold apart by silver hooka. The fore-
finger was now placed in the rectum to serve as a guide, nnd a
transverse incision mode Bcroas the tower pnrt of the VMgina
through its paricteu, so as to expose the cellular membrane
lying between it and tlie rectum. This di^isectJon, passing
under that portion of the vagina which served as n fimdua to
the bladder, was continued upwards between thejie organs for
two or three inuhefi, until the diJJtended sac could be distinctly
felt.
A. TOrv lar^G trocar and canuln was now plunged into the
tumor; and, when withdrawn, a quantity of thick, larry-loiiking
fluid began very slowly to ilow through the tube. About a pint
was allowed to escafje, when the canula waa withdrawn, being
too short to be \e\\ with safety, and a female catheter introduced
in ltd place.
In the afternoon of the day of the operatitm, ahe was com-
fortable. At intervals, however, there were severe contractile
paioi in the nterua like those attending the first stnges of panu-
rition; and by them the eatamenial fluid was forcibly eipellod.
Warm fomentalionB were applied to the back, and un opiate
ai] ministered, by which her sufferingi^ were temporarily relieved.
On the followiogday, I learned thut she had passed an uneasy
night ; the pains contiuuing at intervals, causing a free evacua-
tion of fluid. Her mother estimated, that at least two quarts
280
FEMALE GE:jrrO-CRINAKr OttOAWSp
had passed through the infltrument, with the effect of greatly
dmunishiQg the tension of (Lc abilamen. TowarJa evetJing, eljC
hud un access of [mm And fcYcr, with some obBtruction to the
distharjre : the bowela heing coniftipiited, ahe was ordered caMor
oili Tlie medicine operated with much relief. The uterus
xeaunied ita action, and couhi be felt above the pubea, some-
what tender on pressure, and contracted into a 6uinll, wcU-
deBned tumor*
For about a week elie im|iroTcd steadily, (lie discharge con-
tinuing at intervals. It was with the utmoHt dlfiicuJty that any
iiiBtiumenl could he retained in the opening; and, when dis-
placed, the aperture Wite found to have su contracted na to
render it» repWetnent almost impracticable. The external
orp:ans were very sensitive*
During the second week, she waa attacked with a cntarrhni
affection, during which, from Bome exposure or error in diet,
she was suddenly eeiaed with violent pains in tlic abdomen,
mclcorism, great scnaibility on pressure, with ctliei svniptom*
denoting peritoneal inllammation. Thcac were gi^adually re-
lieved by treatment, the patient barely escaping with hex life,
Dnrin-r this attack, the canuhi had iieccasEU-ily been removed, and
every mecisurc for maintaining the opening abandoned. The
meuatrual secretion came on nntuially, about four weeks atWr
the opcr.ilii^n, and found an exit without diHiculty.
The Bubsequcnt Improvement was gradual, and only inter-
rupted in the course of the atinimer hy an attack of varioloid.
1 siibsequenlly heani tVom llila lady through her mother, who
infornjed ine that from a mere skeleton lier daughter had
become t[uite robust; tliat she bad regained hci^ health and
sti'ength ao aa to be Jiblc to use e:<ercise on horseback ; and that
the menstrual secretion was natural at the regular periods.
Case CLXXI. — Ocvhtiifjn of Vagina nfitr Labor. lic-
ttntlojt of Untffiticiiifi* Operation. I^eliff. — On Feb. 4t
1S50, 1 was applied to by a married woman, aged SO, in
cuueequeoce of ihe suflTcring produced by the retention of the
menstrual fluid from un occlusion of the vagina aubseqaent to
paitmitiuni
:a.
281
In the August preWotis, *}ie b^d been iltJiycretl of licr first
cliilil nftcr a labor of four ilavs, durio;.' ^l portion of wliicfj time
ibe hiTdd of the infunt ren^jtin^d in ihe pelvic. InAlruDicQie
were UBcd, but ineffeclually ; imd the delivery woe ultimntely
acconii>li3lieJ without them. Very severe iiiflanntintoiy tiviiip-
toma, atlended wrth a purulent d!:^cliarge, foiluwed ; and hujilly
it yfoa discovered that the vag;lDa had become entirely ubliter-
aicil, Frum that time, the return of every calamcnml periud
liad been markcil by tJie most dislrceaing palna in tJie buck
ami nbdomeD* lasting three or four days, nnd progrcsfi\c1y
increasing itt violcDce* accanipanied Kith eTiiiie cuDdtitutiona)
diaturbance. Tlieae rei)eated attncka gradually impaired her
health.
An examination ehowed tlicit the va^nna wna entirely clused,
and hai'djy a t>crceptible cicatrix could be detected tu indicate
the line of union. At the lower part of the vulva, an orihce
was discovered large enough to luliuit a probe, which, ou being
introduced, could he passed up a dietant:c of three inches in tire
direction of the tilerus, and was distincrly perceived throuj^h
the rcctu-vaginal parietee by the finger introduced into tlie
rectum. At lliis periled, no abdominal or reetid tumor was
it^ceiliuned to exi^t. It wua determined to ethcriiee her, and
attempt to restore the va>^ina1 |ia«3:ige.
The patient being fully etherized, a bougie iras pasr*ed into
tlic fistulous openiniT- This was followed by the fiugci : and,
by proceeding ciirtfully in this way, distending And separat-
ing ihe adhcrejtt pEirt^, a free o^jening was made of about three
i[jchea iiud a half or four inches. At this point, a regular orga-
nized scptunt precluded any advance, unless by the ^iasietancc of
cutting instruments. A bit of sponjje was therefore introduced,
and directed to be kept in situ during tlie night.
On the djiy following. Uie sjionge was renioved, and replaced
by anotlier, Tliia course was coniinued for a week, when, no
tumor being discovered in the rectum to indicate the situatioit
of the distended uterus, and there being no trace of the os
uteri in the vagina, it was detenniued Lo r^uspead any farther
procec<Ujk;rat enjoining u[Kjn her to u«e all neee»iLry nicana
ibr keeping the podBage open uutJl the dialciitkjn cauaed by the
U
282
FEilALE GEMTO-URlKXnT OBOANS,
menstrual accretion should be ^uf^cterit to aerve 09 a guide to
the knife.
Two montJia ofter, Laving rigorously ibIloweJ up the above
directioua^ she visited me a sccouil time; auttering^ in the eame
vrny us before, and urgently demanding relief. An c\aniina-
tion eJiuLtcd no change iu the ailuaticn of tbe parte. Aa tbe
pain wiw very distrcsi^ing', hnwcver, I eonaenled to make an
iacifiion nt the upper part uf the vagina, witb tbc hope of thivjw-
ing eonic light upon the direction in whiob the eulpirgement of
tbc utenia waa taking plaee. Thid waa d(>ae, and tlje tliaaection
carried ue far aa was ihauglit sale, but with no good refiiilt.
Un the Sd oi' May, I again aziw her. !Shc had tor four daya
been in esttremc pcun. The vagina, eo far aa it had been.
dilated, I found to be of its natural dimenJ?ions» The finger,
introduced into the rci^tum, at once detected, about two inched
from the nnua, a hard tutnot, aucb aa might be presented hy the
enlarged prostate in tbc male, and with as little ecneatiou of fluc-
tnation. She infi>rmed rac, tJiat. for the previous twenty-four
hours, there bad been a bloody disebarge from tbc vagina; and
tracea of tlna aecretioa were perceived when that passage was
eKamiucd, apparently coiaing from the mucous niccuhrauc- Not
tlie sligiitcst inilication uf any tumor could he found In tliia
direction* even when the abdomen was dtrongJy prei^ded upon.
Altbougli tbe rectal tumor waa free from tiuctuation* 1 had
no question, from my prcvioua cjcpcncnee, but that it proceeded
from an enlargement by distention with iluid of the upper part
of tbe vfLgina or uterui^i luid therefore propoaed an operation,
which WQfi reatlily acceded to.
On the 3d oi' July, the operation was performed, tbe patient
being first etherized. The up|>cr and back part of the vagina
was cut freely through with a round-bladed bistoury; and very
aoon, with H dight dlsdection, the tumor which had been felt by
the rectum preaeoted itself, but much softer and more elastic
than when examined tlirough the iutcatlnal wall. A large
trocar was now plunged into it in a direction oljliqucly back-
ward, in order to avoid wounding the oa uteri, in cose that
organ projected into the vagina. A free diecbarge of the black,
tarry substance described iu the last caae at once took place.
OOCLrSlOS OF VAOINA.
2SZ
About half n pint of fluid havir^ escaped, \\\c cfmu]si wils
with<lrrtwn, nnd the fingor introduced into the opciung, which
vftxa enlarp^ctl in eilbcr dii-cctUm with a. probc-poiotcd bialoury.
On exploring the cuvlty, no dietiact projection an^wGiing to
the oa uteri rould be di^eovei-ed. The whole interior, both
of the utcrufl and vflginn, eecmed to form but a diugie receptacle,
a little coutriLCted at one point, like tiie hour-glnse eontraction
of the utcrufi, this nppnrently nadwering to the ^ituntiou of
the oa liiLGe. The mucous membrane npjjcarcd much swollen,
and trftversed by largo vcseclfl, v^lkich etood out in bold relief,
A long, narrow bit of sponge was paaf^cd into the \flgina, half
of it being allowed to remain within and half without the open-
ing juet mj^dc. The patient declared herself at once rchevcd
from all her d[Btrc»aing ^^mptome.
From the difticulty of maintaimng the new opening, it waa
found ncceesary, a fe>s' days after the opcnition, to introduce a
sponge tent, which was removed daily, and gruduidly increaeed
in fli7c. At the end of a week, the patient, jjaving exposed hcr-
Bcir immediately ai^cr the sponge had been removed, was seized
with Bererc pmna in the abdomen and in the lower part of tlie
hack* tympanites, and all the symptoma denoting infiainmation-
Tho treatment consisted in the application of leeches^ and tho
other measures usually adopted- In tliree or four days, the ptun
and tendome^s gradually concentrated at the lower and left side
of the abdomen, where a large, hard tumor could be perceived
through tht parietea* These *jTnploms were suddenly relieved
by the discharge of a quantity of pus iroia tlie vagina. The
tumor in the abdomen now gradiiiilly aubside^l. The intestinal
oanal remained for a length of time "iLite irritable, diarrha;a
being produced whenever she took solid food.
She left town nr July 31st, <juile weak, but improving.
She wae Ji(lvise<] to have a Hinall reilal bougie passed into the
openiug iu the va^^^inat ilaiEy, avs the dif([KKsitiou to contraction
was still great; and it wan tliought unsafe, through fear of
exciting u fresh attack of infhLmmation, to mmnlfilii any sab-
Btanee constantly in the ajierture. For quite a number of
yeiira after the ojjeraiion, she required to he kept under treat-
ment, nt timeaT to prevent the reenrrence of the ocelu»ion ; but,
in [he intervals, enjoyed verv fn-u' lieahh.
d^
-Wh
mt ^ gnr inu,
m A rnnn inllun-
io the alititut
At Uttt estii-
:^ fufnrd from iLi^
L&BdnQ ceased to he
cnntUiiI wilJi Julian in
br HI uliiojiim of its
^mrt^tfi TTM tJi« 'dufttf of il>i}
^^ lOK ftf tfaft faDrtioo* of the
^— ^ irhic* i*tJ ai fiiTt only
OOOLUSION OF VAOrXA,
289
Case CLXXV. — Occlusion of the Vagina. Heitntion
of the MenHnial Fiiud. Opcrntioiu Jichef. — A girl,
16 ycara old, wna ^i^at takerit in 185^1 with pame in the hack
and Joine, such us precede the mcnatrunl l^ux, which did not,
however, nppoar- The psiiag wcro ro^watotl every month,
Uflually Jnt^tiog throe or Jour daye. In Jimuary, 1857, sho
fiuJTered irom rctenlion of urine, which was relieved by the
U6e ol' the tiithelcr. The same thing occurred in Fcbmary nnd
March> In Aprils while passing the catheter, it wob found to
cnccqntor a rcgtsting 0ubet:iiice ; and, in order to |^et it into the
hludder^ it wne neces[=ary ^ofltly to dcprcae tlic bindlc and ele-
vate the point, to Burinount the obstacle- Her phyaiciiiiL then
mode a furclicr eKiiniinatiun, imd dificevercd a round, hard turner
in th? abdomen, and another projecting into the rectum.
I eaw tliia patjcnt on tlte ^(lih of April, and discovcrod an
occlin^lou of the vagina* and a ^rent collection of the menetrunl
fluid in the uteniH. It being inconvenient to ti-ent the patient at
her GV.TI home, it wan decided by the &ienda to send her to the
Hospital, under my care-
Frevioufi to the operation^ the followinrj were the phenomena
elicited by an examination : A E^uUde-sac about half an indi in
depth coribtitijlcd the vagina, at the loner part of which was u
wlute line, or puckering/ perhaps a. cicatrix, the result of some
prcvioufi inflammatiun, A catheter could not be passed directly
into the blrtddcr, a« It cnoountL^red an chxstJc tub^tancc; and it
wa* neccsBiuy to olcvalc ihe inslrurncut almost per|>eudicularly
IV btrcKlucti U into that cflvity. In tfio roctum, a large» hard, in-
*^' ■ r wft/i to he tclt, two inches or nmrc frt>ui the anus,
hl .- .. :....Li^ Hhi pdvi»» A large tumor could al^o be dialin-
piL^hM in ihti abdomen, extondinj^ juat above the umbilicus;
■iXtil the patient uaid iJmt occariinnrdly cilic could feel two Intend
^norft tiK!TC, Ihiring Apriii t!i' :. v-^- 'irui bucn ineessantt as
"fi^ the wcpul*i<ni at flumc nf-m the body* The
4cr ilftlcd. in »p]«intioii of \ho ciumc of the oblitAration, that
ha*! '. ' •' ■!'■'' ' ' ■ . ■ lii.'n tlie
-1] iilcer
ion.
ifi^
\
28i
FEMALE GEMTO-lTElX.Uir OnGATfa.
Case CLXXJI. — Ouni/eiuffii Occlusion of J'atfuin. Op~
erntlon. Jiecover^. — I80I. A girl, iiged 17 years, liad Lteu
eufTering for two years with a aenae of ilietCDtiim and weight
in the lower part of the abdomen and back, atleinled hy a
forcible jjresseirt in thu vagina, as if fur the jHirpoee of exjielling
some foreign ^uh^tance. She had aisa been greatly annoyed
with a fi'etjueut dt'piii^ to iiiicturaLe, and passed water as
oflen OS CTery twenty ramules thrtmgh the day, but less ire-
qucally at night. She suffereti much seviTU [m'ln at the '
extremity of the i^retbra, whidi was aggravated by the pyj^fiage
of the water. She ImwI never menrttruateil.
The followiijg H|j|>earaTi<"es were finmd : On sejiarating the
externa] labia, no traces of the vagina were viaible. At the
central put of the foss;;, nsnally ocx^iipicd by this outlet, the
mCittus urinariiis waa perceived surrounded by suinll vcgeta-
tiong, which, on the slightest touob, ehdted the Taost violent
refiifitance and erica from the patient- A prolie being pasted
into the iiretJir&, its farther progress wa^ resijited at the dUtiiiice
of au inch from the orifice ; but jinally, by turning it upwiirds
in almost a vertirjd directi<:»n, it entereil the bhidder, which
was very nnn'h contracted.
Tlie finger was introduced into the rectum, nnd at once
detect^ a harvl Uirnor two incheB from the tunis, pressing back-
w^iirdH against tlic »4ptne. It seemed quite soJid, and without
the slightest indications of elasticity. On passing the hand
over tJie abdomen at its lower part^ a hanl projeetton was felt
in the centre just above the pubiP, having a prolontjHtion about
four inches in leugth, extending into the right iliac region.
Pressure on thin swelling enured a movement of the tumor iii
the rectiiTn, and was attended with uiueh ^nfferitig.
No doubt romaLned in my mind that ihese tumors were
cftuaed by a retention of the nienstrual Hnid in the uterus, upper
part of the vagina, iLnd the Fallopian tubes.
The patient being fully etherized with chloric ether, an inci-
sion was mojlo transvei'sely across the mucous niembmne of the
lower part of the vflgina. This disclosed muscular fibres, which
being carefully divided through the aperture tlius made, a deli-
cate membriine uf ii dark color protruded. It was suggeeted
OCCLrslOS OF VAGIKA.
285
>y t>ne of Cho "[cntlcmcii prceont, tlint this might popEibly he tlie
peritoneum t wtiichi in Ji vase of lual formation and non-exieten<?Q
of the vn.^nn, hnU tnken nn abnormal {Uroction. For tlio pur-
puse of tceting this, I attempted to separate it from the ear-
rounding tcxtnr»?s, knowinn; the loose character of the ecUiilar
tissue which attaehca the |>critoncura to ihc neighboring organs
And the pelriB. Thia was at ouco fount] to Iw impraeticjible ;
and, on a renewal of the effort, the resifJting pjut }'iclJed, nnd
the fin^r pns&eJ tlirou^h into whnt appeared nt tret to be the
abdominal eavity, so well defined was the anatomy of tho wnlla
of ihe pelvia. The abeenee of inleetines. and the appearance
of a smull quantity of dark-colored fluid by tlie eidc of tlie
finger, agon rniule it e^'tdent [hat the vaL^nn had been opened.
The eize of the cavity ocou|iyinp: the entire pelvis, and the com-
plete al>seiiec of os uteri or other boundary between the uterus
and va<;;ina, were on examination auttidently evident to all pres-
ent.
By the aid of sJight pressure on the abdomen, about half a
pint of thick, tenacious Huid escaped. As thij uterus did not at
oucc take on contractions, no further elTorts were made to evacu-
ate the fluid ; but a bit of sponge was introduced into the o[>en-
ilAg to prevent the parietcB from adhering, Tlic vegctalioDs at
the orihcc of the urethra were now removed by the aciaaore, and
the base of the tumors cauterized with nitrate of silver* To
flhow i]ic extrenje aensibihty of these tumors, it may be ob-
BcrvcU, that, as aoon aa they were interferetl with, the ]Mitient,
although well etherized and perfectly passive through all the
prcnoLis operation, immediately drew back aa If in estremc
pain.
On the day followin^j the operation, ehe woe reported to have
passed a good night. The spong-e waa removed from the vagi-
na, and a free di^^charge of the peculiar fluid took place ; ni^cr a,
few hours, it was again introduccdi No urine bad been paascd
since the operation ; during the sueccci^ng night, however, a
copious evacuation of the bladder took place. She continued to
improve, and the tumor of the abdomen to diminiah, Tlie fin-
ger, passed into the vagina, could distinguish the oa uteri, as it
were, gradually forming iteelf. It waa about tho aize of a
286
FKSIALE GEMTO-UIUNARY ORGANS.
tumbler, with thick tulles, and eovcrwl with Jilated blood-
vesaelfi. The s[njn|^ tent, when withdiawu, waa very otien-
eive.
A week nfter the operation, she waa quite well; the urine
was piie^ed natumn}' and without pain, the senBiiive tumors of
ihe urethra having been deatroyed ; the discharge from the
va^dna hnd parlinlly ccasedf or had hcen replaced by n ecrotu
exudfition ; and her appetite and digestion were natural.
At her urgent rer|iieel, she was then allowed to return honie
to the country, where the treatment was continued by her phj-
eician. A month at^er th<! ojjoration, the vagiaiU discliarge
ceaaed, and she woe reported to mc as well.
Case CLXXIIT. — ■ Conff&mlal Occhisian of ths Vagina,
OpotYitioji. Hdi^f. — A giH, 14 years old, be^n to eutFer,
two years before I eaw her, with piiins in the Jower part of the
back and abdomen. These pains p-adually assumed a perio<ii-
cal charaeier, coming on at an interval of lour weeks, and were
ao inienpe as to require alleviation by means of medicine.
A physician, lieing consulted, su&pected an obstniction of the
vi^na ; and nn examination confirmed hia anspLcioaa. showing
this paeaape to be coinplelcly occluded- An incision was made
lbrou;:b the solid obstruction which preseniGd at that part^ with
the hapCB of die covering a cavity con taJning^ the menetriial fluid ;
but the operation met with no succees. From this time, the
sufTerinffs of the pjttiem gi'adually increased, and, at the men-
strnal periods, were eo severe as to produce a degree of prostra-
tion which confined her for some days to her bed, and finally
even thrciitened life,
"When 1 firat aaw her, the external organs of generation were
BO Heneitive as to cause great complaint on any attempt at nn
examination. The external labia were lound to be well devel-
oped. The orifice of the urethra occupied its normal pOBition,
or was a little li>xver than natnml. Below thia, not the slighCeat
dcproflsion inditiated the orifieo of the va;^inu. The fint^cr, being
introduced into the rectum, dctcctcdi at the di^tunee of about
two inches from the anus, a hard, globular tumor, the size of a
billiard-balh Before removing the fiugcr from the rectum,
OCCLPHTON or VAOrTA.
287
a catlieEer WFut paAjie<I intir ike blaJJt^r : nml tlilfi wtin dL uii[;u fVlt
by tlie fiugiT in ihe i'e4:tiizii. in l]i4? nictlinn linr > tliu ctrniM iii'
the bladder jliii] rtHTtvim unly iiiU^rvcnin;^, firr ii iIjkLhiil'l'; of onu
or Cvro tndiefl, th&t is, as Btr a« the above-mcu turned tiimor.
At tliifl priiEkt, ilie ralliRter c^juld lie niailu Ii» jiii>j< ttn vmz\i hiiIk
of the luniiir. buL was witli dlUkult^ drU'ctcd in i}k rcrliiiri, I
had no doubt, from tbe result of the rxriiiritmtiiin, tbAt tbo
tumor fck in tbe reclunj wa» the uji|K-r \mri <rf the va^iim raid
uterus dUienilet J by fluid, and iJic cause tii'lJjc *eriuufl oym}iOjia»
under which iJie |iaLieiit lal>areil. An ci[H'rHlji>i] wiu tlwrH'^ro
proposed, and at uDC«f vritb tbe ajwlBtaace uf ber phy«iciAiti
performed. An^itLesia being induced, a tranAVcnto inciiion
was made djrcdly bel<iw tlie orifr-e '>r the urctbnL. Willi iniirii
cuilJoBr a diAflcctiun wa^ now made between tlie rectum and the
bladder, mttO. by cuttiug and Ki^'irniiif^ tbe ttMUCi n'\l\i tin;
fibgen, tbe lumor dcM:ril>cd da felt in tb*: nxtum wia rrarhcd,
Ijiog rery deep, dtid &flbrduij^ btii Uitli? ir|t|j<irfimUy ftir a fair
eKamioaUaii. The depth al wlijch it lay, and Jia apjmierit
aaUdiij, for 9 niiiDiail cauAod •ooie cmbamuameat M lo this
proper nmrwK to he pon^jal. c^jccaally a^ one of IIh gewilwnfo
pRBcnl ieemed conTmced, Iraio tt« bavdneaa, that it eould tvA
eoabiB a fanL Boi, fettUy* boii^ aalufied in tny own mind
that tk t^Bor «idd fae ooltii^ dae Uit vrbai had l«m w*-
pertcd, Idetonflnd os pawtiiriag it. Tbecacajjerif the tJiirb,
ttrTyJuJdMOMCBcnifcml Uw truth oC the SMfaam. The
wfitrtmBt was amr ^ilvipd ao an to Mtw two fayai In pas*
^vtAj ofi lala tke earitj *^'*****^*g the fluid, wfairli wna appaiw
csdy the vtervasBd ^iper part «f the vagiaa ilitf^iJ^ ao aa lo
IW MtaeaCcaa twui'mi^g IraiB tbe rifcttt of
Ike
dK aMnwd «n «^ Ike
CUCXIT. — Cbc&MPw ^ fie Tw^uMi oBfvm'a^
386
FEUALE OQMTO-U&l^AKY 01tGA>'S.
was a widow, 45 years of age. The account abe ^Te waa.
tJial elie waa miirncd at an early agej that les prcmtercs tip^
pt^ocheti du mari were ao violent aa to cause a severe inilam*
uiLtir>n of the vnpna^ wlucli cvcntunlly tornunatcfl in the almost
complete doaure of the upper part of the t^anol. At the c&ta-
menial periods, much difl^culty and euflering were experienced
in the egreaa of menstrual Huid, whicK waa discliargcd slowly,
an<i nppjircntlj by a eircuitoue route- Slie surtcrctl from thia
cause uutil within three years, when thut function ceased to be
pcrfurnicU, but was replaced by a njucoua accretion. Her health
was poor, and she had been more or l^a troubled with paina in
tlje back and loiu?, all of which &he attributed to tljc retention
of fluids in the uterua.
An obetiTiction waa detected about two inches from the ori-
fice of the vug'ina, caused apparently by an adikc^lon of ita
parietea. With the aid of the apeculum, a eniali aperture was
observed on one aide, into 'n'hicb a probo pcDetratcd a abort
distance.
As the patient insisted on having an operation, I conecntcd to
do it ; although, at the aamc time, I infornicd her tliat it was
very douhtlui whether the obstruction wa^ the eauae of the
aymptoDis, coiididcnng tlie prc^nt etatc of the fuuctiona of tiic
uterus.
A director waa forced into the paaaag;c, which had at firal only
sdiuLttcd a probe. This waa fuiiowcd by v, larger instrument;
and, by proceeding gradually, it waa shortly found poeeible to
use the dressing forcepe. By thia means, the passage waa finally
enlarged so as U> admit tlic little Jinger, when, by tearing and
dietcnding tlic parts, almost the full size of the original pnsaage
waa restored^ and the extremity of tbc os uteri exposed, buried
ill the adjacent atructures.
The calibre dF the canal was maintained by the same meana
as had been reported to In the preceding casea. The patient en-
presaed herself much re]ie>ed by tlie operation ; and, when seen
a month afterwai-da, there had been no lecurrcnce of the previ-
ous symptoms under which ahe had Bu^ered.
OCCLUSION or VAGINA-
289
Case CLXXV, — OcchiJtio» nf the T'trgha. Retvjiiioft
of thf. M^nxintnl Fivid. Opffraiioii. Relief. — A girl,
16 yearn old^ was first taken, in 1855, with piiins in tJie bick
and loice, sut^li 04 [irercilc tlio meusJ.nml flux, nlimh did not,
however, nppear. The pniiia were repewtLil evtry muDlh,
uaually lasting three or four duya. In January, 1857, she
fiufl'tred fniiri relention of nrine, which was rclieveil liy the
use (if the <:iLthcter. The p&nie thing occurred in Fi^ljiuury uud
March. In April, while pii^F^ing thu catheter, it W](8 foitud ta
encounter a resisting ^itbE^tiince ; and, in order ta get it into the
hladder, it y»^^ iiect-s^ury grwitly to <le[ireHs the handle and ele-
vaitc tlie piijnt, to aurmotnit the obntoole- Her physicijin then
Ukiulo a further examination, and diEcovered a round, linrd tumor
in the alxlomen, and another pnijeeting into the rectum.
I tiaw this [latient on the 2Gth of April, and dia^ivered an
octluiiun (if the v&gina, and a grejit collection of die menstrual
fluid in the uteiois. It heing^ inronvenient to treat the patient at
her own hoLne^ it was decided by the friendu to Benil hi^r to the
ITotipiial, uncJer my care,
Previoud to the operfltiou, the followiaLj were the phenomena
elicitet] hy an examinatUin : A oulnle-wic ahonl half an indi in
depth condtituled the vaj^ina, nt thij liiwer piirt of which waa a
wliitu line, or puckering,' perhaps a ('icatrix, the result of Bomo
previous iiidainmntion. A cnthelcr could not he pa^t^e^l directly
into die bhulder, at< it encountered an elustic uubstance ; and it
was necceaary to elevate tlie instrument nlmoat per[>endicnhirly
to introduce it into that cavity. Tn the rectum, a hirve, hard, iii-
ehi^tic timior y.-wA to he felt, two inelicH or more fn)iu the aiiUH,
nearly filtiiiy the pelvis. A largo limior could ^dsSO lie dii*tiii-
guiaheil in the alidomen, extending just above tht; umhdicus;
and the patient ^tiid that occnFiionnlly she could feel two lateral
tumors there. During April, the pnina had been incessant, uh
if for the expulsion of some substance irom tlie body, Tlie
fiister Htafed, in explanalion of the cauHe of the oblitentliou, that
she hail lieard the parents say, that for a long thue, when the
child wna two or three years old, it had been affected hy ait ulcer
in tfiat region-
The patient being etherised, and the bladder emptied, a &ee
37
290
TEUALE GENITO-UKINAET OttGANS.
tmnsverHc lacUion was inmle iionj^s the ciJ-ile-sjw; wkI, witti n
liulu diflaiiiititjii, a ihVuMc blaJder-like HiibsUnce wua Inniglit
into view. Prcflflure being now made on the alidomeu, and Lhe
pelvic tumcir madt; tense ho as to prnject through the incL^ion, a
lai-gc tmt'iir waa plunged into the cavity, and at once a tliick,
taiTy fluid be^in to flow eluwly t>ut- Tlie finger was nuw
gradually iasinuatcil, ft bistuury introduced, and the opening
Euliuged so as to leave no feeling of confltrictioii in any direc-
tion, Tlic forefinger, being jwisaeil freely into tlie Crtvity, could
detect no eac ; but tlie n&llt) of the (lelvia could be feii on all
sidpijt the colleetion of fluid having been so great hjh to distend
the uterus to its utuiotit eapaoity, and render lir^ walU so thin
tbnt tbey could scarcely be dit^tinguished. She was placed in
bed, and tbe fluid allowed to escape gradually, which it eon-
linued to do during the day. About a quart of fluid escaped,
wbidi at once coagulated, expelling but little serum- Dr* Cal-
Tin Ellis made the following niieroBCopic oh.servalions : "The
meDStnial fluid removed from the vagina eunhuued epilheliutii
cellji ^ yellow, granular corpu^eles, of various bi/cti ; blood
glohulea, evidently recieut ; and very sinalJ, translucent globules
with distinct, though pule, outlluea." On tlie fo]lr)wing and
seciind days, the oa uteri was ohaerved to be slowly farming it^
self, and the thick wulls of the uterus could be detected.
The patient rapidly recovered-
la tlie first of the cases which have been givon, the only
apparently feasible way of arriving at the distended uterus
was adopted ; viz., that of penetrating to it by n dissection car-
ried up between the rectum luid vagina. Tiie proceeding even-
tnated more HJLti-sfnctorily [lian could have been cx]>ected. The
greatest obstacle to a nii>td recovery wa^ the dilRculty of main-
taining the new o|ieningr on aeeount of the dispoaiiion to eon-
traction ; and thia wiis found to be true in all the caties. Wliat
appeared to be a large, free opening, with no reatriction on any
fiide but the bnnca of the pelvie, in the course of a few days
was eunti^eted to a Arm, unyielding ritig, into whicli it was diffi-
cult to introduce a mnall bougie. The sponge tent, when it
could be borne, at once dilated the aperture again to a size us
great lu^ could be wished ; but the e):trerne t^ensitivenesa of the
OCClil^lOK OP OS TTTEHI,
2!*1
parts pmliibitwl, in the case un<If;r nnnsulenitiijn^ a rpnort to
this powerful a^at. In (act, it was GniJIj fuuinl necessary, on
account of the great refiiHtnnce made hy the pitient, to daaifit
eniirely fri;»ni all ajipl Sections, and leave the course of it In
nature- The wubfiequent mnntli. tJie nilameniJL wppenred
sligiitlj; and there waSp sn for u I kaow, no obatrucUon to It
afterwards i
In tlie second case, the obliteration of the vngina, which yvi\x
closeil tliroughuiit imarl}' JU \vJinle ext^^nt i'roiit tin? upper part
to tJie vulva, wn3 also caused by lalxjnous paiturltiim.
It may serve as an example Ut ^how the necesaity of making
inquiries, after a severe t^nse of labor, as to the degree of local
ill flam mat ion, and of taking nieijwnrca for preventing, if possi-
ble, such adhesion as i>eciirred in the second instance. Tliiw is
ji nmlter of difflculty and delicacy; but» us so much ia at «bd(e,
these con side rationfl should give way to u correct appreciation of
tho danger wbich would enavie from neglecting an ciammiitiDnT
when the dij-charge from the vugina is so offensive as to su^-
gpst tlie possibility of gangrene and snhspijnent adhesive inflam-
mation.
It may not lie useless to call attention to Uie great resistance,
and, in two of the cases, entire want of fluclnalioni which ex-
isted in tike distended sac formed by the uterus and vagina, as
felt tliroiigh the rectum, since this might lead the surgeon to
douht tlie accuracy of his diagnosis, did not other marks assist
in forming it.
Recently, I have had two cases of apparently entire oLlilera-
tion of the vagina in marned women, m whom coneeirtiim has
taken place, and at the time oFlnUir tlie heiid of tJie child fon'ed
its way through the septum without injury to the neighboring
parts. Both rases have done well, and [here has been no return
of the occlusion.
OCCLLPION OF OS UTERI,
Case CLXXVl. — Occlusion o/ Oh JJUrL Colhrtion of
Put in Ulertis. Operativn. Protfrcxiii'Mtf Recovery Jrora
UUriae Di9etuK, Death Jrom Oaetric Disoi^fr. — In the
S9S
FEMALE GENITO-TTRINARY OKl^ANSi
followmg cns^, I wns called in oonsultnlicm. A younp; womnn,
17 years of n-gc, on the second dny of her re^lar menstrual
period^ wet her feet; the catamenkl discharge smldenlj ccBfiecl,
and fllie lind a rigor, iVilkiwpfl hv pidn from left ilhim to ribs.
After a little treatment, ahe wns able to be about. The
menses not ap[>enring six weeks subsequent to (Jieir su|>pre*iBiofi,
fihe consulted a physicinnj who noticcil nn unnflual fdlness aboTe
the pubea. This rapidly increased, and \u a few wppWs the pa-
tient presented the appearanee o£ a person at the seventh month
of utero-geBtation . On eiamiliation, ilie uterus gave the sen-
Bntion of being distended, and no entrance eould be made into
its cavity with a bougie or sound.
At the time I wae called, the abdomen was eligbtly sensitive
to pressure, and projected anteriorly to a great degree : but there
waa no eoix^sponding lateral fulness, which we usually Bee in
pregnancy.
Ailer a careful examination, I decided tf> puncture the os,
and, passing a trocar into it with considerable force, seven pints
of offensive pus were evacuated.
For a time the girl improved ; and at a second operation, four
weeks after the first, tliroe pilita of pus were removed-
About n week after the second operation, tlic patient, having
previously lived on a liquid farinaceoua diet, ate immoderately
of potatoes and cabbage. She was immediately seized with
purging and bilious vomiting, which resisted all remedies, and
sank rapidly and died. Her physician informed me that no un-
favorable re-action followed either operation, and that she was
doing very well up to the time when she committed the above
excess m eating.
No poet-mortem was allowed.
Case CLXXVU. — Occhmwu of ih^ Uterus. liupture of
ihe L^ft Fallopian Tube. Fer^ionilis. BtatL — lSb^.
The patient wa* a woman 40 years of age, large find fat.
About tlie year 1854, she bad a very severe confinement, and
had never meuetruated eiucCi For ihe last nine raonlhflT f^Ijo
had been for the most part coiifiued to her bed, and auffered
extreme pain. Dr. D. Brown, on examination of tho abdomen,
OOCXTJeiON OP 03 UTEBl-
293
found a Hrgc, firm titmor, which he at once rcco^ired as tlic
ulcriid diatcnded by the retitincd mcnatpual iluid. When I saw
her, in coneultiition, this tumur wii» very projuincnt, atiknding
out in boid relief from the abiJomcn* Ita up^jcr pmt^ toward the
fltcmum, wild flat; below, toword the pdvb. roiiml ? and in itfi
centre was a deep deprcflfiion. On esnTuina-tiuu uf the vagina,
thia canal was ibund to tcnninate in a smooth eul-do-soc, and
not the elightcHt mark of the oe uteri could bo dist[ni^Jt*hc<3,
nor any thing to mark the point of its oblitcratioEi csccpt
& rcry alight roughness on the vesical eidc of the rogina.
By the rectum, no tumor could at first be foupd ; but, by
prcfleing the tinger very high up into the pclvb, the point of a
firm, solid mass, of a conicaJ ahapc, could be rcjiched. The
patient being in great Huffering, it was decided to appoint a
day for cutling down at the upjjcr part L>f the cul-de-eac of the
vagina, and uttempting to reach the tumor. On the day before
the one lixed for the operation, her phyaioinn culled on mc to aay
that it would be unneccesary, aa, very shortly af'lcr the investi-
gation had been made, a bloody or tarry discharge from the
vagina had commenced to flow, and had continue<l to do so since,
being accompanied by forcing uterine pains, and with a great
diminutiim of the abdominal swelling- Under the cireumfitanccHi
it was thought best to make an examination with the sjxiculum,
on the following day, in order, if necessary, to take the oppor-
tunity of enlarging the opening into the uterus. A speculum
being inCrotluced, at once revealed, at the upper port of the
ragina, a thin, bladder^hke tumor, from which, by a sdirII
o])ening, tlic tarry fluid exuded more freely when pressure was
niflde on the abdomen. The speculum being withdrawn* the
finger at once penetrated tlie thin partition alluded to, and could
be carried for some difllanc^■. in a cnncd direction, toward the
right groin, being prevented from passing toward the ab<.]ocieu
by a firm, unjielding tumor, which npj>c;u^ to be the uteru«,
firmly distended by iiuJd, A catheter, being passed into the
bladder, showed that organ to be forced down hito the pelvic ;
and the finger could easily be passed beyond it, It was decided
to temporise, especially as the dischai'gc c<intinued, and the pa-
tient was getting eB.ac. In the mean tune, it should bo stated,
294
FEMAJ^E GENITO-URISAKY ORGANS.
the right lobe rif the abilominul tumor had disappearod. The
pntient sulfpred no inconvenieace or pain from the esaminatiou,
whi4.'h vmA a alight one.
The following dny, ehe wa* suddenly seized with a violent
pain in tlie abdomen. All the ei^s of high peritoneal irri-
tation were evident, and coatlnjed for about two days, when
alie died-
A post-mortem examination expkined the eauee of death.
The right lobe of the lutnor had bten formed by the uterus,
which had emjitipd itself through the vagina. The left lobe
consisted of the left Fidlopian Uibe, enormously diatcnded into
a very delicate sac, by the retained menstrual HuiJ, There was
no communication bet^vecn the Fallopian tube and the uterus ;
and the former had ruptured, and discharged its contents into
the sibdominal cavity, causing death. This ttimor, which waa
felt through the wallj^ of the vagina and uterus, had beeji forced
over into the rigfit groin. The cavity of the nterua was con-
tinuous with the vagina, the os uteri being obhteraced. In one
or two cases of occlusion of the vagina which T have had, both
Fdlopian tub^, in a distended state, could be felt lying on
the uterus, but were completely emptied by the operation, at
the same time with the uterus.
HTFERTROFHT OF CERTCX TTERU
Case CLXXVTIT. — Btfjiertropic Elongation of the Cer-
mx Uteri of Iw^nty-six years' standintfy with Projection of
the Enlarged Os beyond External Organs, Ulctratlon.
IJemorrha(fe. Operation, foUoited hg Cairiphte Cure. —
1862- The following case iidly suBtains the anaioniical de-
scription of tiie disease as gi\Gn hv Iluguier in his very inter-
esting and important work. It also shows how unsafe any
surgical procedure would be, based on the idea of a simple
enlargement of tlic os and cervix uteri, without tating into view
the very remarkable diiiplocementa of other organB which oceur
in the course of the disease when it haj? proceeded so fnr as to
be projecled to any extent beyond the labia.
A Indy^ 56 years old, and of rather a delicate constitution,
im^-ERTROPllT OP CERVIX UTERI.
295
mftrriod when Iwenty-nme yenrs of age, shortly after her mar-
nage took a long vojage, and eutt'ered aeverely from eea-riick-
ne8B» ftillowed by a niiflcarrioge. About a year after, she waa
confined with bor fir&t child, Ixaviog ti tedious labor r this was
followed hy BomG prolnpHue of the womb. During a eubae-
quent pregnancy, the pro]n|>8us woe relieved; hut, after the
birlh of the child, it wae reproduced in a greater degree than
before, and eince then ehe mny he said to have been iiontinually
Buffering from disease of the womb, "When I first eaw her,
the OB uteri wns enlarged, and projected between the exiemd
organs, irritating all the neighboring parta, and giving nee to
conBtimt embnrraasment in locomoiifin. The brain nlso, to a
considerable e^ttent, was sympathetically afJceted ; and for a.
number of years she had been ecaroely ever free from a eense
of weight and pain in the hend- For Borao niontha before I
fir^t attended her, ahe hud been confined to her room, both
from the irritation of tlie'diseaee, which c-aueed great dir^eulty
in walkinr^, and from the debility produced by repeated and
aevore homorrhagen from an ulcer of about the size of a quarter
of a dollar, gituatetl near the end of tlie tumor, and similar to
the ulecmtions noticed in eueh cases by M. Hiiguier. The tu-
mor seemed to be of an erectile character, having periods of
increai^e and diminution of eize, the former state being ac-
companied by an effusion of blood from its face.
At the time of the operation, she was quite pate and thin, and
BO feeble as scarcely to be able to move about the room- The
tumor presented the following appearances : It was from thrco
to four inches long, and about four inohes in eireumference at
its eslremity, its base covered by mucous mombrane, which,
from long exposure, had, to a certain extent, assumed the char-
acter of ekin. On the under and buck part of the tumor, near
its end, was the opening of the os, into which the finger could
be introduced to the extent of from two to three inches. A
probe passed about two inches farther. At the base of the
external tumor waa the meiitua umarius. A catheter intro-
duced into the bloiMer took a downwanl direction, and its point
could he felt half-way down the tumor. Of course, tliere was
no cul-de-s&c of the vagina in front ; but behind the tumor the
29f>
FEMALE aENITO-URlNAET OROAKa,
finger could be introduced lo a depth of from two to thres
inches- Oa esplonng the rectum by the touch, the finger
could be hooked downwrirds into the peritoneal cul-de-ane,
which was dragged di>wn by the tumor to a distance of about
two inches external to the cavitj' of the pelvis. The body of
the uterus was felt, about the thickness of the thumb, and an
incb and a half loug, in its natursJ positiou, Ii will be seeo,
from the above defscription, that» by any operation for re-
movini^ nil the tumor which projected between the labia, about
a third or a half of the bladder und a oonsidenible portion
of tlje peritoneal cul-de-sac would bo included in the mci*
aions.
The operation was performed on the 18th of November, 1862-
The patient being etherized, the legs bent aa in the operatifjn for
lithotomy, the extremity of the tumor was tinnly seized by
strofig hooked forceps, and drawn downwards and forwards.
An indHion waa made ifi the back part of the tumor, alxmt two
inches from its extremity, and jnac in front of the peritoneal
cul-de-sac, which was marked by the finger booked down into
it from the reetnra. Thia investment being dissected bac^kwards,
the enWged cervix was cut into iibout iin inch higher up, until
its cavity wna opened. Large vceseU, which now spouted in
every direction, were tied. The diftseetion was then continued
in front. The tumor being carried l^ackwards and a catheter
introduced into the bladder, an incision was made directly in
front of it, and the bladder dissecte*l off fi'om the tiody of the
tumor aa far as the level of the incision on the posterior aspect
of tlie cervix. The section of the tumor was now completed,
the base of it being firmly held by the booked forceps until all tha
bleeding vessels were secured by ligature*- The furm of
tlio iuciaion is well i^hown, in tbc woodcut, by tlie enrve^l dotted
lines :?, 8. Great care was taken to make the diasectiou elowly,
and to secure every vessel as soon as cut ; uid by tliis means,
although many vpascls were divided, the loss of blood was very
moderate. On rt'laxing the hold with the forceps^ the portion
of the uterus which remained, together with the adjacent organs,
resumed their natural poflitiou in the pelvis. At the end of the
operadon, the pulse^ probably froto the ailmulus of the etiier,
HTTEKTliOrHY OF CERVIX UTERI.
297
wns niiK'h strnnger thau at tlip coinmenceuient. Tlmre was
Mime ii!urs(^ii [inHlui^eil hy Lhe ether, litil nu vuiiLiLtng. Slitr taak
brnnJj' tn the course iif tlie night, anil imregoii^, fur a pfiin ia
llic abiltiinen. All went on >\tll fur two or three ditys; on the
23cl, hiiun^ sonic paid in ihe abdiJincn^ slie waa relieved hy a
hot fomentuliLin, On. the 24th waa eomfortjiMe; liui] un opi-
ate Hi ninlu. On the tJ^th, having gune uii perftcUy well for
a week, she waa BeizeJ wlili a \try Mcvure chill, whidi ItiHted
thre<^-([ijiirter^ of un hour, mul wms followeU hy gi-eiiL re-uclioc,
hot skin, intcnee hcudnphe, groat tliirnt, ^i% I could col dis-
cover the siyit*"5t. leiidcmepta of ihe Jibdoiiien or any ether evi-
dence of hmul Irouhte^ and L was told that she Wiia subject to
fiiinihtr nt(aL-kj4. I hnd thus far been unwilling to disturb the
bowels with iiiediL'ine. An enemji was oi'dereJ, which had no
olicL'tf and w:m folLowed hy a duse of tincture of I'hoburb. Ou
the following day^ tbe 2l?lb, she was wholly free from fever;
and, the medicine having not ypt opecaled, a dose of iiifnaion of
rhubarb wjis given, wirh The effect of producing two JejecJiona.
After ihici, she hejjau to tnke wjlid food. On tiie 1st of Decem-
ber, bIig hnd another chili, whit-li was relieved as before- Ad
eiajiiinnl.laii ait tfn^ lime, wirh the speculum, showed the ^urfiicc^
froin which the Imnur b:id lii-en ivmovcil, conmvckil to tfie si^e
of a quarter of a doUrr ; two or three lignturca which still aj-
hercd were taken invny. About four weeks nftcr the opemliorit
tbe patient was able to wiilk about, and was c[iniplett'ly relieved
of all irritation uhout the pelvic organs, which were retalued m
tlieir rmtund pnsijioMs- The pain and feeling of weight in the
head, which had oppressed her so long, had pnased off fw if a
cloud had beer swept away. She returred home about the niirl-
dle of December, and 1 had the ^mtii^ taction of treeing her en-
tirely cureil alxjul two moniha later. During the latter part of
ner stay nt rlie Hoppital, she waa kept on as full diet jth she
could bear, and porter and epirita were given freely, with the
effect of relievmg the very anicmic condition under which she
labored when she entered.
This ease ia interearing from the perfect cure of a comphonted
and rare disenj^e of many yeni'fl' durntioiiT and from the openitlon
being the only one, bo f:tr as I know, lliat haa been done in
aYPERTROPHT OP CERVIX UTERI,
299
In eonnectioTi with thia case, the following one of hypcr-
tropic elougiition of the cervix, mid eulnrfjeracat of Ihe os uteri,
together with fibroua tumora of the bcHiy of the organ, may be
mentioned : —
Cabs CLXXIK. -^ Bypertroph^ of Cervix UUri. — A
widow lady, 48 yeara old, and the mother of one ehlldi came
under my cnrc at the Mas^iuehusetta Gcnerai Hoepital in May,
1863. Fifteen yenra betijrc, ehc discovered a ^rnojl tumor
in the left aide of the abdomen, which gradunlly iDcrcn&ed
in fljzo, attended witli a sent*atIon of weight and bearins; down,
but without aeute (min. Tliis was followed il year a*tcr by
a paridytic attack of the left side of the bwly, from which
eho piiilially rocovcrcd. Profuse flooding Imd occurred several
tintca during the four or five inoatha immediately preceding
her ndmiasion to the Hospital, motcrinlly diminidilng her
Blrength. She experienced much difficulty in poesmg urine, a
fiiet easily e^cplnined by the displacement of the uterus and sur-
round ing organs.
She was a good deal cmacintcd, but had a fair pulse, and waa
able to take aonie cserrii^c ont o^ doora every day. The abdo-^
raen woe enlarged, and of a cuniciU form, from the preacncc of
a tunrior of about Iwkc the size of a coeoa-nuti An elongated
tumor, nearly three inches long, and of about the snme circum-
ference, projected liclwcen the labia, Thia tumor, which might
at tirat flight have been mietaken for » eimple prolnp&us of the
vaginiv, roneiatcd in reality of the elongated and hyperirophicd
cervijf and ofi. The meatus urinariud opened npoa the upper
and front part of the tumor. The boundary between the tumor
and the coata of the vagina wns marked by wrinkles of the
mucous membrane, A careful expluralion of the abdomen dis-
closed two tumors, one above the other, which together filled
the eavity of the pclvia, and encroached on the rectum. Simp-
son's sound ciiuld be passcrl but a short distance inUi the oa :
the finger waa nn-e&tcd at the oh internum ; but the obstacle was
coeily overcome by the use of n apongc tent, and tlic finger then
passed readily into the small cnvity of the organ,
A consultation with several geutlcmca distinguished in the
300
FEMALE GENlTO-TJfilNAIlT OliOAKS.
obatetcnc art resulted in a dociejon unftivorabk to any operative
interf'ei-e»ce»
Tbc patieat remained undor observation in the Ho^pitnl about
a fortnight, when she was flcized witJi paioa in the abdomen,
aiid died witli ft^niplome of pentnniti^.
On post-mortem examination, a Im'ge intra- mural tumor waft
diflcovcrcd^ oblitemtin^ nonrly the whole ciivity of the uterus.
Thifi wag the tumor which hnd been felt immediately above the
pubcfl. Tlio second tumor» which hod been felt abo70 the first
one, wita attached to the extcri^>p wall, directly over the other,
and was connected with the uterus only by a email pedicle. A
third tumor, of tho size of a pi^oon'a egg, wna found ne^ir the
upper port of the cervix, making its way into the cavity of
tbc utcrufi, and ini;*lit probably, after a time, have made ita ap-
pcurancc ihj-ongh tho o&, and thui^ have come within reach of n
surgical operation. The external tumor proved* OA bod been
EU|iposed, to he the oii and the greatly elon^^ated nnd hyper-
trophlcd cervix* which, hnd there been no other disease to forbid
it, might have been removed ae Ju the coao juiit related.
OVAtUOTOMT.
The extiq)ation of large ovarinn titmors haa been orcnsion-
ally practiflcd for a long time. Witliin t\ few roara^ tbc opera-
lion ha!^ been revived in Kiighuid and in thie country with
remarhnblc eucceee ; many putients, othcrwiee doomed to a lin-
gcrin-r death* having been completely eured by it. The great
obetaele to the Jiiore free |>orforu>ance of uvnriotomy ia the hesi-
tation which ilie surgeon feds to advise, or oven to permit, a
patient in the enjoyment of moderate hcjLlih to undergo an
(jperation whii;h may ulmot^t immediately prove fatal. In it^clf^
ovariotomy is not more dangerous thim many of tiie reeogniicd
enpitul openilions ; tlio difference being, however, that these last
are done in n jireeeing emergency, while ovariotomv generally ia
not. The proper course of pntctiee woidd therefore ecem to be,
to miike a fair fitatement to the paiicnt and frienda of whrit they
have a right to expect from the operation, leaving them to
decide for themselves, I bave once been cojuplctcly Buccc&efal
301
in the treatment of an e^ormoiia unilocular cj5t of the ovary,
in which resijiration wns impede*!, the liinba ceJematous, and the
l>atient riijdJIy fuilinj, by evacuating the cyst, and Jcaving tlie
caniila in pudition ; making occaalanaJ uac aftcrvranla of iodine
iujectioosi to correct uffenaivc di^harge»»
One point to he eapecinUy noticed in the manner of perform-
ing ovariotomy ia the method of eecuring tlie bleeding vee-
cclfl oF tlje pedicle- The plnn now most in favor ia by drawing
the fltiimp out of the woundi and comprcBsiDg it in a clamp
made for the purpose. This proceeding, however, is aomelimea
iblloned by severe pain afler the opernlion, e^ipccinllj if there
is much tenaion of tlie parts. Professor Simpson, of Edinburgh,
haa lately recon J mended '^ acupitsaure'' aa a aut>&litnte for tlie
clamp, and claims for it substantial advantngea.
Although it ecema almost superfluous to give the preenution
not to mistake pregnancy for ovarian tumor or dropsy, yet 1 am
led to do it from the fact that aucb mistakes do occur* The
difTcrcnlid diagnosis fa not always easy between ovari.tn lu-
inur and pregnancy, and we should remember that ihcy may
co-ej:iaL I have heard of iu^taucea where the abdomen of a
pregnant woman has been puncturett for sui»poseil ovarian di\)p-
»y. The rollowing cioses in my practice are adduced as illuatra-
live of the aubject; —
A patient applied to me, wlio enid she had a tumor appear
under her ribs immodlalcly after her last confinement, and at
the end of nine months — when I saw her — her abdomen was
immensely distended. Rhe said tlmt she had been fidviaed on
operation* Not ha^in^ the time to examine her, I sent her
to a fricntl distingui.^hed in the obstetrical art, who informed
mei that, nl^er a thorough examination, he fi^uud pregnancy
existing^ with n great aiipemhuitdnnce of amniotic fluid. She
was confined very soon ailer, with a healthy cluld. In a caae
of supposed ovarian disease, sent to me from a great distance
for operation, the symptoms had been anomalous^ and such as
early to lead to the auspiciiju of tumor. On auscultation, 1
heard the sounds of the fa'tal lieurt. It is very possible that
pregnancy In this, as in the next case* had supervened on the
original tumor. lu a third case, and one which would be much
802
F£HA1.B OeWITO-UKlHAKT ORGAPTS.
more likely to Ipad lo error^ a womnn njiplief] at the Hnapital
with an ovaririn tumor <jF one aiile, of'eif^hteen months' stnndirg.
She waa l.realed by die iiilernal ntlminidlration and external H,p-
plri'Mtioii tff iudirjc. Slie ftjijjljcd once or twii.'e afterwards, at
intcrvnla of two or throe moniha, the tumor gnidijully enlnrjiing.
Finallj', having delayed for sii or seven months, a. tumor, winch
was supposed to be the same, waa found, filling the tvholfi
abihMnen. She wjln Bhorlly after eoniinedn ;ind since then I
Lave not heanl from her.
Cask CLXXX, — Lnrge Ouarian Ct/^ti. Pifnrlr/Tf. Ca-
nnid hft in ihc }\'infnd. Cure. — A married womnn, nged
41 yours, enter&l tlie Hospit.il. Marah 1, I860, with n large
ovnrinn tiinior filling th** entire nlnloTiii?!!, presBing tip the ribs,
and encroaching ro much upon the cjivity of the chest, as to
cnuse great difficulty in reepimtion. The limbs were in a
highly (pdemafona state, and she was m a very feeble condition
anJ rnpidly failing-
The tumor hpgun fourteen months before, and increneed
griiJually until it measured four feet m its greatest circuraler-
ence.
As it was suspected that the tumor, which was tiniforndy
elastic and ^uotuiiting, waa unilocular, U wne decided to punc-
ture it with a large trocjtr, nnd lenve the caniila in the wound,
This I did March 4tb, and drew off eighteen quarts of light,
strnw-colored fluid. The onniihL was left in the wound, and
secured there. March Kith, the plug was removed from the
canula, and n pint and n half of Jluid escape*!^ thicker and mora
gelatinous thnn thnt drawn firi*t, Mnrch iS^lh, the diflcha:'go from
the canida was thicker, and somewhat of a purulent character-
In April, from exposure, a sudden swelling of the abdomen
took place, with considerflble tendemes:*, attended by a febrile
AttAck, the dtschai'ge from the sac becoming somewhat ofTensive.
A weak solution of itHlfne was thrown in witfi good efTect, and
corrected the offensive ttate of the secretion. Const it utioiud
and local means were also u^ed to nllnv the irrltatioQ,
April 28th, the &ac had contracted, very much, sr> na to form
quite A smrdl tumor in the abdoaien. All the aymptonis de-
VESrCAL CALCULtlS.
BOB
tailed nbove — such q3 difficulty in brciithiiig, Jropsy, &.c. —
were com|it<^tRly relieved ; ant] hIih left the Ha^pitid in iiii improv-
iQg condition. I fieurd frum her a year afterwards, fjuite well
and sLouI.
The v.(ic then formed n dTiiidl, Itnrd lumor* ubuut the tiize of a
billinrd-balt, on the leil j^Ide of tlie abdomlDail ciiviiy.
VESICAL CALOCLDfl,
Case CLXXXT. — Large Vesical Cafculuft in Femalt,
fiUiiitj the it?hole Sht/iffer. Litkith'iitf. Tit^corenj. — In
Jiirie, IMG5, ;i woman, *S6 yejiia of nge, entered tbe Hospital
under the care of Dr. Francis Minot, in nn ejctreme atnte of
emnciiilion, suffenng; from dispose of her blndder. Dr. Minot
eoundeil her, and, detecting a Blone, referred her ti> me. It
Beem§( thul, twelve years before, after the birth of twins, mieto-
riCLon bucniEie painful and fre^^uent, unil the urine waa niixeil
wiih bhjod. The nymplonis were then alleviated until her
second pre^imcy, when they returned. For the last eight
raontliH, these aymploma bad been constant, confining her Id
her bed, with a degnw of pain ref|uinng tlie constant use of
htrge diiJ^c^ of nn>rphine. S^^e had no power to retpiin the
urine, whieh dribbled away, mixed with mueiis, pus, and blood.
Or a ebemieal evariinalton, it wiu found to be very strongly
alkaline, eiaita(n|ng a ihiek, ropy deposit, with some alhiimen-
Under the niieroscope, many bl^ud and pus eoqiusdes, epiihe-
lia] scales, and crystala of the triple phiisplintes, were observed-
On eoundini* the bhidder, it was found nearly filled with an
iumeni^e cdctdus.
A question arose in thia caae aa to the clioiec, ennsidering her
feeble state, between lithnlritv and lithotomF, It was decided
that this should depend u[iou the hurdnes^^ of the Atone.
She wna etlierized, and the Bione aei^ed with the llchotrire in
ita shortest diameter. The screw was npplie*?, and the stone
easily crtithed ; the fra^mentu were aeiied twelve times with
great rri|Jidify. ami thoroughly broken up- The dtjbria was
lln'n seized with a htl^, spiton-biUed femnle lithotrite, — which
J bud contrived lo work with one hand, — for operating in tbe
304
FEMALE GENITO-UaiNAaY ORGANS.
fbtufilc blnddcr ; the othci' hand bcin^ oi^cupicd in tliG vii<^mn id
Biipporting the blndJcr, and guiding tLe fmgmctit^ into the jawa
of the instrument- For three ot four days after the operation,
no rru*ruiente cscnped, althou;;h there wae a ^real acnee af relief.
At the end of a wecU, tiic operation was re|Jeftted with the
fcmalo lithotrite, and a great quantitj of fran^menta removed*
At tlic end of another wcick, it was a^min repeated under other,
aad the blaildor to zdl nppcoranee etfceCuuliy cJcixred. The
atone, ia its largest cireuiuterencc, must liave been at leaal ax
inches. The pntientf from a stale of exhaustion and constant
eutlcrinfij, wa3, at the end of five weeks, restored to better
health than she had ever before cnjoved. Two raontha al^er the
first operation, & second waa rcrjuired to remove a Btnali frag-
ment which remaiueth
HEXAL CALCULUS.
Case CLXXXII. — Oalculuft in the Kidneij^ toiih « FU-
tulona Opening^ supposed to be Carionit Jione. J^eath*
Aittopfiy. — A widow, fi^^ed 45, entei^d the Moaaaehuaetts
General iiuapital, Oct. 1, 1858, with what waa suppuacd to
be cariea of a lowoi- rib or of the tvunsver^c proccse of onu
of the vcrlebrB3, Thirteen years before, ehe had fidlen down
two paira of atairs, and wa? supposed to have broken one of
her ribd. yhc soon i"ecoTered autficicutly to be able to work,
bat etill had eone^tnnt pain in the side. Ten years afler^ the
pain increa:^ed. attended with Pwclling. and an abecees formed
in the loina juat below the last rib, which waa opened, and a
quantity of ptis evacuated ; u fistuloua opening remained i and.
when ahe entered the Hospital, it was recorded, that dead bone
eould be felt by the probe-
Oi:t. 3d, a eponge tent was introduced, and the opening grad-
uuUy eolargedi
Oct- Ifjtii, the patient waa ethemed, and the surgeon in
charge made a amall incision so as to facihlfite exploration. No
hone co»jld be detected. This examinolion was repeated on the
22d, at which tiiuc the discharge from the wound was conaider-
able.
RUNAL CAI^CL'LUS.
305
NcT. Sihf she cfLine under the care of another of the aur-
geons. No dead bone cuuld be found wkh tiic probo ] but on
I>ec- 2Qth, the patient being etherised, an iDcUion was mn.de,
and bone waa supposed to be felt, but could not be removed.
March 1:J, H^^y, ehe came under my care. A bent probe
was passed deep into tbe wouiLd, ftn<l, bein^ (!urrii^d under tbo
rib, oooosionalJy atruck what appeared to be hone dtvcstcd of
pcrioHteuin. All the other surgeons present pr<.»beJ tho wound ;
and the conclusion arrived at waa, that the substance f<?lt was
too deep for a portion of rib, but probably wae the tranavorae
process of a vcrtebm in a carious condition.
From the depth and circuitoue route at which the eubslanco
was rcnchcdi and the great solidity of the surrounding tt^^tures,
which hod been so long iaHnmcd, it was found quite impracti-
cable to seize the supiiosed bone. The opotiiD^ waa thurcforo
dilated by powerful ibrceps, free incisiona being out of the quoa-
tion, irom the danger of cutting into the thoramc or abdominal
cavity. Tbe attempt at removal was necca&anly discontinued
for a time* as, from the very feeble condition of the patient, the
administration of ether, probing, or any unu«aal interference,
was accompanied by great depression of the pulse and exceasivc
firoBtration.
The patient luid a rery ycUow. almost jaundiced, complexion,
through the whole duration of the. treatment, with litdc or no
appetite, bowels cxceeslvclv constipated, and i\ constant nauaca.
The urinary secretion waa very scanty and disturbed. Au
attack of nausea and vomiting always followed the use of the
probe, so that 1 was very averse to interfere with the wound,
and avoided doing so unless stnmglj sohcitcd by hcr-
Aprit liJth, she had severe pain in the aide^ which was a little
rehcvcd by opiates.
On the night of the 21st» there wqfS severe pnin in the bowels.
During ttic morning of the 22ti, she was very weak, with eon-
aiderable tympauitea. k^hc ioiled rapidly, and died in the
evening.
The autopsy wo* mode by Dr. Ellis. ''The pleura, lungs,
and heart preaente<l noUiing very remarkable. The perito-
neuiDt omentum, and other parts, were reddened ; and a large
306
FEMALR fiENITl>lTKIXART ORGjIKS-
qimntity of piiB vvll^ found in l)ie caviiy of ihe (ient*iTiciim-
The liirge inteHtineri were quite firiuly iidlierent id Uie kft hiiii-
bat region,
" The fient of tlie left, kidney wits orni[j)ed hy a dense ma*iB of
fibrou-^ ami !i<li|to9o tissue. Tlic truL ^nrfnee of thiA preHenieJ,
for the nioBt part^ the i^ame upjueiiruiice ha the exterior ; but in
iJie L-entfe viiui a portion of reililUli ^nh^taneei perhaps un Inch
in diiiineter, nnd near it otliers of mnallL-r size. Witbin this waa
a smaller ctivity, liiipil with a serous memhriine. Thia resembled
the pelvid, nnd was oct'upied by an irregular, britn^^heil ciilc^ulua,
of small »[zv^ of a yelhiwish wOiite izulor, and lauunated. It
vfiw retjiineil in ili* ])i.wilii)n by one or more prolongations. At
the. part which ailhef^d to the poriterior wall of the ub(]omen was
an opening through which a, pn»be passed into the cavity, und.
came in eontitirt. with the caluuhis. TIlij^ opening n-ns, undoubt-
edly, continuous witli the dJnu^ known to &xUi before death ; but
tlie point was not investigated until after ihe separalion of tlie
kidney- Nothing was noticed indiealive of recent inftainniatlon
having its oHgin in this part of the abdouieii. There was. no
caries of any bona; but the sinua ran just below the lost rib,
wiiieh eonJd be touched jjy a probe.
"Wliat appean^l to be the remains of renal subwLanee waa
examin(>(l by the miero^eope ; but the infiltration of Fat globules
made it impossible to distinguish any thing else. There was no
traue of healthy tissue.
"The cortical substance of the right kidney had an unusuall/
white appearance."
ABSE>XE OF VAGINA AMD UTERUS.
Case CLXXXTTT. — Absence of VfifftJia and Uten/s. — A
very delicate and intelligent young woman, 21 years of age,
applied to me in March, 18S0, and after same hesitation in-
fonne<l me that she had never nienptrnatp<l ; ami that, an
eKamination having been miide by some female physicinnj she
bad been informed thsit a malformation existed (iboui the organs
of generation. To my question, whether any symptoms ever
occurred of a disposition in the menstrual secretion lo establish
307
itPcIF> slie eaij tJint, vrUen about fifteen vears of nge, ehe was
Beizcfl n'JCh Yiolcnt paioa in the back^ loina, nnd Icga, which
recurreJ, itn*! ktpt up at intcrvnle for the BpEice of two or three
weeks ; and that ahe wns informed by ber physician, that it was
probably an attempt of the system to estabbah the re^bir
montbly pcriLKla, This attaok, however, passed off without the
menatruatzon making ita ap]>e!irance ; and there bad never been
nny indication of the pcrlurmancc of that function ainco, or any
vicarious ilischar^ claewhcrc to take its place-
On a ]>artial examination at tliia time, witb tlic patient lying
on her aidc^ 1 felt, in the u^Uitl eitnatiun of the vagina, a ainatl
opening, into wbidi the probe pasaeJ up readily three or four
inchee. 1 therefbrci perhaps too hastily* informed the patient,
tb^t the n^dimcnta of a vagina existed, though quite emuU, and
could probably be enlar^l hj an operation* I made no farther
examination at the time, but could not explain why the men*
fitrual Huid shouJd be retained while the passage existed, which,
thougb very small, must apparently lead up aa high oe* the
uterua ; and at the same time why there waa no tumor, and
none of the ueual autfering attendant on retention of the
menatrual fluid within die uterua- The patient, baying no con-
venient place in Bijston for the operation, decided tu enter tlje
Maitaaehuf^'tta Gem;ra! Hospital, wbidi abe flid about two weeks
al^rwardsi when elie vrta etherized, and a thorough investiga-
lion made of her case.
On ocular inapection of the external organs, I at onoc foand
that I vras mistaken as tu tbe existence of any opening into the
vaffiua. The o|tuning, in fwct, which I bml taken for it, was
that of the urethra displaced from ita usual aituation below the
pubes to a poitit about tbe centre of the vulva, perhnpa an incb
in front of the anus. A catheter bein^r introduced tbrough tliis
aperture, tbe contents of the bbidder flowed freely out. Tlie
catheter being left in the bladder, a flnger, introduced into the
rectum, came at once In contact with the instrument ; tbe vagina
beia]^ absiznt, and nothing but tbe coats of tbe rectum and
bladder iTitervcuiiig. The finger being now pae^ed higher up,
aud hooked, tut it were, into tlie cul-de-aac of tbe peritoDciini,
no uterus could be discovered; but its place was occupied by a
3oa
FEMALK aEKlTO-URlKARr ORGANS.
cord somewhat larger at tlic centre than eidea, and this cord
being (ijUowod lip, at the distnnco of two or three inches from
the central purtioHf a body could h^ foil about the i^ize of a
common gnrdcn bean. The pn.tient in other respects seemed to
be well-developed and perfectly formed.
The nnnoimeement ot the actuni etJite of the case to her CAueod
grcflt diftreaBi As it was of importance to discover whctlier
the ueual ecxuol pcculiaritica existed, 1 made, with tie iiiuch
delicacy as poapJbJc, eorae qiieationa on this jwint; to which
she replied, that she had alwa)ra ooneidcred herself a woman m
every respect.
] made n second examination of the eu^e some days oftet^
wards, with the patient in the erect position, thinking that, if
any uterue wcro present, I ahould tbiis be more likely to detect
it than if ahe were on her back, but with the same result as
before.
In a late number of Guy's Hospital Keports, an interesting
case is given of ahscnce of the vagina, where the literua beeame
so diatcnded by the menstrual tiuid as to ret^uire an operation.
When the patient was first examined, the surgeon pnaaed hia
linger into a passage supposed to be the vnginai but which be
soon discovered to be the dilated urethra. The uterus wa^
punctured through the rectum to the entire relief of the patient,
the aperture remained open, and she was beard from af^rwards
as havino^ the mcnf^truol disehargo regularly through it, and
without any difficulty.
Case CLXXXIV. — Complete Aiisence of Vuguta nnd
UCerus. — April, 1858, a patient supposed to have an oeelu-
eion of the mgina was sent to me hy a mcdieal friend. She
wna 25 years of a^, wdl developed, about five feet two or
three inches in height, and hod been married four years. She
had never menstruated; and it may be mentioned, that her
mother did not menstruate till the. ngc of twenty-onei afler
she had beer married one or two yeara.
On examination, I found whjit at iir^t appeared to be a very
em&ll varrina, which would only admit, with much suffering to
tlic paticut, the little finger. The sensation imparted was as if
ABSESCt OF TA^^DTA AS7> tfTBSTrB.
SOS
the firg^ had pusswl through thp tiasue of an old ci(7atrix-
Suppoj^ing thiB tn Itr tlit^ vngimi cfintracled Ironi some iiifluiiima-'
torr procesa wliidi had occun'ed at un early [H^riod of Jifc, she
was adviecd to go into the nfispitJiJ fur fwrther investigation.
Having entered, aftfir the hipse of il few days, bLc was ftho
ized previous to an cxiiudnalioiii both to eave licr fLtillnga on
thti ACUTe of delicucy, and also to allow of any surgical opera-
tion. If oue should bt deemed neccssjiry.
On inspection, the hreitsts wera found to lie well deveh)ped.
The external organs of generation, the clitoHfl, nymplire, &c.,
were Dormnl ; there wiia hair on the pubea. In the fiituatiuti
UflnrUly occupied by the vagina was an ajKrturu large enough to
jtdmit the liltle fif»ger. No nrethni could be fount!; and thia
amused euapieion as to the true nature of the ca^C' The finger
Wild mtw |)H>sod into the cruinl, itnd the ether hand being plut^ed
on tlie exterjiid wiJU uf the abdomen, it wna evident that both
coverings, or ratlier both walla of tlic bhulder, were not em-
braced between them. The finger being withdrawn, and a
catheter inti'i^hjcecl, the urine at once flowed liirough it, show-
ing eondusively that tliis whs the bhulder, and that the finger
hiid been pas:4ed through the ililate<1 urethra. Tiie finger being
intnxiuceii again n*i before, and a fingur of the other hand
passed into the rectum, no tracca of vagina or uterus euuld
bv found ; while (Le forefinger of the left band in the rectum
could Ik; hooked, as it were, into the culMle-sau of the perito-
neum, and tiiijn dragg*^! down ne:irl/ to tlie Miua.
From tlie result of this exanunation, il^ was at once evident
that no snrgical operation could be of any benefit. I was dl^
posed, however, to keep her under observation until the next
uien^dual etfort* which, uccorduig to her account, took pl^e
niouthly, and was announced by pain in the back lasting four or
five days. In case any rudiment of the uterus exisled, it wae
thought probable it would be manifested at that time. She
was therefore advised to remain In the Hospital to afford further
observation of the case. Nothing however wus di^eovcreil bear-
ing ihe leaft resemblance to a uterus.
During tlie four years of her marnsge* so ftir as I could leam,
A very partial indulgeuce In sexual intercourse took place, which
310
FEMALE OENITO-URINARY OHGANS.
resulted, probrtbly, in the grcMt dilatation of the uretLra which
was ob served -
The above caee is interesting from the fact, that the patient
pfesented perfect oxteranl development, flceompanied by the
uaiial Bf^xu^l feelin^d* with a eninplete nb^cnoe of two cjf tlie
importniLt organs cngarred in the sexual tunetions. It may be
added tliat no viearioue discharge of any deeeription supplied the
pliice of the uienstnial secretion.
In one or two infitances which have fallen under my no^cc
when the vagina and wtenia were wanting, the urethra wae
pliioei! lower down, as in tho above erase; and, insteiid of occupy-
ing its ordinary aituation, it ibnned a continuiition of tlie rudi-
mentary vagina.
A case of entire absenee of menetmation in a younfj woman
may here he mentioned, who ooneultod me some years since-
A sound wfts passed- into the utenie, but no obstruction was de-
tected. This patient had a vicarious blocxly dischiirge from the
rectum onca in six weeks, lastinjr some days. Development
and eexual feelings were normal.
HEHMAPHRODISM,
Cask CLXXXV, — Sttppofed Encephaloid Tvsttoh.
OpGrvxtlon. Deaths Autopsy, I/er^maphrodism* Zhfinase
proved to have li€Gn Ovarian Tumor.- — A pcrpon pHn^ the
name of Thomas M , 21 yoars of age, apphed to me in
April, 1851), on accoLnt of a great cniurgcment of what appeared
to be the ri'^t Iceticlc* His external appcnrnnee w^ie tbiit of a
young working Iriahman. The beard waa full, etronjj, and
black, the Jaryos of the ordinary size, and the voice masculine j
the ehouldcra were broader than the hips; the muscles vrcro
well developed; height ^ixty-fivc inches, of which thirty-throe
were above the pube^, ami thJrty-two below.
The patient's own history of the case waa as follows : Early
in life he lost, or had had removed, the left testicle, but could
give no particulars of it. This account waa probably folia-
eJous.
The right teaticle was greatly enlarged, measuring thirteen
TLKRALIPHEEODISM.
311
inchca in circuinfurence, ecven und tliree-qiiarters in len^h,
en;i^-aha|ie<lT and extended nearly tw^o-thirda of tlie distance trom
the pubes to tlie knee. It wa« i^JcceueLvcly tanset hard, and
seemed tw henvy to be supposed a hydrocele, aJthougli tbe
grcnt evenness of tte surface sccmcd to make f^iidi a i^uppuaitiun
probiiLlc. There were large veins on its auifuce. What seemed
to be the Bpermutio eonl woe well defined uhove th« tumor,
thoujfli 11. little hji-rder than natund. There wns considcmhte
complaint uf |Hiin in the hack and luiua, which was attribuied to
the dniggin^ weight upon these parta- The paia in the tumor
itseU' WflB ncit csecGeive. The testicle had been, he fiaid, of
normal size till about a yeur before, when he received a severe
kiek upon it. Aflcr the tirat oeuto symptoms had subsided, it
bej^^an to ewcll slowly ; hut within the laat month it luul in-
creased very ropidly. The eesual feelings and power of erec-
tion continued natural till ^ix weeks before I saw IuiUt and
since then they had completely disappeared- He never had
sexual intereourse- About a zuontb tiinec, both hrcasta began
to swell and become painfiLl ; and, upon examination, I found
them to be of the size of those of a young female ; the glutidulur
structure could be distinctly felt, and the disk wne about four
inches in diameter. No fluid iasned from them on pressure- I
eould not learn from him whether they hud prevJoualy been
larger than natural ; but the present inereneed i<i;te seemed to
have oorrer^ponded ifk time with tlie loss r>f sexual desire, lie
stated tluit hie health was failing, he had lost his appetite, and
woe deBirotiB of an operation to roUcvc him from suffering.
He was sent to the Mosfiachusetts General Hoapital, where
tiie tumor was removed on Wednesday, Ajiril 13tli, and the
supposed cord tied en r>iagse near the abdominal ring; some
dieaeetion being neccif^ary in order to reach it nbovc the disease.
PrevioiiJj lo the operaticuT be had been excessively diflidcnt
about having the genital organs examined, and at this time the
following a|jptarance3 were first remarked. The glans pcnifl
appeared normal, but impcHorate ; the body of the penis was
from two to three inches in len<;th. Cummcncing al>out an
inch from the gluns, and oictonding to wi(hin two inchea of
the iomsj was a fissure having on each mde two flaps of delicate
312
FfiUALt: G£KJTO-L-RIN.\Br ORGAITft.
eftfilM^lium, pim'tJy resembling the rymphsp, whit^h, liein^ eepa*
ralui^ prcwni^, as it were, the extern^ or^uis of tLe femtde.
At t)ie iovrer part of tliis fiaaurc cunuiienced up|Hirently tlie ure-
llira; nnd, tin instruineDt lieini^' iiilrtKluccd riljout Uiree incbesi
nrutcr rwaped freely- Extemnl to the fiaaure* the 0k.1i] wiA
llrin imt\ dcViPtiXe, like that in tbe npi<rhlM>rh(HHl of the J«]A]e
urgniu of gencrntioa. The pubea wna very fully fiovertid with
hair, wblch vra« bhuved ta tiicilituie Uh? dretnt^ing uft«r the oiiera^
tion. Dr. Dyer, boiise-aargeon of the Hospital, at my request
took A caat of the breasts, their □p[>eaFance was so UDiiMid.
My inrjitiri^Fi wnulil hnve been iniich more jmrticular in rcgnnl
U> i\k jjrcyiuuH hirilury, aiiJ e^^fK^oiiilly lis Ilj any th'mg retiem-
bJittg tbo tuetibtruul diudmr^c, if I hud had ihi slightest eiupr^
diiti o(*lhc pflticm'ii sex.
TIk! day nhcr tbo D|)cnLlian, the jintient coni[ihiiiitx] n great
dind ijf pjLin in tlie HlHlcimen^ iind inuoh fever, slUo of tJiir^l*
nhich wnji [Jiirlly attributed to the edier adiuinUlered. T\m
ftrbrili.i iLcrion j^radtmlly inoren^ed from day Ut d.iy ; ibe swt^litig
ant] (luin hi tlie ihbdnn^en, however, subsiding until duiith, wbiiJi
l***.k |i|)U'o on tliG *oventb day afler the operation.
Am lAfLniiniithin of the body was ninde on the following day.
Itridi liinj^M were found tituddcd with Jurge musi!ii?4 of eam^erous
mutter, unci vrero ulhorent at ccrtnin points to the pleurre. Tha
liver nt firiit iip|i(-an-il healthy ; but. on ]>eing cut inUi, il numlker
of euvilim were diricoveved about the «ize of a lilltert, containing
n thirk ndlky ^uld. On tlie ^line, at the rout uf tlie mesentery,
wan u miLAti or enbu'god lymphatic glands* the ebAni of them
ujiU'iulhkf^ diuvii from tk> edge of the rim of the jmlviK nearly to
t\w ^niiii, iniii'h duUontil, and not |>eree|ttible clirough the nralla
uf tlie nbdijiiit'iki The neig-hborbood Chf the nng, ju«t ttbave the
»|Hil wliero tho llgiLlnre hud been applied, wns in a ^ngrenoiu
uitidlliim. The ihU^JsEJinvi brinir removed, ex^KHied tike fuHow*
U\^ reiniirhikh](i ai^pearam-es in the jtelvic orguu : The bljidflcr
wiin nniniMvhiiL disteikiKd^ aiid jutt bclund it lay a wcll-fi irnieil
ni(ii LiM 111' iitilnrtd ^liie, na in il\c unimpre^iated state. On the
b^i^ lide of Ute utoruH, the Fnllopian tul>e terminated in it» fiai-
brinlinl rvheniily. midir whieb by llic o^Tiry, rather smaller than
iiLktkinLl. uiid \\ilh one or ivny liiUc bdtadfi of adbe^iou running
HERMAPrrRODTSW.
ai3
between it and the Fnllopian lube. The ovary, being incited,
diapl:iyctJ ita orilinary slriicture. On the right siJc, the tube
ran nlcng unUer the poritiincdin, titrntid upwiw"<]rt, and wns lost
in a diai'a^Gd maas in tho ri<^ht givin. The ^uirtB wsm now
removed whh grent care irinn the pelvis by Prut'easor J, B. S.
Jackaon.
All the jwlvic oTgana licing remuvcd, and placed on a table,
we proeeedeil to invet^ti^^te the rclntian of the dlffbrcnt organa.
A probe was paa&e<.l into tlic uretlira, and went reailily into the
bladder; being witlidrawn, and depressed a little, it passed
with ef[i.ml fueility to the fdndua of the uterus. The parta were
now turned over, aud the back of the vfl^na and utcrua laid
open. Tilt vagina, which comrienccd about no Inch from the
external orilicc, waa nearly four inches in length* and tcrmiaaled
in the OB uteri ; which, however, did rot inakc much of a relief
in the vagina, nlthmigh the dialinclion in the two textarcf* wna
fiilly marked, Tlic arbor vine was very distinct, and bcautiliilly
ehown : it extended nearly up to the fandiis of the ulcrus- The
blowpiiie being introduced inlo the left Fallopian lube, air
parsed freely through It, and out of the firabrialed extremity.
A probe cuuld be passed for a certain distance freely in the right
Fallopian tube, but air did not pius through it as in the other.
In regard to the tumor removed, the whole aubstaiice of it
Bcemcfl to be converted into cnecphaloid matter, and its natural
etriK-Inre lost. The external covering was adherent, except at
its anterior part ; it was cut into early in the operation, and
about a gill of a yellow-colored serum eseaped^ exposing, on
the upper part of the organ, a collection of beautiftiUy colored
cystd, of all sizes, like a laaa* of brilliant cryatais-
It would have been cjttrenidy intereating in tbia cnee to have
decided whether menstruation had ever taken place through the
urethra; but this, unfortunately, I bad no means of determine
ing.
The organs being given to Dr. Hodgca, the demonstrator of
anatomy to the college* for the purpose of a more minute dia-
section and inveatigation, be kindly furniehcd the following
report : —
40
314
FEMALE GEN rrO-ITRI NARY OBOANS.
'' PilmiK Hevtflnpfnf^iil, llisil "f jl irmle. Pi^iiIh. uIlil'Ii is rfiul of An
adulu JiiiU not uf a yoaiiu mtu^iiies ul^iig its dur^um two and b liali"
indicfl. The ^lane, of pro[»orlio(mto ^iec, 13 wtvereil, excofit in llie
immediflle vitinity of wlier* (he tViPiiLira should Vie, by si weU"developpd
pjTipuce. Thu uiiiihra being deft from ibe meutud batkwiirJp. llie
prepuce ]s not frotnplcted uiidcmcaTli, but bccomca IoaI in tlie aheAlh of
tLti pen 13.
''Th6 ui^fhra ifl tmcenble, along the under enrface of the penis, from
the mentns 3J inches, and disujipi^nra in nn uriHce 2-^ iurln-'s in front
of iKo nnuB. Tbroughout Ihis dislanoi-j it crio?i^l3 onlj of a fi&sure, or
bqIguBi tlie aides of wliiuh, hiiring irreguiar burd^irs, arc in appoaitioi].
It iri tilled wid; uell-dinmi 'tended miinoLis membnini'; and liaa, at vari-
ous poiiila. dia(ia(^t LKuna'-
^^ Divcra;[Dg obljqucJj' up^va^d8 aud outwnrds from tlio aides of the
nrelLra Rve fold^ of inu^gnmi-riU ■'on slim ting di^lint'i Inbiai mnj»m and
minora. On llit; left, iit tht Mv ef lliedo lubiu, arc ludUttuct lutuks of
cJL'at rices.
*' KsaTnined iTiicmidly, the peoia tronsisis of two corpora cavcrnosft,
meiisuHng from tbo meniiia to their bifmvntion 4 inchea. They ler-
miLUiti^ ill ;^Tll-Jlt]lrkeJ orura « atid Ibe ui-rvirs, arteries atid vslus of ibe
dorsum of tlic pcniSf hnve iht? miml siao and position. Tho corpus
spongiosum ia well developed^ but split longitudinally mio two hnlvep,
nhidi iiTf. to Ire ^eeii on diljer aide of iind beldiid tliti f^iqH>ru ciLver-
no&a, Ainil corrcfijiond cxtorntdl^ to ivo Iblds wlilijb form the ijibia
minora.
" CdWpcr's glandft were not found,
^' TLu mutfcli^ of th(j perimLum nvK soiacvth&i eonfu^i^d. bul the
following were dUlint'tly mudu out: eroctorofi pcni^s comproasorcs
nrtOirae, Itvuior and apbincHir aoi ; anterior to the latter was anorher
ellijiLirul gphLiicteE' mu^ide, I'orre^fionding, probztblyf to tlio Hpbincler
TagiiiiC- Tho Irftosver^us ijeriuti, as /^ucll. was not mndu o«L
" The bladder is of ordinary fliao, but its tnuaculnr development ie
greater iban u^naL It hjia two ureters, normel its lo their entranc^e and
olLtirwisi^p Fnjiii the iDlt;mhi orilli:c of tho hbiddvr [tj the 'vagina
uruLbrolis ' it is I ^ iui-h. Laid open uJon^ its nntcriar surface, it& nOck
19 Embrflced by a bi-lobed pro^lato glauii of about half the natural
adult dimensions; pttsieriorlj to rliU. tlii- nGc-lc ]a Lhi<;kenEd, and ths
section ie as llirougb a fitructure resembling the pitrsiatO' Ou sijufei-
ing Lbi! jirontQliJi ils Be<:relion is seen lo i&aiie ibrough euvernl aporturca
on each J^ide of the urethra, where the prostaiiu eiuus usually exists.
There is eo venuDontanum ; but where iL should be» and where the aiuus
pocularifl would be foundf the urethra and vagina blond, and a probe
HEB«ArjTR0Dl8M.
315
maerted uml pnsaeil bzirkwartla cii!frs \\\e vnglna ; papspj forwanle, it
nppours extermilly at the orifit'e in iVont oi' fUe nnua. llehirid the
bliulcfpr are found the titenis tuid viigma.. On dlsi^t^t^frng up the hlnddt^r
froru ihb vngina, as fur djwu as the proeUkLc, do vesiculic acrnmales are
to be foQUti
^Tfae uterus and vagina are 5J inches in length. The uterufl, 2^
inches long ami 1^ inrh wide at its widi-'ft jinrL f^iiHist* of ruiid]i9,
bodv, npck, nnd os. The m^ck lin? uninsuiilly well-marked aibrir viloj.
Jusi williin Ihc 05» the mucoua munihriine npfn^nre abraded. The body
has a trinn^lar cnvity» into wlii'-h the Fiillopmn iiilw»9 tnier by large
erifloL'S- nie vngina, .'^ inrh«,i long jirul Ij hicdi widti, ia ru^oiia,
eapedally near its lerminalion anLtriorly, ord liaa disiincl tolumna.
AuterioiLy it contraclB to turminaic ia the eontiE ofHiLinon to it and the
urtihra, uDit nt ihis ^oIdI hns a sulHL-icuily vretl-marker] hymen.
"Till: Falliijiiikn lube uf the n^hl dule prnaji^ uirto he hluwn through
itfl whole Icfi^lh. Near ila inrmi nation in a fimhrialed cxtrcmityi it
htii-ome^ a little convcluted anil dilated, iLs Length ia 3J inches. At
a dimanre nf '2\ ineEie^ fTom ihe iiIt'niKf on the ]e(i side and in its dsuhI
poAiiiou* ia ibii ijvary »ilh a lubulatt'd auiTacep
" The broiid Ij^unent na cai'h side e^iats as in an ordinnrj female
uterue^ On tho left side, (he ruund ligament i^ to be M3on diverging
frrjro iIhi Uro»d. juid pun*iiing, sii fnv oA lrnc('iihlu» ihe iisnal eoiiree
whidi it would put-sijij uudtr ordinary ncalomk'ol £.'oniil(i>nn. On tho
right eidu, the Fallopiaa tube ndnits the passage of air only for a cer-
taiu dlsianc'e. N&arll}e uEerua, it is of large size ; hut it soon dimioifibes
and hecomuB dEnallur* It 'us tracL'ahle to Ihe (loiut at which ihe *eord'
of ibo tumor W[i3 divided, and ia acctjmpnnicd by ihc round lignracnl in
its whole distanee ; uo appearance iodicating the usual divergem^e of It
frnm the Fallopian t\i\te on ihe anterior siirfaee of tbe broad lignmant-
No ovary ia fbajid on this aide.
"The reclum lies bohind ibo ulorus, and is in all irapcets normal."
Dr, Ellis, raicroscopist tf> tlie Hospital, gives U9 tlie follow-
ing reeiiiifl of his invoeti|ritioa : —
** Exiimined witli the luicrosfope, llic breaate were found to be com-
posed of lihmus tifsnt, nnd a t'nw Bmall nuclei. No lobuk'S wtre aeen.
**Tlie masd reinovod before dealh ronsialed of two jiarUi, the largest
of wliidi wa.^ rounded and ftuhd ; ibe ulher was c?*iDfH>»cd of cy^\s. The
former vvua 4^ biijlita long, '^\ wiJi?, and 'J( thick; Ihe Inll^p, two or
three Incdiea in diaioerer- On c'ioee examitiation, nuiUing like a vaa
defercaa euiiJd be fouud ; bnl at out! part were a number of puridlcl
blood veut^b*"
316
FF^MALE QENTTO-UBIKAnT OBOAKfi.
Mtmarhs, — The iiitcrnnl or<;jnTifl, in the fmHC wc havo been
considcria^, accm evidently to btltm-^ to tlic female ecs, with
the exception of the pi^oetate glunJ- The iinpoitant'c of diia ua
connected witb the mnle acxuol Gr;^na has diminished in ibe
eyc8 of diatinguishcd piiiloeuphical anatcmii*td who have lately
writtca on the tiuhjectt bcin^ coneiderod ad much an nppemliige
to the urinary organs aa to the sexual. We therefore, with
aonic difficulty, account fi>r the impttut^ given to the external
mide organization, heard, larynx, peni?, and general niaseuline
formation of the body \ and the viewa we have entertained iit:
regard to the eft'ect of tl»c sexniil organ^^ on the cxtcrnjJ charae-
tor aeem to be very niueh diaturbeJ by the proeent cneo. It
mi^lit be very interesting to truee tbc nnalogiee between dift brent '
organs in the male ftud Pcmule Byetcnw, which are euggcatcd in
this instance ; but we will i"cfer to the very thorough and inter-
esting paper of the distiiiguialied Profeasor Simpson, of BdiiL-
burgh, on hermajihrodiaia, in the second volume of bis obsletria
works, edited by Dr. Pricatly of Edinburgli, and Dr» Horatia
R. Storcr of Boatoni where this whole subject has been moiA
fnlly elaborated, and we may almost aay cxhauetcd.
In connection with the above caae, I append the following,
reported by me to the Boaton Society for Medical Improvement,
in May, 18a7, and extracted from their records ; —
"The Riihject oflhis very nneommoa deviaiion from naiure was 25
yenra of nge, bora in Maine, of healthy paronle. He was by oecopa-
tioQ vt aailor; Jind ihc aptieurancGH to be iJodczrlbcU weit^ only dj^ovot-ed
whca brought to the prison, where, or being undresat*! to put on thftj
pHsoLi elulherL. lie w^s ilioLj;^ljt, froni Lhi:^ lur^e &i/e of tht brcoslN Co bm]
a female in did^uise, and wa.'^ tlicrefurti Li^aQafcrrcd to iho surgeon
cha institution, Dr. Morris, for extmiiimEion- On my visil to hi£ eel
he seemed to have nn objeelion Lo an examination, when it vras e:
plained to him tli^t it WLts for a edealific object.
"Beginning with the iaee, the fcaturoB aro i^oEl. and the osprofiBJoa
mild; thpre ia no lii*ard. Tlie nenk is of medium ^xtx and length, but
rising tovhujd tlii; huc'k< as iu tht; f^nm^c. The shoulders are tdoplug,
round and smoolh, the lausdea not beiug prominent. Th^ upper ex-
tremities are ilelicate, and llio hamls t^miLlL Tlio breastB, which ar<s
th& nichit striking fii:tiiJre in (hia peraon^ are large, nroM-dtvelopEd tivt^n
fbr a fomal^T quite handsomely formed, with large blue velna rtinning
HEBHAFHBODTBU- 817
overtheoa, ha in & nursing woman ; the nipples being largef wttb a broad,
dark areola- The abdomen is quite prombenc; ihenavddeep; the
hipB very broad, aa in the female. There is a small penis. The scrotum
and teslicles are very small, the size of the latter being that of a bean.
The logs are short, the middle of the body beings by measurementf half
way between the umbiliuus and the pelvia, instead of being, as in the
male, at the pubic region. The voice is maaculliie; the sexual propen-
siUes normal.
*^ Tbe remarkable feature of this case la the fact of the small male
organs of generation impliinted on a body almoet entirely female. Cases
constantly present themselves to the observation of medical men, of
malformed genital organs^ hHving the appearance of a combination of
the male and female; also of men with a large manamary organ- In
this case there can be said to be no malformation."
CILiPTER VIII.
THE EXTREMITIES.
FRACTnilES.
The great impcrtnnco of these injtiriea, and the absolute ne-
ceeaity, in most caaea, of proper treatment, have given them
a very prominent place in the surgery of nil nrres. From the
enilieat times of wliich we hjive any record, down to [he present
dfty^ the trentinent has been oaeillating between the employnient,
on the one hund, of powerful eng'inea for their reduciion and
retention in place ; and, on the other^ <if simple rest in an oflsy
position. Both of those evEreme modes of prncLice bave l>een
exfensively employed within the past thirty yenre, and Loth bave
undergone grent improvements.
In my early pracike, I was in the habit of Inying great stresB
on an immediate nnd exact application of retentive measures t
often, I Tioiv think, to the discomfort of the patient, urid per-
haps in deference to the prevailing opinion. 1 have since
become convince"] of the propriety of dning as little as posaible
ffjr the first few days ; and have generally been content with
nijikintr a sUirbt e^ttenjJiion, so as to brina; the broken ends of the
bone to*retber so far as they wjII come without violence ; then
wailing until the irritabiJity of the muBclea Las subsided, befora
proceeding to the application of the permanent apparatus of
splints nnd bandages. In many fractures, wliere great immediate
tJiatortion is produced by muaculur contraction, after a few days
of rest, combined perhnps with gentle extension, the broken
boQca seem <juietly to settle down into their proper places ; and
the whole treatment, sifter the proper upplieimon of splints,
resolves itself into careful watcliing, with occasional slight
mnnipnlationa to remedy accidental diaplncements, and to prevent
excoriation.
FRACTITRER-
31*1
Professcir Tlflmilton, of New Ywk, by ihe ediibitior of a
greal number of cnses, treateil with the best received jippflriiius,
Ims laid the profession under great obligaiionflT by showing; that
the perfect iwlnpl:Ltii3n of broken bone, and n cure without de-
formity, is the exception, nnd not the nile. To any one who
takes a rational view of the question. It will easily be perceived
that it 18 not the bone nlone which is injured in cnsea of frac-
tutx? ; but thiLt the soE\ parts, auch ae periosieunii must^leSi
fiuctA, ami integuiuenC, are more or le^i^ implioated. Swelling
ensues; and, even if it were possible to exactly discover the
siluaiion of tlie fnictured ends, the manipulation is reaiateJ by
the patient. £[her, wltich of lute yeur» has nsttisred ao much
in die dla^osls of these coBea. ie not alxvays at hand; and,
evon if the bone is replaced with its assistance, displacement
may at once recur from the Irritated musclcB. Generally
fipcaking, a sliirht inequiLlity about the bones is of little conae-
quence. AJthouffh looked on hy the public a» owing to a want
of skill on the part of the surgeon, it is, in reality, unavoid-
able ; and ultimately, jp moat cases, nalure remedies any incon-
venience caused by it.
Fractures in the nejghhorhooil of joints are always senou3 in-
juries ; and^ with few exceptions^ are apt to be followed by more
or less permanent deviation from the natural position of the
bone or bonce implicated. In fractures about the hip-joiut,
years may elapse before the lameness is overcome; and, in
many ca!?ea, it is permanent.
It ia impossible to state exactly the time necessary for the
union of a fractured bone. It depends on a number of circum-
Bianccs ; namely, the health of the patient, the manner in which
the fracture was received, the pnria injured which are ntterwatds
en^a^ed in the reparative pnxx^s, and the treatment. In chil-
Idren, nt the end of a month after fracture, I have often observed
myaelf^ and requested others to observe^ perfectly dry crepitus
tliat could be felt between the broken ends of the bone ', the
limb, at the seat of the fracture, being Hrm, and, to ail appear-
nncesr able to be used.
Angular distortion after fractures FihouM be treated, as soon
as discovered, by gradually increased preASure, applied by meona
320
KXTIfEMITIES.
of a *trflip;ht splint nnd roller, or nJhcaive atrnps. It Js worthy
of remiirk, that very grcnt deformity may be corrected in ihU
vray in young persouflT ^VQ^ lorig Mftei" the receipt of the in-
Fnicture of the clnvit^le is pcchnps one of the moat comraon
of the injuries to bonee* and is one of the most troublesome to
treat according to the old eomplioflted method. Miiny years
since, the simple npparritng of Dr. Foic, of PhiWelphia, was
intnjducL'd by me into the Massncluieetts General Hospital,
where it cominuc;) to he used with some sliijht modifications.
It consists essentially in a pad for the axilla nnd a bag for the
arm elung from the well shoulder. Many eases of this fracture
do well without eapeeial trentment ; and we often see it already
in a fair way to recovery in ^'Inldren broii^lit to na for supposed
lameness of the shoulder, resulting from a fall a week or two
before.
Frequently, from the swelling of the soft parts, the cellular
jnciubrnne in the neighborhood oi' the clavicle being very loose
nnd extensible, it is almost impracticable to discover the frag-
menU. By placing the patient on his back^ with perhaj>a a pillow
between the siionlders, ns the swelling subsides, the frngmenls
will generally L>e fuund to hn^c assumed as good a posltioa
SB they would have done with the most elaborate apparatus. In
comminuted fr.ictures, the central fragment or fragments are
usually beyond our couItoI. In one inatanee, I have fleen a
shar|> piece of the bone st^inding at a right angle between the
outer oncfl^ wliicli could not be displaced by any justifiable force,
nnd threatened to make its way through the integument. This
was prevented by means of adhesive plaster, npplied in such a
wnv as to bring different portions of akin suceessively over it,
nnd thus too long pressure at any one spot prevented- The
eluirp point w.aa nltitnately partly abaorbeJ, and partly efl-
veloped in the callus ; and the patient recovered perfectly, with
the exception of a very slight irregularity of the bone. The
reeulta of fracture of the clavicle arc almost always favorable.
In the very large number of caees which have come under my
notice, r have never known union to fail e?ccept in one instance,
— thiit of a sailor severely injured at aea by a fall from a maat,
PRACTCBEB.
32L
imd not subjected to trcntmcnt, the blow being a direct one at
the Bcat of fracture. The ordmnry obortening wltich occurs
after thia fracture doea not accm to iiupftir the power over the
arm.
The diag-noeis in fracture of the con<IyIcfl of tlie humcrua,
with dislocation of the foi-c-ann bwckwanlfl, or Sn fracture
of the humerus just above the elbow-joint, in the adult, is ren-
dered very ubscurc by the swelling whjth almost immediately
cnsuea. The foi'c-arui may uaiially be ca::Hily drawn into place,
and the injury thua di^tinj^r'uUhGd from a eimpio dislocation.
Splints are borne with ditticulcy ; and it h nccesaary to keep the
patient ju bod, with the arm rcs^tinf^; on n pillow, nnd apply
cooling lotione to reduce the inliammntion. When this is ao-
compUdiod, angular Bpiitita of wood» guKn-pcrcha, or paatc-
boarj, may be used to steady the joint. ThU fracture, under
the beet trentiticotf is apt to tcriutuatc ^vitli more or Ic^s loss of
power to flex and rotate tho fore-arm. Ultimately, however,
very serviecaLle uhc of the limb may be gained. The injury
uaually occurs from a dii"cet blow ; and the inflnramntion of the
Boft porta in the neighborhood of the elbow is more acvcre
than in aimi>le dislocalion which rcpulta from iadireet violence.
Fracture of one of the condvlea of the liumoriirt into the clbow-
joiiii ifl very apt to Im foUo^vcd by aillic^iona ami lose of motion.
When there ia lujtjUion of the joint, in addition to the fracture,
BpUnls beeome necessary; but ahould be removed, and passive
motion begun, as soon as the tendency to displacement la over-
come.
Fracture of tho lower end of the radiLS, which ia of so fre-
quent occurrence in winter^ from a fail on the honil, ia apt to
be followed by deformity, and impairment of the motion of the
part. 1 have treated tliia fracture, in many cases, with the
simple ond Jngenioua spliut invented by Dr. Henry Bond, of
Philudelplua. For facility of application, as well as for tho
comfort of the patient, it appears to tne to otlbr im])ortant
advanta^ over any hitherto invented : not excepting the fa-
mous piBlol-abnpcd splint of Nfkton, which, however, in some
caeca perhaps, may be found very useful, ca^iecially in those
attended with much lateral displacement. In Dr. Bond'a Gplint,
41
EXTEEWTTIES.
Ac hand grasps n wonden jjfld, the fint^e beir»g left froo during
the treatment, txtal suihcicut mtftiun jtlluwcU llicm to prevent llic
etiffnesfl which is npt to take pJnoe where the crm ain> hand
cro confined by brtiidnp;e3 between two epUnta.
Fracture of the lower third, or email part, of the lep, is
often diffieuU to manaj^'e, «winj; to a projection of the tibia
which occure, attended with more or Ices dcvlaticm of lie leg
irom a elnu^jlit line; giving rise oceiLeioiinlly to lamenc&fl, by
rcBtricting the ran^re of dexion of ihe ankle-joint. This devia-
tion is best avoided by placinf^; the limb upon a double inclined
plnnc, ajjplj'in*; extension and counter-extenaion by meane of
adhesive fitrupa, faetened above by upright Btanchiona, connected
Tvith the leg part of the nppiiratus, itnd below to the foot-piece.
Where the akin is tender, ondobnoKioue to pressure, jsuepeneion
may be tried; the foot bein^ well elevated, Thia fracture may
aJso be saeceflsfidiy irentod liy the starched or }>lafitcr bandage.
A slight decree of deformity ia almost always left where the«
hoA been diephicenient in the bcpnning.
For fracture of the fibula near the anlde, with displacement of
the lower fra^'nieut, the powerful aide-^pJint of Dupuylren fill-.
file nil indications-
Transverse fracture of the pritellaT attended, as it often h, by
great aeparation of the frjif^ments, may be moat flnccesafiilly
treated by position alone. Thia 1 tried at fir^t with the body
elipfhtly bent, and the limb raifled at a ^Tcat an;;le fixjiu the bed-
Tbe eflfect of flexin*,' the thi^'h i^o tnucli waa to render the
patient very uncomforlable. I waa therefore led, aa an ejtperi-
mcnt, to place the hmb perfectly flat on the bed, which 1 found
answered better than the theoreticul posture devised with the
idea of mare perfect muscular rela^Lation, The old methods'
for confininj^ the upper frajrment by bandages are jdwuye ineffi-
cient, ucleps aided by a correct position of the limb, and nre
Tiaelcas with it. They give riee to great swelling and mucb
necdleHe sufferinp^, besides oetually dernn;;inii^ the position of tho'
fragmente by ao tilting them as to prevent their pmpci: approx-
imation. By the u*e of the ingenious ateel hooka of Malgaignc,
it \s claimed that a still more necnrale adjustment of the pirta ia
obtained ; but the plan has found littlo favor in this country.
FEACTHRB9.
323
The inatancea cf this fracturi? ^vl^ic^l have occurred ia ray prac-
tice have been chiefl/ liic rcf^ull of direct violence, though quite
a irnmbcr of them were cimscd by tuuactjhir contrnclion done-
Twice I have met with fracture of the patella from the kick of
a horac ; one case did well under the use of a starched bandage,
there ht'ing but little scpiiration of the fingmcntJi ; 'ii\ the other,
the banc was broken into acvcral pieces, and the knec-joiTit im-
plicfltcd, prmliit'ing an inflammation which retiulted in death,
Trjuiavcide fracturea of tlie patella are united by li^;uncQt,
acconhng to my obaervation, aod perpend icu Jar onea by bone.
The latter leave no troublesome crt'cctfl as a rulci the opposite
being true of the former*
Fractures of the thigh of late years, unless for eome epeeial
rcodon, have been treated by the apparatus of Deanult, modified
by the late Dr. Flagg uf thic^ city. It conaldte eancntially of a
lung outride and a ^hort inside splint x a band around the bodj
with a periacjd sti^ap attaclLcd to it, fur co u a ter-ex tension, and
a croes-piccc hclow, uniting the outer and inner splints, with
straps of adhesive plaster between for cxtenAiun, The inechod
of cxtenaion by banda of adhesive plaster, by whicb auch good
results are ohtaincdi la due to Dr. Joeiiih Crosby of Mandies-
ter, N,[I. I have employed euccetisfiill/ at tlie Hospital,
within a few years, as have other surgeons of tliat inatitutjon,
the plan proposed by Dr» Buck, of extension by meanH of a
weight attached to tlie ibot ; the thigh being supixirtcd by
ehort padded epluita, and thu counter-extension ohtiuiied by a
periuenl strap. By raiBing the foot of tlic bed, the weight of
the paticnt^a body. In most inatanoea, gives sufBcienC cotinter-
cxtcnaion. Dr. tiwinbumc, of New York, has modllicd Dr.
Buck's apparatus by dispeneiug with the use of all splints tor
the thigh. Evcrsion is prevented by placing bags of aand
by the side of the limb. The great advantage of this treat-
ment consist:^ in leaving the lunb open to inspection. It must
be flaid, however, that we can use this method only with in-
telligent and perfectly docile patients. In very old and feeble
|Ksreons, who frc^jucntly cannot hear even this eligbt restraint,
the double inclined plane or tractnrc bed arc to be preferred to
any other apparatus, and permit a greater change of posture*
3S4
EXTttEMlTIKfi.
I have fleen a few cn§e3 of oblique fracture of the lower part of
tlie fetintr, just sbuve llie camlyles, cfLiised by a ?a\\ from ft
lici^lit, iiii (lio knee; the upper fni^nitTil pnijectiu^' up juBt
above the joints and reaifiting all e^orts for its reduction. This
wiis the result of perfuralion of ihe muscles bv tJiK upper sharp
fragment. In Sir Astley Cooper'e grea.1: work on iJialocationa
ard Fractures, this is well depicted. The process of restora-
tion goes on very slowly, and the result is that the fragments
unite »t iin nngle. It is po^aibler when the nature of the t^ase
IB detected early, that the bone inio;|]t he disengaged by man!*
piilaliane under ether; but the swelling caused by ihe injury
ensues so nipitlly, and U eo gi-eat, that the exact condition of
the parts is liable not to be reoognized.
In oblique fractures of the femur, except perhaps in very
young children, more or less sliortening- always remains, even un-
der the most skiiful treatment. It ie* however, generally so slight
na to be of but Itttte consequence, frequently not exeeeding a
quarter to a half inch ; In which case k is compensated for by
a deviation of the pelvis. The lime rerprireil for the union of
a fracture of the thigh is usually HtntL>d at six weeks ; but it
does not follow that the callus has Income firm enough, by this
time, to udmit [>f the use of the limb in stamlin^ or walblntr.
The too early use of a frjtetnred limb is often followed by the
gi-aduid bending of tlie bone, resulting sometimes in conaider-
able dpformiiy. If, for any reaflon, il is thought proper to
allow the patient to rise frrrm bis bed at this stngc of the trent^
ntent, the liuib should be aupjiorted either by splints, or iha
fitarchsd or planter bandage, mid crutches ueeil for a time.
Patients with fracture or dislocation of the Bpine, the latter
helng seldom unaccompanied hy the former, I have often treated
in public and private practice ; and have a few times cut down
upon and removed fnictiired and di.splaced pieces whicli were
pressing upon the spinal eord. In one instance^ — a man wbose
neck was dislocated from being auddejily and forcibly bent down
by striking agjiinrtt a beam, while passing into a sbcd on the top
of a load, — a temporjiry reatonition of innervation was jirodueed
by making tractions on tbe liE^ad, by which tlie dialocatiou was
reduced. After thie, the patient waa placed in bed, the Leocl^
FH ACTITRES .
325
of it "beinjT raisec!
form an mclined pL
ith
Btron|T
hxn<X uiirlci" bis chin. He died, however, with the usual eymp-
tomfi atteodlng thU accident- I do not remember^ out of quite
a ]nr*ro number of ihese injuries thai Lave fallen under my ob-
eervaiion, a sin|T|e axse that nas benefited by any o[)er]itive
procedure. It may poaaibjy be the case, that this bus been too
much neglected of late years from tlie want of EUCcess attending
the operation. An insfsince may oecur now and then in which
an operation iiiigltt re^uU bappiJy. The suhjeet haa recently
excited coneiderable discussion abroad.
Of modern npplinncos for the Ireatiaenl of fraeturefi, the
ftfarfhed bnnda;re of Seulin, or, still better, tlie dextrine band-
age of VelpGfiu, or the plaster of Parla apjxiratiu, ore among
the most important. There are, (n fact, but few fractnrea
in which thev are not useful at some stam^ of the treatment.
■ o
In simple fractures, where there is not much injury of the soft
parts, the bandage may often be applied with advantage im-
mediately upon the receipt of the injury. In other cases, it
is necessary to wait nntU the ewelling and inflammation have
subaided. After union has been ejected by the use of other
appIiimL-es, the starched or dextrine bandage is very useful in
supporting the nowly formed callus, and guarding the limb
agikiui^t accidents when the patient leaves hia bed.
The application of these bandages is very simple, A dry
roller of old linen or cotton is first ap|tlied, to prevent adhesion
of the bandage to the skiO' A. common roller is to be dipped
in the adhesive liquid, either starch paste or solution of dextrine,
and is then to bo applied to the limb in the ordinary manner,
taking care to make as few reverses aa possible. The dextrine
solution, which may be made in part with alcohol, driea sooner
than the starch, and make^ a firmer ca^^e wilh the tiume tiuok-
ness of roller. If starch i^ used, the whole should be strength-
ened by strips of wet pasteboard, placed on the outside of the
dry roller, before applying the fctiirchwl ono-
The plaster apparatus consists, first, of a soft dry roller or a
thin layer of cotton, applied next to the skin, and covere*! by
a second roller, wet with water. The whole bandage is then
covered with piaster mixed with water to tlie consii+tent^y of
326
EXTREMITIES.
thick crcnni, and confined, if necessary, by another roller. The
aurruce of thie may be smoothed with a little more plaster, ajv-
plit:d vrith the palm of the hand, and the whole apparatus com-
pleted by a coat of ehelluc viimtEdh, This appnrntitB ia easily
applied, and becomes perfectly solid in the eourec of tlic short
time required for its application. The platter ehtmld not be
wet until the moment it is to be used; and, if it still Mta too
quickly, a little alum water may be added.
The etarchctl bundn^^^ may be emplnycd with grent benefit in
those vexatious And often unmanageable injuries, — apraina of
the ftriklc ; thus allowing, in some cases, of locometioTi at OTiec,
whcro n tedious confinement would be necessary under other
treatment, I have alao employed it, for the purpose of com-
presaioQ, with cxecllcnt reaulta, In that very trouhlcsomo dJscaae,
milk absceas*
Case CliXXXVl. — Fracture of the Malar Bone. —
1861, A gentleman, walking iu State Street, was run against
by a drimkcu man, who atruek him on the aide of the fuec with
hia head, fracturing and eftuaing the depression of the cheek-
bone. I saw him immediately after the nceidcut. He eaid that
he felt at the time ne if he Eiad received a blow from a hammer.
The malar bone I found broken, and the external portion drirCTi
in, and firmly fused. 1 made an effort to raise it: firat, by
mani[)ulntions on the outside ; and afterwards, by ]jnssing the
fingers into the mouth, and forcing them up under the zygo-
matie arch. Failing in Uiia attempt, a wooden spatula who
pressed up in the same way, as Far as it would go» and an effort^
made to pry the bone into place. The effort woe ineflectual,
ati<l the bono did not eccm to yield In the least. I thereforo
ndviacd the application of an evaporating and anodyne lotion
to the face; and asked him to report himself to rae again in a
wcok, ofl be lived out of tov^. At the and of that period,
1 f'iuD<l tlmt he bad ]>rotty much recovered from the soreneaa
produced by the blow : but the depression of the bone aiill
continued.
I had oecaaion to ^ce this patient for another aecident, nearly,
a year after the date of this injury ; and found the face quiti
FHACTURES,
827
well, ftnd the irrejriil^rit/ of the >>oiie <?om|jletel7 oblitovntod.
The pnlient informod ine that he hnd experience J no interference
either in the mu^eular or nervous apparatua of the fiiee. The
orhit, iQ Chlfl case, was not ap{>irently implicated in the fmc-
ture.
In a BimilAr case, which occurred about the same time, the
flccitlent being produped by a blow of the fiat, nnd in which
T irnde the same efforts to reidnce the bone, but without efleet,
the nltiinate result wivs the same. So Jlir its T kii[>w, thU im the
u?iinl history of those cases ; JLltempta nt ropliiceinent being in-
effectual, and the results generally favorable.
Ci^E CLXXXVn. — Fracture and Depression of the An-
terior WaH of the Superior Ma^eillary BoTie, with the Malar
Bone. — The following is the only instance I have iieeo of this
uncommon ncc^ident. A gentleman coming one from bjithing
slipped suddenly on the seaweed ; and. before he could protect
himticlf with his hunds, fell, n prtijeotin^ rock striking him under
the eye^ and depregi^ing ihe midar and the upper part of the
maxillary hone at the [nargin of the orbit. The aufferijig ttt firi>C
wne intense, and, na it suhsitkd. left the jiiw and the teeth of
that ijide in a booumhed state. Tlje depressed portion wa& 6xed,
ftnd of course coidd not ha^^e been eleiTited except by means iif
a trephine. Tlie patient recovered well, thoHp;h slowly, and
without peroeptihle UoEormity ; the nerves of the tuotb being,
for a long lime, in an in^en-tihle state*
C\,SE CLXXXVUl. —Frtichire of both Upp^r MaxiUm^if
Bonefi-, and Separation ft^m Jiones of Face. — An old lady,
aged TO, descending some ateep steps into a cellar, foil, and
received the full force of the fall on llie faee. 1 saw her shortly
afterwards, in a state of imminent uuffocation. The superior
maxillary boaes were detached, and hod been driven back into
the throat; the whole face, in liict, appearing as if forced in*
wards. Both from the bJooil^, and from the obstruction caused
bv the pressure of the bones in the fauces, breathing was very
laborious, and wati becoming leas and less possible when I euw
her.
ExixaariES.
Tbe boBBi were dnvm fanrvdB« wad cmO^
pUuv: naMTTtaee uC the ili^J«^«*«» ww
bukdigB, aecurio^ the upper u>d lover jawi Uigctlia'a
fiKid b«uig ^ren beCwccn tlie teeth.
Great nrelliag and eockyiouus uf tkc face AiOovrd ; bat tW
indured pairu uniioJ well wilh tlie boon from wlikli ihey had
been AefMraled, md iKe wnmui faUy recovered.
T luTe twice met witli this accident, boch caws occnrring in m
elmUar way.
Cai^k CLXXXIX, — Fntcture nf Epiphyn4 of Betti of
Hamtru-s. — In Jii&e, \^T->h^ d girl, 16 rear* of age* wwm
brtiuglit to me, wKu hatT fallen duwn stain the ni^C befone* aad
wH» »aid »1ie liarl wrenrlipc] her nhnuliter. Sfie oould not raise
ttie ami willujut great iliffi^ultv, and tlien? iraj« niticb teodenMea
over tlie dL*)[oid muitole. The «ha]>e of the shoulder waa
Daturai, the head uf tlw bune being evidently in \ia place. On
sHzing this with '>ne hand, bhiI rolatinj; ihp humerus wiib
the ullier, ihe fieud of ihc bone moved with the ehafi, and no
crepitus \sAfi felt'
8he vru> fmniiTicd by a number nf Hiirtreonfi. nml Mime
thtmghi it lo be n rupture of muscular fibre;* j olhers, fitmp!j- 4
ilraln.
In tlm coiin*e <jf llie invesli^ition. the arm vjtp raided up to
a ri^fbt Jm<r1e, unt^ earned aumewhat backwnnls, when, lin ruta-
tii^n, an fjcx^a^ional crepitus could be di«linguished.
ThiH examiiiaiicjn bein^ bnmn with dtfficLiltv^ it waa dere^
mined to i/tltenze her, wKi':h her piirenls wmitd not eonsent 10
till the followin^day. The ne*l iliiy the tviie pbiced fiillv under
ether ; and, the uiurwIfrH being rekxeil, the herul r»f tbe bono was
projeeted fitrwarilft, iia had fjcen done the day before. Tlie epi-
phyAiA could now be Aeiz<^l wilh ihe finirerH; and, the shaf^
bein*^ rolale<l. It moved freely wllliin the capsule, independently
of the re*t of the Ixnie.
A [uul wiis placed In the iixilln, and a t^houlder-splint ap-
plied: the arm waa confined to the Hide, and supported in &
flling. She canu' to the }loMpit:d, from time to lime, for advice
nnd dreasing. TJie bone umteil very rapidly, »uid, in tiie eourite
of a Tow wi^ckd, ihc uiotious of the arm were entirely restored.
FRACTDRES.
3^9
This case is r|uitc inlerestinc frtun its rarity^ °'^^^ from the
foct of the obscurity of tlie Ultt^osis ;- uo ci-(?|nlu3 btin^ fell
while th<? am was npplied to the Btdc and the hoad of tlie hoUG
dtawD tightly up iuCo the Bucket by the irritated musclce.
These, bmn^ rc^bxed by cfbcr, disL'Iorfcd the nature cf the acci"
dent.
Case CXC. — U)ittmltd Fracture of tht Ilamcru/s^ Bt-
ttm~ Cure. — A iriuii, 55 years of age, wru brought tu iiic by
his phy^iuhin, in the Intler part of May, Id^l^^ with no unuiLiteJ
fracture, ^ituuted about (be iniddlc i)f the rtgl^t buuienis* Tlje
fracture Imd birn ciiu^ei.'d pix nmutha before by a cart ronmng
oTcr t}ie arm. It hod beta trcfited in the usual way, by epliDts ;
but tlie L'udd of the bone hail fuilt^d to unite, and the limb In
couaequenije wua uficle&s : the fore-arm mi.i flejtcd ou tlic itrai,
and the elbow was more or le^e etid\ There waa complete flexi-
bility of the nrm at the seat of fracture, so that I had great
doubt aa to the auccias of any operation.
This ease beliig an ap[iropriate cue, I determined to try the
seton. The fracture waa obliqUL'i Lhu lower fragment lying
directly anterior, the upper pofalerior. An ijistruuieut travcri^ing
the fiaaure, between the t^\o fractured eud-"^, wh?^ liable therefore
to Hti'ike upon the bundle of veseels and nerves which lay directly
agoindt the interuLd line of fracture, rendering some canlion
neeestary in tbc manugeiueut uf the opemLion, which was done
as fullows ; —
A long incision, corresponding to the line of fracture, wai6
mmle directly behind it; and, by di^aectiou, luus^cular fibre
was cxpofled, Tbta being satisfactorily usecrtaiacd by tlic point
of tJie finger, and the vessel* pulled forward out of the way,
the ectun-nceJleT threaded with a akein of ailk^ was forced be-
tween the fractured eitda of the bone, and tiirough the muacic
and skin of the opposite eiJe- A free rush of artcrud blood
followed the passage of tlie instrument; indii'.atlnv diat some
arterial braiteh, of eonsiderable aize, had been wounded. A
folJed towel was now placed over the wound; and firm cotu-
prBiflJon made, by means of a roller, from tlie baud to the
4£
a3D
EX THEM I TIES.
filiuuMer. Tlio pnticnt v.-^e pbiced on his bnck ir
the arm ("Icvjitcd on a pJlow In tho bent putJitRin.
lie pue*jf:J n preity t'Onirortalle iii;^hl, nnd hnd no bleeding-
Thc boTKlftpie w.i8 reinoT<;d ; but the doth, whidi ha<l become
saturntcd with b!ootl nnd dried, thus forming a cln&p round the
limb, -Aas not intcEt^^red with, ns it vrns found tltc cimuhitioD m
the nutin veseel was well pertbrmcil.
All the dret'^in*re were removed on tlio fourth day : the arm
nnd fort^-arm were jduced in a giittu-pcrclia B[ilijit, well moulded
to fit the in^ido.
No i^on&littitioiial irritntion of any conP(^r(ucnce followed the
opemtion, or nny piiruleut depoeit, eueh ns I hnve frequently
witncPBcd. On July 20th, after the ecton had been in plnce
thirty tliivBj tliere being some indiention of this ooeurroncc, the
aeton wna withdrawn. The wounde at once rapidly healed;
nnd on the SithT an exaniinulion being made, the bones were
found firmly united, nnd he was allowed to hiy aside liia eplint^,
and ''o nbout with a ^lins*.
Shortly ulier this, im attempt huvirin; been mnde to overcome
the BtiflbesB of the elbow, which had remained firm]y tlexod
einoe the treatment for the accident, the mobility at the seat of
fracture wna agnin felt. The aplints were therefore re-applied,
when union again became firm ; and it was deteniiined to make
no farther attempts until the lapse of time should have insured
the huny conEolidation of the humerus. This p^^int is worthy of
notice, as I have twice seen a fre*h union in the femur destroyed
by atteraptfl made to overcome tlie BiiilheBs of the knee-joint.
Case CXCI. — Fracture of the Longer End of tht Ra^
dius, teith othtr FracUtrci. Deat/i. A.titopni/. — 1851, A
man, 30 ytars old, was brou^'hl into the Hospital, liaviog
fallen a distanee of fortv feet tlirough a scuttle to the floor.
The following is from the Hoepitid records: —
"At entrance, at 6, r.M,, there ia fracture of the right ra-
dius^ apparently jual above the joint. There is great deformity,
eimidatiag dislocation of the wrist backwards. Crcpitua dis-
tinct.
^Tlic right leg is shortened, by measurement, ono and a
FIUCTURES.
331
quarter inchcii. Ir is cvcvteJ, with ed^^e of foot lj"iQg flat upon
die ti»(jle. There h distinct orojiitus at or neur tlio cervix fetno-
rift. 'When preswng the two iliac creste, tliey yield sensihlvj
and give a feeling of indistinct crepitus/' He dieii nt 10, p,m.
At the siutopsy, llie following wore some of the pathologioni
nppearfmccs eihihitod : The right radius was fractured trana-
versely, Imlf an inch above the joints with a comminuted frac-
ture cxirndinfr inta the joint. The internal lateral liifament wjib
torn BWiiy frturt its attachmejitis to iha ulna, carrykg u bit of
the bone with it.
Tiie right feriuir wiw the sent of n commimitod frnetnre
lliroiji^')! the troclinnter ; nnd a longitudinal fracture of the shaft
of the bone eKtonded from iia cervix downvvordd fur four inchea.
Neither of the^e fmctures coniraunicalod with the capsular
ligament.
The right snero-ilinc aynchondrosift was torn asunder, and the
bones forming it fractur«l_ The rnmtia of the iachiiim and
pubea was fractnrefl. The lower half of the sacrum and os
coceygis were t^omminiiled.
Remnrh», — The fracture of the lower eitremity of the m-
diiia is an accident of peciilirtr interest to i^nrgeona from the
liability to deformity, in spite of the best-direclod treatment.
The variouH apparatus invented by distingu inched eurgeona, with
the ohjeet of preventing this deformity, ^huw the imporinnee
nitached to it- From simply regarding the external appenmnce«
pre*iented hy this fracture, it whh formerly supposetl that the
bones yielded in nr oblique direction : but observation of pniho-
logicnl specimens luia fthow-n that it u, on the contrary, almost
always transverse; the jvefadinr dcfuriniiy arising not so much
from the overla|>|nng of the fragments, as from the direcliofi of
the displacement by mn^cnhir acfifin. Dr, Smith, of Dublin^
in twenty spefiniens which he exmnined, found the fracture to
bave a transverse direction in eighteen. In the present instance,
it wna tmusverae.
Case CXCIL — Fracture of Arm , with Stihse/^nfnt De-
Joi'un'tif^ lii'^lnnifioit tiif Force nfttr Six 3ToulfiS. — The
following is an instithce of tlie length cf lime at which an an-
332
EXTREUITIES.
guW deformity from friictui-c may be remedied m a vounr*
perBon. The [latient was piiitly under uiy charge, and pu'tly
under that of one of my rjollenniiea. A boy, 16 years of age,
enlerod the HoBpild on the y«li June, 18ii3, who, six months
before, bnd fractured both bones of tlxe fore-nrni, near tlie
middle* by a faU. Splints were applied tioon Eiftcr lite aceidont ;
find, u'licn tliey were removed, &t the end of fi\o weeks, the
fracture bad united, but lite arm was crooked. This deform-
ity liad inorcaaed, and ibe usefulneHs of the arm was inipaired
by it.
There was a Inrge callus at tbe point of fmeture. The
deformity was of two kinds ; consisting of & partjid fixed pro-
nation of the arm below tlio fracmre, nn<l nn angulnr cutx'ature
in the eenfia oF flexion- Straight BpUnta, well [ladded, werai
&|)plLed on the flexor and exten^tor surfaces of the arm, siud]
firmly secured by bandiigea.
Tbe use of these splints, variously applied, Wfts contiuui
for one month, at the end of which time the arm was a vei^]
little straighter. The patient, being dissati^fled with tlie elo'
progress of the cure, although it waa gradually offefting the]
objeut, on the 10th of July was eiheriacd, and the ami for-
cibly Btraigbtened. The ordinary apoon-ehaped epiiiii, with a
ToUer bandage, was tben applied- In a little more than a montl
after the operation, the sbnpe of the arm was found to be noi
mal^ nnd the fracture quite firm. He wad discharged from thaj
HoBpital, with onlera to continue the use of the aplinis for sotnei
time. On the 12th of September, the fractured arm was ns
strong as the other, nnd perfeetly straight.
Fractl'Kes of the Pateli^, — For many years, I u.^ed
the ordinary' metbods proposed by Sir Aetley Cooper, Boyer,
nnd otbeTS, for the treatment of fr-icturea of the patella, such t\s
mecliaciic^ak contrivances made of wood, or powerful straps placed
aboTe and beloxv the fractured ends, which were approximated
by screws, straps, alnngs, or bandjigcs; and I was alway*
struck by the great paia and sM'clling prcwlueed by their fip-
plicttlion. They Bceaietl to ftcl principally on the akin, even
wlicn applied in a moderate manner, so as not to produce in-
FRACTUREa OF PATELLA.
333
jury of the intejriimcnt. If thoy hiul nny mode of ncting on
tlic broken boncf, it was to ilcprc^g thdr ed^cd, itad tljrow the
fraijtured faoes forwurdt*. Tliie idea ho& eince been verifi*id by
obeerving one or two epecimena in the MLiseuiu of ihe Boaton
Society for Medical Improvement, coUeeteJ by tlie didtin^iiflhed
pathologist, Dr- J. B. S. Jackatm. Secii^g the I'eeulte by the
old metbod, it occurred to me to tniet uhooet entirely to posi-
tion; the only aeceesory means einph*yefl beir;^ a broad strip uf
adhtiiivc plaster, with a hole in tbc centre In-r^ onou^di to
receive the patella, which is applied after tlic inflaimuotory eymp-
toiDs have sub[jjdeiJ.
My plan of treatment baa been this : Immediately after the
accident, the patient its placed on a bed, bis leg miecd on an
inclircJ plane, to form on angle of about 45* vk'itb lus body-
A cradle is now placed over the foot, to prevent the contact of the
bed-clothes ; ond comprcaeea are placed over the injured |>nrt, wet
with Bonie cooling lotion- In eaae of any f^^reat indatnmatory
action, leeches are opplial ; but thia has very rar'ely been necc?-
Hary- At a later period, when pieaeure can be borne wilhout
any uneaaineae, a atrip of plaster, arrnn^ed na almvoi after being
well warniedj ia nicely adjusted on the thigh by one end, Tlio
upper frognicnt of the patella ia then engap^l in tbc opcnini;,
slowly dmnjijcd down, and the other end of die piaster is then
made to adhere to the front part of the leg. Circular atrapa
may be used if ncceartary. The comfort of the patient m im-
meaaurably f^CiU, comfwired with the tormenting applications
formerly need; and the succgbs of the treatment is quito aa
good- Stillr it \s< eumewhat doubtful, wbetber, in moat enaca,
tbc fraelure would not do quite as well, placed in a bnm splint,
gently supported by bandagea without elevation. In fact, I
have tried thid pliia a nnmber uf timea, nnd with good auo-
cesa.
The late Dr. A. A, Gotdd, t^ number of years ftince, at the
time when I was first trying the method by poisillon, reported
to the Society for Me<lical Improvement the case of a patient
whom he had treated by keeping the limb aua^jendo*!, at an
nnglc with llie body, from the bedpoi^t, without bandages, wbiclt
wud followed widi gratifying success.
During tlie year 1658, himng hn*] n numlK^r of caaes tintler
my wire, out of iJie H4r»]>iial, in wliU;fi I was Mc to fulltiw
tlieir i^rrjgreas, I was soinewlmt siriirk at the viiriou* peHcKis aI
whicb |>:L[ienU recovered the use of tbc limb, ndcr the aovideuL ;
null fnuiii] !t much lijnir^r, in mti^t cust!^, llinn wju generally
0Lij)[iueieil. In order to nbuir information on the subject^ I pro-
p(t0Cil ihe questioD ai one of the nieelmgs of the Society above
men^oueil, and found fmni ibe experience of other medical men,
that Fui]u<? of their pntii-iil:* hatt recowrcHl in iibout three months ;
otb4^r« rtiiuired one or two years l)«fiire tbe siiflhess was luat,
and ]jower of flexion ref^toreil : one eaj^e wju?. nientioiieil in whu'li
t[ie pjiver uf the limb never rvturneUi and die jmtteiit wha
oblijjwl to go about on crutches. The recovery of the free
iDolioTk of tbe liuib did not ci)rrf;^|>*JTid in tlie^e rases irith tlie
completeness of the union of tlie se^tJiniteil fragments: some of
them doing remarkably well wltb qnitc a luug liguiucnloua
union.
I propose to Illustrate tbe ftbove nbserTaliona by a nmnWr of
cases wliich liave comu under my care, treated by lartuus
methudtt,
CaSb CXC'lir. — Fnirlure of PuUlfit. -~ A young lady^
about 2>i years of age, while barhing in tbe Eea« in alteirjptmg
to lilb u]> a cliiUI, fdt n Mit]ihn k[i;i|i uboiit tliG Vnvp, nnil imme-
diiite/y lost tbe power uf supporting herself, 8hr' was aH^isted
out of ibe water, anti tnkeii home ; when the left patella vsbs
found to have l>eeii broken, and the fniginenis sepunilefi fnim
one to two Incliefl. T saw her a few boiLrr* afterwanls. She
waa i]iri:cLed (o be pljK'ed i>rk her baok. the le-;; aiul ihlgh to l>e
idii^iitiy devilled* and a LMmpreai^, wet with spirit and water, ti»
be applieil uver the joint. Ueiiig suinewbiit dclirare ami dys-
pe[Kic. lier food was ordered to he careriilly rcgulale*! ; and, to
pjifclrdly obviate tbc 111 elTecte of confinement, nhe was lnitbe*l
over oace a. day with warm eult water, tblluwed by uiodernte dry
friction.
After tbe first or second day, finding no undue inflnmnintory
action aKiut [lie Joint, anJ even feiu'ing a want of at^tidu, tlie
wet applii.-JLt]<HJd were diM'outinued, and the limb plai^ in a
holluvr aplhit, more fuUy to prevent ilcxiuu.
FRACTUnES or PATELLA.
335
Thi? piLtient was confined about &ix wecfcfl bcfpre tlic union
BecmcJ to be auHicicntlj' firm tc nJlow her to get up- She wna
then permitted to rise ; a amdl epiint i>f ;>;LUtu-pL3rcliit boing
phuHKl nt the back of the joint to give it support. This was
removed daily, iind gontlc flcsion given to it. Finally, at the
end of ucarlv three Tuonths, she was able to bear her weight OQ
tlic litub, and go out sLipporlcd by a. cane nnd erutcb.
About citrhtcen monlbjs after tbc accident, altliou^jh cvory
means sueh na frictions, iubrieftting tbe part with ointnenta, and
m much ticxion as could be nindc withoiit danger of brcnking
the intervening li;;amcntDits union, hnd been ap]>licd, ebc woa
still unnbic to bond her Jcg fartlier tbun at a right angle. The
Bepnmtion of the fragnicnta wa& from a quarter to haJf an incb.
Once during this period, apparently from a. peculiar state of the
constitution, die had an ntliick of eynoviCid in that kiioc ; tlie
otlicr knco-joiat being, at the ^auic time, a Httle tendcr-
ThiB accident, it should be observed, occurred in a lady of
very dclicnte constitution. The limb, from the first, was un-
restruincd by baudagea ; pretty early flc:iion waa used ; and yet,
at the end of a year and a hnJf, the limb could not be complete-
ly bent- The treatment above deecribcil, of frictions and gentle
flexion, was continued, and, two yearj* tiftcr the injury was
received, ahe entirely recovered the uau of ber limb.
Case CXCIV. — Frrtctnre of Fatella. — At the same time
tliat 1 liad the preceding oaae under my care, a young woman,
about 25 yeara old* of powcrfid make, acting a^ son'ant in a
friend's famify, was brought into the Hoapitnl, and eamc under
my Dorc. Having fallen the day before, while descending the
atnlra, she struck her knee, and produecd a lTJi<;ture of the pa-
tella. She was placed on a fnictitrc-bcd, the lower portion
of which supyiortcd the injured limb, elevated at an angle of
about 30". Her head and slioulders were also slightly clevnte<i
in the same way. Cooling appIicaLiona were placed over the
fragroenta, which were left entirely imrcstraincd by any bandage.
She was confiacd by Uie accident about two months ; and, when
she left the Hospital, the fraelurcd ends were scpamtcd about
half on inch.
336
EXTREMiriEa.
T saw tliifl pntient a nuTiil>er of H:jich nfterwnnla. At the onJ
of »]\ nuiiiLlif* frotu tlie ncruSt^nt, altlimigli tlie union was per*
fectly good, and all the a]>[iroprinte meana had been used to gain
the ufifi iff tlie joint, she Btill retjuired a very iirm-laL't'J bandage,
tuippurled IjUerally ; was unahJe in bend lln; limb so «j Ut pick
up any tiling from the floor, and wus obliged to wdk wlih ihe
support of tt cane-
Cask CXCV- — Frm:ture of Riffht Puiella; SabAequ&ni
Fniuture of Iji{fl. — A iiion, aged 33, a iitechanic, fell, .Fan. 7,
t^triTf on tlie ice, and fractured his rigbt piLtellu tranaverRelv ;
ihe fingniculB Inking separated about un inch, lie aixiW^reil but
Jittlc piun from the injury when brought into the lIoapiLnh lie
Tvns put upon the iiii'lined i raclu rc-hcd , and treated at first in
the &iiti\ii loniiot^]' as tlii! prcccdiug aiA^a : {^tripa of adhesive pljtu-
tcr being u&cd afler the iufljLUiinalioii Imd ^ub^idL-d. He was
discbnTgi'd well, uu March 22c!, the fragments being eeparated
jibiint a llkjixl of an inch.
On Nov. 22» lHo8, lie wafl again brought into the Hospital,
having bad hii^ left koce atnick by an iron bar, which produced
a IranBvi^rse fracture of the putella ; the fragnientti being separ-
ated about tliree-tjiiarlers of an inch. Ili^ leg wo^ jilaceJ on a
Goodwin^a »[jlint:, and much elevated.
Ou Feb, 1, 1859, tbtrc wna good liganjeutoUH union, with
sepanition of about oiie-tliird of an incli ; and he vam allowed ti>
get up, the limb being supporteil by a baudage. On February
20th, aunie ehght aepamtiou of the jjugmcnts was found to Imve
tiilten place. Do March 1st, no further ae^wiration liiwl occurred,
the tipace between tlic friignients being about half an inch.
An cjiiimjnation of the other limb of this patient, the patella
of which had beeu broken nearly two yeara bcfoit, diacioacd the
fact, that the fragmcnta had been scpara(td in au extraordinary
manner at leoat three or four inches, lie six'\d that, on leaving
the Hospital, he had ussd the limb witliout any precautions. la
conaequcnce» the fragments gmUnally became separated, and lie
finally lost the power, almost entirely, of extending the limb ;
DO that, in walking, it was neceawiry to lift the leg from the
ground, and give it ajerk forw^iirda by a sbghtly lateral motion.
FKACTUttES OP PATKLLA.
.^37
Moreover, if extreme cfire wols not taken in miina^nr; the joint,
by walking- n-itti the head and eliiiulilei'^ bent turwariLn so as lo
throw the centre of gravity rather in front of tlio knee, the
joint would give way, And throw him upon the ^fround.
Case CXCVI- — March, 1859- A man, 30 years of af,^,
conmdted me for an injury of the lett patella, which, he said,
had heen rractiired twelve years before; and for whitih he had
hei^n treated at the Hospital in Dublin, and bad a guod use of
the limb eiuce. The day hetorc I eaw hiiTLt he had fallen, and
felt Bi»mething; ^vc wnv about the knee ; and 6upixi«ed he had
met with the same accident a scound time.
1 found what appeared to be at first a vertical fracture of the
patella. But. on more cnrctul ecrutiny^ what aeonied to be
a fiasurc in the bone proved to be made by a projection of the
outer eondyle of the femur In apposition with a very small pa-
tella of tc^B than half tbe natural aize-
On csamininp: ihe rif*ht limb^ in orrlcr to make a ('oin|>ariaon,
I found not the fllightcs^t tracca of any patella. Th« joint, in
feet, could bo fully exjUored ; and seemed only lo be covered by
skin, fascia, and capsular Jii^mcnt, The patient naid that the
motions of the joint were [x?rfectly ^ood ; and tiiat the only
explanation he could i^vva was, that, when a {.^hildT be bad an cx-
tengire euppurating sore over the knee-joint, following emall-pojc .
For the present injury, attributing it to the rupture of adhe-
siond, I udvifled him not to conftnc hinieelf, but to have a knee-
cap well ndjuatcd, to attbrd the limb eupport* J£c presented
himedf, some dayi* afterwai'd?, with thifl appliance, walkinj^ with
cose, and only cmbarraflued on mounting a ataircaee.
Case C^^CVU. — Fracture f>/ rtitella. — March IG. 1«59,
A man. a;;ed 40. This patii^nt was in the Mo^saehu^etta Gen-
eral Hoapital four years bc»fore» with frnctiirc of both thi^B,
from which aecitkrt he completely recovered. To-day, be fell
downstairs, and struck directly on the right knee. The patella
wo^ found to be bmken into three piecea, with but little wep-
iiration of the fni^ments however. He was immediately placod
in bed, with hiB limb resting on on inclined plEinc.
4^
flS8
ESTKEMITIES.
Diiiiii)^ Cte. trcatiiic:'nt nf fiie case, there was fjut Illtlc pain,"'
iilllnni^li cuiissidenilile eiriiaitiu touk place. The I'ecovery whb
excellent.
Case CXC\Ill. — FracUr^ of Patella. ~ ^^a.n'h 17,
1850. The piitieril. a man of 60 jcara, fell from a hnj-iuow,
ami titnick h\s k'fc knee tju the hum tiui^r. There waa a fractiira
of the iJiittlla, witli wry- great elfLisioii.
lie wija placed In l>cd, >vitL lile leg i^ating on an inclined
j»lflne. Tlje case went on to a favorahic terminatiou.
Case CXCIX, — Ilupiare of the Tendon of the Qu^uln-
ceps Extenstir FcmorU Muscle, just at its Imrcrtian into the
PattUa. — III connection with fracture of the patclU, the fol-
lowing case may be given. It was treated hy poaitioa about
the same time that 1 began thnt treatment of fractures of tlie
patella, and ia o\' ytvy rare occurrence.
A nuin about 00 yenra old^ aul^ject to rhcuuiailsnu while
sweeping tlie pavement on a frozen suiface, slipped; and, la
endeavoring to recover himself, felt eometljiug give waj^ sihout
tlie knee-joint, and at once fell to the grounJ. When brougbi
into the lloapitTd, A woa founJ that a wiile g^p existed hotiTcea
Lhe ijuadLiceira tendon and the patella, tim fikiu hn'nv^ depressed
at that point, so that the knce-jolnl coulJ be completely explored
by the finger. The patient was jilaccd on ius back ; and the leg
elevated at an angle of about 45° from the bed, and supported on
an inclined pljtnc, and cooling lotions applied to it. Much swell-^
ing and effiisioji into tlic joint followed; and, :ia no advantiij^c?
could he perceived from the use of bandagcci, tliey were laid
uide. Union gradually took place between the tendou and
patella; anJ, oftcr a treatment of a number of months, be
finally recovered a good nae of the limb.
I have BCcn three or four instances of pcraonA who, having
received a bloiv just below the patella, faded to recover the tise
of the leg. On a very careful inspection, a transverse crack, or
rupture, was dUtingiilshed, partially diviJ'ing the Bbrea of the
lii^ainentuui patcllic. There wjia uo otbcr aj>|x.-arance or sym^i-
loui to explain the Jota of power over tlie leg. These patients
FRACTTUUES*
33y
did vrcll aflcr a ronfincmt^nt of from three to bIx months in a
hmn epJint,
Case CC. — fracture of the PelvU, teith Rnplure of
Bladder. — A innn, 30 ycara old, died on liis why to tlie Hije-
pital, a l>ank of citrtli hurin^' tjtUcn on liiiii nn hour before.
The following were the nppenriincee presented by the body ; A
fulness WHS obeefTcd in the ri^ht ilinc region- The pcrinroum
was somewhat fuller than nntund to the right of the medlnn Hiie.
The left eide of the pelvis appeared drnwn up» 60 that its api-
noua process was nbn^c the level of the ri^ht epinoufl ]>roGe93>
The rlj(ht lower extremity was, by mtftsureincnt, onc-hii)f nn
inch longer thnu the IcfL On cxaiDiuAtion uf the pelviif, n
fracture was deteeted near the aympbysie pubis ; flido one through
the left eacro-ilinc syiichondrosiflH By riiiatinff the left lower
extremity, tbc Ictl ilium was freciv mov^nblc, with boiuc crepitus
attending the motion. Powerful fiexion of the right lower eX'
treiuity produced an indistinct crepitua in the joint.
A enthetcr wn? pnasedj with aoroc diflieullTi through the
urethra ; and its [xiint ooutd at onec be dbtlnpjished in the CAvi-
ty of the abdomen.
Fermi^siou being obtained, the autopsy was made tire hours
after denih, by Dr, F. J. BiituuteiLd* then house-aurgiiou at the
Hospital, who drew up the following aocount of it ; —
*' Oli eultiu;; into the pvritotieal ravity, it {» t'ouDi to be entirely
filled with blood. Ilh poflierior wall is uovereil wilh a durk-eolorcd
eeokiymo^is, aud ij4 rnr^ed by m large efliiBinn beneaih. A Minnll li^r-
uia of ihc lirt«iie:<, esliiriiJtl la lUe iicnloiAcmn* iibuut llii: aiic of dm
ItilLe fia;^i2rf proLrtides thmiii^h the mcmbrauUf baek of llie nghl os
pubi». The coufusbd Btiii« of the purts beneath the pt>rironeiim ren-
der* u rabiilft eiaminntiiiQ impossible. The btriod has unilermmerl
dji: perileoeal cdvily, nud lullltrnEmI iLu JlJaeua Jiud p,«oaB musclv:i.
^' The blmldur ia ruptured lo the extent of nn inch above the tri-
angiilnr li^^nmeni, and posierior lo the iiymphysis pul>i&. The flingno-
n\A uf frticiuce through the ^yuLpliyni^, and ihron^h ihe lef\ scicro-iliae
ayaeliondrorsia iji found lo havo l>eeu eon~c^[, The IrogiDBats of iho
latter nro sepapflltd to lUo width of n. fiafc»tr, la addiliou, the rigLi
nreiatiulum is ero^^ed by ^^uv^end frnemreA] whidi evieud througb die
ischium and iliuui, entirely isolatiaj; aevorrtl pieces uf hone. From
UQ
EXT&EMITIBS.
tho fundus of the nccfAbuliim, & irinn^ular pi«cfl of bane has be«n
dr»wn inwHrda, am] the correi^poDdiiig butI'wb of llie hpftd of ihe
&mur a cnisli^ lo tlje depth of one or Ino liuee. Ligameutuui Ustv&
Case CCI. — Fracture of the Nnch of (Ac Thiyh-bone
in a Genlhman J^n^ty Yearn uf Agt. Recovtry^ — The
genilernan who wua thr t^uhjwt nf thia case wn« n |>ei>on of ihe
most energetic clinriioitr ; hi* beuhh had never been abused by
any excess, and he had always lived with the utmost siiii*
plioity- Tlis mind wan of great !^^tivily, mid he hnd ocpu-
pied many positions of distineiion and Im^t in ibe tiiale aiul
country.
His cnse wji^i parriculnrly intercBting to myaelf from hi*
having been braug)»t into profesftiunal relatUmM with five mem-
hera of my family, diinng n period nf ninety yenra.
The fi'Jirture was produced hy a fall from hiu cliuir, Dec. 11,
1861. He wn« imflble to rUe, and was placed upon n. mat-
treas, on the floor, in which poaiticm I saw him half im hour
afterward.
The Jimbs were found of an equal lengthy and there was no
Bversion of die fool. On gentle rotation of the limb, with k
finger in the groin, a distinct crepitus was observed. The tro^
chanter rotntod with the shaft of the bone.
About eix hours after tJic ae(^ident, a fracture-bed, wiEb a
triple inclined plane, having been obtained, he wna placed upon
it. Before thi*^ was done, it was found ihat the foot was everted,
and the* limb ahoitened lietween one and t^vo inches. After
being kept \\\ this position abuut two weeks, he be'gau lo be un-
easy; complstncd of aome Eioreneits of the back, in apite of
every precaution which had been taken, and apoemodic actions
in tlie extremities numifested them^lvss- He was then moved
to a new bed, which I had coutrived for the purpoae, oonsistinj^
of a triple inclined plane, placed on a fiecoml plane, with which.
hy a rachet movement, the patient could be brought up into &
sitting posture without di*tu.rbin<^ the fracture, and the pressure
brought more on the tuberosity of the iaehium and thighs. By
the use of this bed, hia condition wae nincli improved : and. in
FRA(7rUREfi,
341
the course of the winter, he recovered the ueo of the limb, with
some ehortcning and cvoreion-
Dunng the trcaimcatf he onee or twice fell into a boiuho-
lent Btatc, in which he remained two or three daye^ the pnUe
bocomLDg extremolv slow ; and fcora were entertnined that life
would ecaec in one of these attncke. On iirimiiijj; out of iheiUf
however, his vitnliiy was gradually restored.
He Jiverl ahout ii year uf^erwarda : and finally died quietly
without any luatked Byinptciii£ of diaeadc.
Case CCU.—Fiftcture of the Uppey* Part of tie Shtfl
and ^^ck of the 0» FeuiorU^ in a Lod^^ agtid Eitfkty-eix.
^o Crepitus* DGuth in one Week. Anfop/nf. — 1854, Jan. !>.
This pnlient) ahoiit a week before her death, foil in her room,
striking on the trochanter of the nglil tlii^rh-bone. She was
UQflble to riee, and was taken up and placed in bed- On ck-
nmination, it waa found that the rij^'ht lower cxtr«nuty waa
»hoHcued nVjoat an inch, and the foot everted. The thigh waa
much swollen. No crepitue could be discovered on any motion
given to the limb. Sbe was |)liie<d on her bat^k; the limb
iupported on u double indined plane, mn<]e of |>illowg- She
complained of but litUc |>aiii in the injured part- For a few
days she did wo)]. The bowela then became constipatedi the
puJse failed /rradtially, and she died on the ^ixth day from the
reception of the injury, a|)parently trom the nliock to u £y«tciu
reduced by i^e.
On a poat-m^Ttem esacunation, before the injured parts wero
exposed, an attempt wae made to obtain ci-epitua ; but none was
produced by the ordinary motions of the limb. By extreme
flexioAf however, uslnn; at the ssmc time powerful rotation, a
crepitus could be did tiugui shell. On making an incision over the
trochanter d<jwn the tbi^h, the fat and musclej^ were found filled
tviih extravuHated bloods There waa a commirmied fracture of
the ehaft of the bone, jual bclcw the Iroehontor; and another
fracture cxtcndin^r upwnrde from this as far ae the edge of the
aocket, eeparatiu^' the neck oi' the bone from the trochanter.
But little blood wtu ellused into tlie cavity of tJie joint.
Tbifl caae le worthv of remark u» ahowinjS' how extensive a
B49
EXTREMITIES.
fracture mny he ; am! yet, fnnu tlie exIravii^Jtiian tif blood, ni
frcuji otlier causes, one of tlK- print-ipal (Ii(igno»iiic signji of
ture, crepitus, not be obtained.
Case CC^HL — Fracturt^ of ike jVe-.-jfc nf Thhjh-bojte^ in
Old Ltidij One Hundred Years tvnd Six Montftn old. It
ftersioH of Foot. Dpnth little tfeei^ aftern^nrdfM
Wnioti of Fracture. Solid Collection in R^f^t-utft. — Tli*
old l^ly wlu> w;i4 the subject of ibiH notice died Jaounry,
1837, lifter a long life of uninternipled ^ooil health, ngeJ 1'
years and 6 iiitmliia ; her ilt'atli Wlii^ fiiiiilly aroi-lemtcil bv
fiiicliin? of MiB liip, whiL'h occiirreJ u few weeks previoiiBlyj
For n year, she hud lieen subject to some abeiraiiou of mim
whidi refjuireil lier lo he nonifwhat reMmined in Iilt inrulonx
aiid» fls filie ha<l a tojistaut desire lo leave the hoii&e, her cloili*
Avc^re taken from her, and fihe avjik conliEied oa inut^h ns pnaslblc
to the bt'il. Three weeks Iwfore her Jewth, while lefb by hi
self, she was IhmjiI by the [mrsona in the nmrii lx»h>vv, to get oui
of her bed ; ami, while walking ai^ross the riHwn, to fiiJl heavily
on the lloor. Upon g<ung into her chamber, t*he was fouiii3 [in
triite, and unable tu ride. She wqji inuuediiitely earned to bi
bed, iier niedirul sittendant cidled,aml, an ejianunation beii
niade, il wns discovered tliat a fracture had tjikeu placQ throQi
the neck of the ihij^'h-boae.
There was but little ilisplaccjuent of the fractured parti^
limb being u little jihortened and the foot inverted; and it wi
detennintrJ, ihcrtfore, tijat the applieatiun of any nppar^tiii
fur ennfiniug the limb would he utinecefasary, poeiiiun only bein;
relied u|>t)ii for the union of the bonftK She wiih dirert&I to In
upon Iter back; and a pillow wan placed under the thigh, ao
to ktep it alighUy Hexed on the pelvia. She died about three
weekd after the ucciJenl ; her death taking jihiee widiuut dullFr-
ing, and apparently occasicmed by the combined effect* of
accalent. Bind the etinfrnej puaition neceswrlly attendant on \t.
It may be well to «ta[e tliut the dcusen of the old lady remain)
perfect to the hiet. Her hearing wuh ^■'ood, mid abe was abl
to read the pmnlleat print without the uau of gluHsea.
The hiidv was ejtaniioed twelve bour^ rtfier Jciith, and pri
FRACTUREB-
343
eented the fiillowing- appearanres i Stnture BTnn.ll, abocit Eve
feet ; very little emadulion. On ihe lt»wer part of tlie tiaflrura
wae a g&ngrenuua apot, two m<iheri iti {llonictt^r, occnsioncd by
the long preamire on that part frdtii lier conllnei] position. The
left, lower oitremity was shortened perlinps a quarter cjf nn
inch, nnd the toea slightlj turned inwards. Upon oponLn«;^the
heai]« aboal a gilJ of serum es('npe(l from the cavity of the dura
jnaier. This inemhrane wa* strongly adherent throughout to
the cnmiura, requiring llie iise tif much force to Heparate il fr<»m
its altachinenta. The Huperficird vee^sels of the hrain were much
diriiendeil with MoihI ; it« tiidi^Tanee of good consiHteare, nlfuring
otherwise uothirig remark iifile. All the t^uture^ of the cruiiium
were completely ossified. The cartilnges of the nba were not
ossified, as is usniillv the cn^e ia old per^ouH, and were eanily
cut thrtiugh with the knife.
Tiie lungs were of a dark-blue color on the left ttkle ; at
the ^Liuiinit, strongly BcUu-rerit to (he rihs ; and, ^t xWu point,
a conglomeration of small semi-transparent gramdutiouB were
found embedded in the siiLstnncc of the hejdtliy long. These
granulationa were scattered throughout the lung; but lit no
point wns tlieix- nny iippearanee of tieatrices or tubendefi in a
softened Hiate. The edge?* of tiie lower lobe of tl»e right long
presented the most mnrkefl appenrance of emphysema. Tho
heiu^ was small; its cavities filM wtth hhick, iircoagolited
blood- The free edges of the valves of the aorta were not
ossified: wX their ba8es, however, and at that part of the
florta opposed to their eilgcs, were two distinct ossenus rings.
Patches of osseous dE^posits, some of them an inch in diameter,
were ecallorcd at iatcrvals throughout the whole cimrae of the
aorta. The liver, kidneys, and spleen were perfk.'tly lnydthy,
and of ilift naturati color and consistence. The stomach was
remarkahly small, — its eitlibro nhout the «aioe ais that of the
duodenum, from which externally it was difficult to distinguish
il, — ami pre^'Cnted much the n|ippnrnnei's 1 had observed about
a year before in the stomaeli of nn old lady who hiid destroyed
herself by starvation, with tliis exception^ that, in the latter
cose, the mucous cont was much more corrugsilod. The inte;^
tjnea were generally of amall size ; at some points, in the large
344
EXTSBXnTES,
intestine** not Wing macp tlian half an incli in diameter. At
tlie levtum, LowHver, a very remai'kable |ibenon»entiD ^reAeTiLed
iUdf-
The inteatiijp w^s liery diliitod iiitii a large poucli, completely
Med hy li liall of liurdeiied fecaJ matter, wLicL, occupj^Iiig ttte
wLoIe cavity of the pelvis* forced tlie bladder completely out of
its naJund Hitujillun; bulotv, thiA nuiss was Tound prea^ing
down ojk the jicrluLcuin, and «Ii<^hlJy ddutlng the Anu^. From
nil appeiirnuceft tbii^ ball niuat hute been for a lon^^ period
In tlic situation in which it waa discovci'od. as ohe bad cuoi-
plained of no 6uffering, nnd the bowels had been peiHcctly
regular up to tbf duy of her JeatL. Tbe nialter evacmited of
court»c passed down at the eide£ of the obstruction.
Tbe bljidder was large ; ite mucous coat somewhat reddened,
find ratbcr softer than natund. The utenis whs about ilia
eice of a hozel-Dut ; and, on cutting into it, a email quantity of
pus, apparently of recent formation, escaped from its cjnity-
Nolbing remarkable was observed about the ovaries, eid(er aa 1x>
size or consistence. Upon examination of die hip. It wa^ found
that a fracture had taken place at that part in a very remark*
able luarmer. In tbe fir&t place, a fracture citeniled frfJin the
trocbanter transversely throiigh the neck of the oe femoria ;
In the aecood place, tlie trocluuiter m^jor vva« completely sepai
nted fronj tbe body of tbe bone. The difiplacemeiit of the fr
lured portions, however, was very slight ; tbey being interlock*
by Irregular aerrations, although freely movable on each others
The troclianlcr minor was nearly split through. There appeai
to be no attempt nl uuiou*
The reinarkiiljle fenturea of this case are ; First, the invi
fiioii of the foot ; second, the want of ossification about the ril
which would naturally he expected In a person of wiicb advantii
age; third, the small aiic of tbe stomach; fuurtb, thu yreai
maaa of hardened feces in the rectum, allowing, ncverthelessj
tbe regular passage of matter at the shies, so tliat, previous
death, nothing of the klud was suspected. A case in which
Birailar c-oUectlon took place ie given in one of the numbers oj
the "London Medical ijasctte/' The patient was a Inly eev*!
cniy years of age, who had auffercd for some time with most
FfiACTURES.
345
csf^rucmlinrr paina in the lower pnrt of the roctum- These
p)UnB were periodical, utid similar m their character tii the
beariD^'-down paias of labor- An examination being finally
made, it was found that a large masB of hardcued feoen, of the
size of the hciu\ of a l"ull-gr<>^^n fa?tU8, \ra.s preasing down upon
the perinicum ; tfie nnuB bein^ distended to tlie siae of a erown-
piece. Thitt masflwofl broken down with the bnndloof n apoon,
and the sidferirigfl of the patient immediately relieved on the
rcnuival of tlxc obatruction. Nothing of the kind Jiad been
soapected, ae tbo patient liad always enjoyed n re^Iar state
of bowels, I have met with a similar instance in the case of on
insane pereon, alao in the case of a fracture of the neck tif the
thigh-bone in an old gentleman, hereaRcr to be related ; in both
iitstflncee requirinf^ a prolonged opei'ation ^vith the ecoop which
aceompaniea lithotomy inRtrumenteT for removal-
The inversion was caused by the aerr^Ltions heeoniiDg inter-
locked; the blow breakin^r rhe bone, and at the same time giv-
ing It a Iwidt inwards, in which position it waa retsuned, aa above
deacribedn In conclusion, it may be observed that the bones
were not more brittle tlian is ordinarily found in persona of
forty or fifty yearti of age,
I have in my posse^aion a apecimen of intrii-C4ipsuIar frnc-
ture of the neck of the femur, with inversion of the foot, oc-
curring in a lady ninety-three yeara old. It was |>resented to
me by tbc venei"able Br- Alden, of Randolph^ under whose care
the patient was.
Case CCIV. — Intra- oapeular FmciurB of the Cer^'ix
FetnorU. I^a(/i/ro?n Intestiiial Strangulation, — Dec-ltt50,
A gentleman, 83 yeara of age, fell upon a carpeted floor, striking
the right trochanter. Wlien taken up, he was foimJ to be suf-
fering severe pain : tlie foot was everted, and the limb shortened
half ati inch. He was placed on a triple inclined plane fracture*
bed; the foot being supported by means of piUows, and pro-
tected by a cradle- At the end of seven weeks, he was able to
move the log witliout pain, and the foot was not disposed
to evert.
On Jan. 30, 185 1> he was seized with a pain in tlie epiga^
44
■- A JjAcMic aa* al ovoe 9*ra, filling trmarvrrstAj
^ ibt aeck «^ iW bow. TW p^ie, kwcra-* «cr« &i3k-
mfidej ; wad k *u «mI«- afcr c&ito «f ferofctc nvcabuB
E wic* thai Ac7 partiifir mM^J A yrtiw ^ At
. al ifae bftdc pan of the ca/nx^ wtmitimri catire.
wMV, ont iBto BDo^er ; mod ■■ aUtimal sbortncaa ^ tbc Gmb,
fFMa the panZal drajrinz-np of the ^^ft of ibe hooe bv moscD-
Id di« foUovinv caj«. the piUienl walked $oake ^ftsnoe after
ft compkie fnclnre of ibe Deck of the thigb-bmie widun tbe
capmUr llgamenl. He oerer wonld ^abmit to tay fljaUaiatic
treUmeni, ocrt tbiDldo^ bu hip lfft>kpD. sikI never reconved tbe
tuc of tbe limb. He died two vear^ and a half aftemid^, with
a cerel*ral attack, attendant on a ?uppre?i4ion of arine. Tbe
fa*e ha^ Ijten fulk described bv Dr. J. C- Warren, under
wh'rt^ i-are be at first was, in the American e^lition of Cooper
on " DL-bfcation^ and Fractures," and is acoompanied with &
w^jiidcut. For tbe la^t vear of hi? life, he wa* uikder mv care-
('\>-K CCV. — FrnHnr'^ "f tfi'. Cf-rr/jr of thp Oi Femoris^,
v.iihin th*: (J 'pnul'ir Liffftrnpiit : irtfh n partly O^seouSy and
parity C"rtilftffinouti Union. Locomoti'jH ofier Injury. —
FRAtTURES.
347
"The patient was a gentleman af ediimition nnd ttileots. Ha
studied medicine in tlie early part of hU life, but ntterwards left
it for anotlier profession, A conslhution nniuridlj wesk, end
impaired by diseasQ, ^ndnally gave way ; ho thai, at sisty, he
had IJie nppearjince of decrepitude. He liowever continued to
go out and attend to ^ome business, till he renehed tlie age of
BGrenty, when he met with & peculiar accident-
" Being a member of the Massachusetts Senate, he waa in the
fWt of ascending the titeps of the State House, for the purpose
of taking his neuul seat with that ho^ly, wLc& he fell, and struck
on the Jeft [trochanter. On arising, be found himeelf quite
lame, though able to t^tanJ and walk- In this condition he
went up the atepe, and entered the House, where he remained
an hour and a half, and made two or three speeches ; during the
last of which he was obliged Co sit down, leai'ing it unliniahed,
A carriage being called for, he was sent home, and I was re-
quested to Visit him.
"I found him in his parlor, eitting on a gofa, with his feet on
tEie Hoor, as if nothing had hLippencd. He descnbed the acci-
dentf and I directly eame to the coDcIusiou that he must have
fractured the ncek of the tiiigb-bone.
''On examining the injured limb, I found no appearance of
distortion, deformity, or any other change. It was of exactly
the same length as before iho accident (having been rendered
half an inch shorter than the other by an injury o\' the knee,
received at an early period of life). It had the same direction
with the other- He could stand on it, but not walk without
euffering. Tliere was no appeai'nnee of any detached fragments
of bone about the articulation : the troiilianter was |>erfectly
sound, and in its plaee. There was, at that time, no tender-
neas in the groin, nor any inequahty. The passive movemeniB
which I employed produced no pain, with the exception of strong
rotation outwards, and strong flexion of the thigh upon the
pelvia. These movements produced some degree of pain, but
not very coneiderablo. There was no crepitus.**
Po^t-moriem ExaminQttQn of Ike Seat of Injury. — "The
muscles about the thigh were thin and wasted t the capsular
lii^menl wns tLIclic'ried, but regtilai' un the outfiide. On cnltutg
inti) tilt articulation, ihiTc v^na nn ijjij>(?ai~ance of recout indam-
mAtioD ; the neck of the thigli-buiie wns Absorbed ; just mt the
cJgc of the nrticuJar fiurfnce wa» n alighl vWtng of tlie bone.
acai'relj \i&ilj]e in the t-ye, hut perfectly aeiisible to the toudi,
which jjidiuiteJ tliG sG-dt of the fmctiu-e. AVhi^n Uie uttenijtt wm
made tn niovi; the shaft tif the htioe upon the head, t^o lut^tiou
hct^veen ihem cuuld lie perceived- A terticaJ fiectiou through
the liCiiJ nwl neck of the Ixme u~ne then inude : the plucc of the
fnicturc wuH thu8 faiind to be nidJeatcd by & wliltt: Line running
acroae the neck of the hone^ Jind liaviny^ ihc thicknefls ot' the
thiitieth of an inch. lu onu of the fractured eecdtins, m*
motion could [>e pnidiiceJ between tJie head aud neck uf the
hone ; ill tfie other, dliirht motion exiBted. The preparation ]&
m the IVarren Miidcuin."
DISLOCATIONS.
Dialocaliuiifl are neitrly as hjipcirUint to tlie surgeon as fn*c~
tares, I do not jjropoae to go into any detailed description
with regard la th<?m, but only to make a few reiuaika on cer^
tain piiiiita which have seeuied to me to be of apecirJ impor-
tance.
As a general rule, dislocations are rarely prcH^ut-ed bv n direct
blow on the joint. AVIiere they occur from ibis canae, tliey are
lieimllj accompanied with a fracture.
I have never seen, nor do I know of, a coee of eimple die*
location cf ihc hip-joint produced m tliis way. Dislocations of
the dhoulder-juint nrt: deMTihed bv aiilhnrK as trdting place cither
by fflJla on the elbow or hand, or from a din:ci blow on iLc ahoul-
dcr. Mr. Brj'ant, in Cooper's "Surreal Djclionary," fttales,
that, "in thjity-one {Hit of thirty-four ca*efi, llie eauec of the in-
JU17 wHfl a direct/all upon the ahoulder, either forwards, back-
wards, or outwanJy. Tn two iiisUni^es ordy of dislocation
downwards, and in one of dialueation downwards and forwArds,
WM the hone displaced by a. fall upon the eitendcd arm,"
M. Malgaigne says, on the contrary (p. 462 of his work on
I}idlocati(jnH), eiieaking of cne of the niobt common dlslo-
DlSLOOATlO^a,
349
h
cations, — the one urwier the coracold proccee, — as foUowa :
*' FinrtJIy, in very rare cases, tlie sub-coracoid dislocation ifi llie
effect of a. direct How on the Bhoukler, the arm not hcin^ raised.
RicUemnd uppesire to have ohaorved one ease in a quarrvman,
who, HurprUed by n caviog-m of earth, atriick the exteriml part
of the shoulder against a pillar of a gallery ; bttt we ehdl see
that the^e aorta of faUa produce particularly incomplete dielo-
catioas. and especially iufra-coracoid dialocations ; and perlinjie
that of Hichcriind bi-longa to one or the other of these two
cat^oTiea.^'
The error, probably, which has ariflen, in apeaking of these
diBlocations induced by a blow on the shoulder, U in not stating
whether the arm is applied to the side, or raised at an angle
from it. In the former poaitioM, it would seem almost impos-
fliblc, by a blow from above» to drive the head of the bone down
below the socket. In almost every caee where I have seen dia-
loeiitiona occur from & f^ll on the shoulder, the arm lyiug at the
side. — aa in persons who fall, like the intoxicated, without an
effort to save themselvcti, — a crepitua was found to accompany
the replacement of tho head of the bone, which was easily dis-
placed i\g\\]j\ ofter reduction, as if the aupport from the front
part of the socket had been broken away. In one case of dis-
location, under the clavicle in iront of the coracoiJ process,
which is said by Malgaigne to be produced by a blow on the
shoulder, tiie man vvaa jammed between two heavy ft'eight-cars,
which doubled him up, as it were, dislocated Ida shoulder for-
wards, fractured the collar-bone in three or four places* and
fraclnred his ribs, driving ihciu into liis lunge. The head of
the bone was replaced before I aaw him ; but, learning the way
in which the accident was received, I made investigation to sec
if crepitus was present, and found it, but not very marked,
DislocaUons of the elbow-joint usually result, so far aa 1
have obscrvedi from falls on the hand, or violent twi<]ts of the
ibre-arm, blows on the back of tlic elbow-joint producing frac-
turea> or fractures accompanied with dislocatioUi
Dii^Iocation of the knee-joint, unless It ifl a compound one,
I have rarely seen. Of diepliw:euienl of the semilunar cnrti-
lagea of the knee-juint, I have seen a uumber of lustatioesp
350
ESTREMITlEa,
They havH fK^currpil from a twiat of the limli^ or from cAtclimg
the foot In the I'arpei : sLiid I Iulv*; always replaced lh<?in by
fleeing die thigh on the body, the leg an the Uiigh ; iben,
by giving tx latt^ral or jerking motion to the joint, and auddeoljr
strajghtening it» the i^artihtge has gone into plcce-
In difllocationa of the outer end of the elnviele. I hnve not
vrltncfidot] much mi(^esH In the treatment, nor much ultimate
weakness of the arm by lie rerniiuhig out of place, nUhoiigh its
tou free pky may hf. h soiirtre of (lisromfort. Dr. FuIls, of
Baj«L Boi^ton. has suggested a nuidi]i<^tion of Bartlelt's appAi^
tud furr broken claviele, nj& a, reniedy for thin aocidi:iit, which is
etfecteil by nn additional aboulder-^trap over the injured shoul-
der.
I would mention here the firllowiDg ayinptom, which is vexy
frequent after recovery from dislocations of the ahoulder-joiat ;
and. in fact» other accidents in which the deltoid muaric is in-
volved. It ia the want of power in raisin^^ the anil above A
certain angle, wliich so frequently fellows, I Imve often seen
patients many months, and sometimea years, after a difli^catioDi
who, Imving recovered all the other motions, ore unable to raise
die arm beyond an angle of Ay or 50°. In cases of strjuniug
of the .shuulder, produced, for instance, by a per-^on swinging
Limaeif off from u whmf to a aliip, I have ubaervet! this sviup-
toni after a period of two yeiua froui the time of the accident,
attended with much pala» Li tjvo inHtances* it was cured bj
keeping the limb at rest two or three monthe. In the eori
part of 1S(JG, a lady considled me for this reason^ who, sixteen
years before, was tluxiwn out of a slcigh» and struck tlie upper
part of her shoulder on the curbstone. She could elevate the
arm to about 45°. It could be rotated freely inward?, to any
extent, but scarcely any oiitwiu'ds. On llie hack part of the
head of the bone, I discovered an osseous Iamp< which ap-
peared to be the greater tubercle knocked backward.
"Tliis/^ by the way, Malgiiigiic says- "is often broken when
the head of the bono is driven forwards under die clavicle by
a direct blow/' Lately, this lady, while exerting; herself in
packlag a trunk, felt soinclhing give way about the dehi^id
muscle, followed by an ecchymosis ; showing, that, even oiler
DISLOCATIONS,
351
this Upae of time, the injury to its fibrea h&d DOt been re-
paired,
Tq following tlie wardi; nf Lisfranc, la P&iiSt I nutinnl a
mrmber of fswea of injiinfs of tbe slioiikler-jomt, which he con-
siderLHl utiomnloue, und whicli were supposed to be p^rtin! dia-
locations of the shoulder. These parientfl hnd all rereued tbeir
injuries by a blow upon the joint itself: the head of the humerus
seemed to l>e displaced slightly forward, or sn if itn the edge of
the glenoid cavity. It could be easily replaced by a slight
effort, but wns at once dlspkced when abnndoned fo itself.
iNime time afterwards, I observed, in the *' Mediro-t 'hirurgical
Review,'' a drawing of a ca^ie w^iiii-b had been oonsidi^rej one of
partkl di>t]ueation, but ia which it wr^ ahuvrn that the front part
of ihe RoelvCi hwd bec*n broken off; thns allowing a flight dia-
plaeemenL of the Lead of tlie humeruB fi^rward, and ending in
the formation of a new Hucket a little in front of the old
<ine.
About this time, a sailor was brought into the MassachudGttB
Heueral Hiti^pital, who liad fallen fi-nm the mast of a ship, and
had reeeived fatal injuriea. Among others, there whs apparently
A pivlinl diglocaiion of tbe fthonldnr. On eicjifninanon, a dia-
tinot eeebymoflifl wna found on the external aspect of tlio joint ;
nnd the front part of the socket had been broken off, ao that die
bend of the humerus lay pnrtiidly below the coraeoid proccas,
T>iiriny severid yeatfl in pniccioe, before I fully nndei^tood
the nature of the lesion, I obnerved eHses of dUlocation of the
shoulder, in which, afler reduction by the usual methods, tLe
bone iahowed an unusual tendency to return to its former aiate
of displaecmenl- In these easea, I found, on a stnet examiiia-
tion of llie patient, that the injury had licen inflicted! by u blow
upon the joint itself. Latterly, 1 have orcajiioually met with
eases of recent dislocation which have been brought into the
HoapitaJ oti account of the supposed fiiilurc to effei^t rediic^tion,
but in which the real difficulty hjy, not in replacing the bnnc in
its socket (which wna very easily eHTectcd), but in retaining ic
there after the removal of the nrlifi<!ial supports- I Buppo&e
these eases to he fractures of the edge of the soclfet, or it* ear-
Uliginous ring, bv a blow nn the shoulder. It is dirtieult.
howercTt to prove this by anatomical icTefltigntiotit onr oppor-
tunities to do eo bemg rorc.
This joct ia one pf coneidcrable pmcticat importance. Whea
B p&tient cornea under our oof ice, with a recent di^locatiOD of tht
BliouliIer-ji>int» he mar be iiskeiJ iu what manner the injurr was
recf-iycd. If by a blow on the shoulder* a bruised epot will
gencrfilly be fLiund ; and, if ^n ecchymoeia alao appears within a
ahort time, either m ^ODt of the joint or along the eide of the
arm, the dia^osb of a fracture nuty ahoost certaialy Le mode.
If. on the contrary, the patient has received the blow on the hand
or elbow, with the arm iit the same lirac more or Ie«# extended
from the thora.\, we may expect to find a simple djatocatioo ; or,
If there has been great violence, we may pt>93ibly find it com-
plicated with fraeture of tlic neek of the humerus. Impacted
iVacturc of the head of the humerus, occurrtag from a blow on
the shoulder, is the only injury likely to be misUiken for the *>-
called partial dislocation juat noticed. Malg^ai^e mentioDs a
dia]jlat:cmcnt of the tendon of the Lod^ head of the bicepa. as
giving the appearance of partial didocation-
The moat important part of tlie treatment of dislocation
of the elmulder, with tracture of the socket, consists in retain-
ing die bone in poeilioti after it has been roduocd. This object
ia well attained by the uee of Foxs apparatus for fractured
clavicle ; ihc wedge-ahaped pnd in the axilla preventing the re-
production of the dialocfltion. In old caaeSf witli eonipleto
displacement, considerable force ia oflon required to break up
adhesions, which arc generally more tenacious than in cases of
old simple dii^tocation ; prohably on account of tfic additional
inflammalory aclion conaequcnt upon tlie fracture of the eocket.
Greater care, and a lon^'cr jvcrsistence in the uac of mechanical
means, arc also ncccdsary to retain the head of the bone in iu
place while the new socket h in process of formation. In fact*
1 hjLVG Been the head of the bone displaced by a slight pressure
with the thutiih while bciu^ examined after reduction, the arm
being at the lime firmly bandaged to the body. In old dislo-
eatione, an entire loss of muscoiar power might olao allow of
this.
I have had Eu treat several coses of dislocntion of the ehouJ-
i
■
DISLOCATIONS,
353
der, with fHiCtureofthe nwk of the humerua. In two mHtances
in whioh I was called while the muscles were fltill i-elajced, and
before the patient hod rec4)vered irom the dcprci^isin^ influence
of the aliock^ it was found jiodsible ti> effect reduction by making
ejtton^ion of the shaft of thti bone, at (he same time working
llic Beparated lieati into iU socket by tirra preeeuro with the
thumbs- In cnse reduction cannot be thus oftk^ted, it id 6lill a
qneation whether the shaft of tJic hone should bo carried b^ck
mto the old socket, ao as thus to niiike at ouce the hi^^t [inurti-
cable Joint; or wlicther it should be placed in apposition with
the head, aud nn attempt made at reduction after" such a lapse
of time an may be thought suthciept for the union of the frag-
ments to take placo. The latter ui(3tho<I waa tried with eu<^(7Ges,
by D^. Jolin C Warren, on a young man, whose caste he re-
p!>rted in the "Boston Medical and Surjifical Journal'^ for 1828.
Immediate reduction having been attempted ia vain, fi-acture-
opimmlus was applied- After seven weeks, extension was made
with pulleys, and the dif^locatioD re^iiiced. This coac is quoted
by MaljTitijrne, who con^i'Iere the precedent worthy to be fol-
lowed in similar* casos^ I also atlcnipted the Bome treatment in
a CJ19C wliich oecurrod nearly twenty years ago ^ but, in tlie
attempt to Ijrcak up the adhesions whioh bad formed during
the six or eight weeks that had olapaoii, the C4dlu9 gave way,
and tJic fracture was rcprodaccd. The broken end of the bone
was then placed in the glenoid cn^nly, and the patient recovered
w^itb n veiy useful arm. Tn anotiier ciise whieh came under my
tiotieCf the arm had been paralysed by truitlet^a attempts at reduc-
tion, I saw the patient, in consultation with other eurgeone, at
the end of seven weeks, when it was dt'cidcd to leave ti»c broken
end of the bono in the socket. I afterwards loarnod that the
pnmlyais gradually passed off, and that the patient recovered
the use of the arm-
Dislocation of the hip-joint, so far as my own observation
t, may take place upon almost any part of the pelvis in tiie
imediatc neighborhood of the acetabuhim. During an at-
tempt at reduction, made under ether, I have seen almost every
kind of disphiccmcni imitated. !□ the course cf my practice,
I have hod three cases of dialocations downwards and back-
us
wardii ; anp nf llipm in n hrty of itbi venrs of age, the ynijng»t
|»iitJL'i]l in nhiHU I Uave. I'ver Been (JJ^Kic^ihon of ihe licnd of
the JemLir. I have mi^t with a di^lt^calion of one chi^h into tlw
funimen ovale, the i^thi^r llii^ih belii^ dislocated upwiinld :tt llie
same time, with iiicumpU-te fmctuie uf the nei'k of ihe bime;
the fractureil |inrtliiji» Hcjmratiiig ju*t ne tJie head IiaJ beeo
ri^Fitori^d to Its place in the j^o<;keI.
1 hiLvc ouly oai^ Heen ii difiluculion of thu hip in the femalei
— a |i!i(i(-i]t wImi Cjttiit into tlje llus|iit:il under Dr. Cubol, who
reilnetil it : ami I believe that there is hut one Budi i[ij^raDf?e re-
conled in tiie work £»f Sir Aj*tle_Y Cooper on tliia diiljjtt't. TTie
ravil^' of l\\\» dishrcjition in women in n fitcL of ij:rea.t iiiqwrtanDe
in (listinfTiiMhing between iVacinreA, and dia[iUcenieiit« uf tlie
head nf the tlii^'h-boiie.
It \s well kmiwn as one of the iliagiioatic niaiks of Iracture
of the neck of the femur, that the foot ia turned ou[iV7U'c3«t and
the lunl) shortened. In dislocation on the dorsum ilii, tlie limb
\s Uirntu] iiiwan1j4. with a like :fliorIeni:i^r, As an exreptioti
to tiie rule in fructare of the nec^k of the tiiigh-boae, aud us n
^Kitnt of* reseniblaiire to dinhiciition ii[ion the dorsum ilii. I would
refer to two easiyt ahvady given of iiiveisicm of the foot in frac-
ture of the cervix feinorls in old wmnen. I have aUo cibaerv^,
in the courae of the reduction of a didlocatton on the dorsum, the
toes heconie everleii ; the hend of the Tmm' tjikiiiir a i^itsition m
front, go ufi to pre>%nt zaor^t uf the ap^H^arance^ uaualJy given hy
a fracture of the neck of the hone.
Tlie iifle of ether hiia nuide a very gi-eiit ehnnge in the prac-
tice pursueil in the treiilnient c»f dislonirioas of the hip. whidi
can now be very Jreijnently ledni^ei) l>y manual ii'tfli^lance uiJv,
thua enabling ha, in many cases, to dti4j»enaG entirely with pul-
leys; and, by flueceA*4ive movemeiilh of floxion, abiluetion, and
rotation, to rec^ture the head L>f tlie bone to 'ii6 liocket with r^
maikiible facility-
Caae CCVL — DUioc'dion iif fits Skoulder^oird of ci^ht
weths' standing. Ueductinn, — February, 18G4. A woman,
4!3 yearfl of age and in fair hesihb, wjis taken, afier the delivery
of a healthy diild, with severe puerperal convulsions, lasting
i
WflLOCATIOKS.
355
P
twenty-four lioure. Diirin^f thlfl time, ahe wns corTmually
throwing; bewGil' violently iibout in the bed, unless restrained
by nttetidants. After she had recovered from the conv-uUiona,
it WAB found that tlvi left sUoulder-jiMnt wns muub awollen nnd
bruiseJ on its outur side, with an ecchyiuoaia nintiing iViww
upon both the outer and inner eidea of the ami. The arm wna
useleBB* At the end ofsiic weeks, the swelling havint^ subaiderl,
it wEia discovered that a dislocation existed, Attemjita were
made, by niuiLual exteni^ion, to reduce it, during whti^h taore or
lea« crepitae could be diettn^uiehed.
From the liifltory of the case, — that is, from the fact of there
having been groat tiwclJing, attended by cochymosi^, — I sus-
pected that a fracture must Lave existed in nildition to the
dislocation -
The head of the bone could he felt in the asillu, and, with
the neck, seemed to be a little enlarged, PulleyB were a|^[Jlicd,
after ibe patient was tborou^'hly etherized; nnd, llie adhesions
having been rupturcKl by forcible rotation of the limb, after
strong extension, nn attempt was made to carrv the head into
itfl place- Much evepitus was felt ; but the effort to restore the
bone to iiti normal situation failed. The [lulicvs wore sigain ap-
plied^ nnd powerful rotatory motion given to the buraems, so as
Id carry the bent arm through threc-<iuartere uf a circle. The
knee was now plneed in the axilla; and, the pulleys being re-
lajied, ibo bead of the Ijone was j>rit>d into place- The arm was
tbea confined to the body by a bandnge. On n slight pressure
being made upon the bead of the bone with the fingers, it slipped
partiiilU" out of the aoekpt ; and thia continued to recur when-
over thtj bone was re".luc;cd, until it waa prevented by placing
a bu-ge pad in the axilla, Thi^ arrangement wus adopted
throughout the treatment, ibat is, until the kpae of about timr
wcekfl, when it waa found that the size of the ]>ad could be
«omewh&t diminished. Tike patient then went home, with divec-
tions to continue the use of the apparatus until no farther dispo-
sition to displacement should exiat.
October, l?*b4. — Thia patient consulted me again, now seven
months since the reduction uf the dislocation. 4Sbe said that,
ouee or twice attcr she relurued home, tlie bcuic had slipped
.^56
EXTREMinRfl,
otit of pliioe, Init liad Ucfii etu^Ily rediireil ; and slit? thoiig'ht thai
it w»8 nut yet ill IIh jiroper ikWiJuh, as nhe could uuL make all
the UMial nuivenients uf llu: limb. On ciaiiiiiialioD» I fuuiid Uje
bhi>iildi-r nciirly us plump aind round ns tlie iftbcr, aail> in fnt-t,
a Ihdt^ luurc jiroiJiinent, \'mm the liubit of cuETjking It elevated
during tbe Ittng couive of biLuda^iiig to wliich it biid been fu1>-
jected. The wliuk Itiiib looketl h^fultliy, luid ihc u^^c of it wof
good, with the (rice^ition of tlie rnotioiia kA' tievation »nd »b-
diiction, wliicb vie often tiee iriiiJitiied fur a ycur or luui-e after
a simple disjiliirement of the booe, or even when die muscles
hjLve been injured by ii suvere atrjiiu, " ithuut fluy dijlucation.
It luigbt bf Mieutiont^J, diat no uiollvn iuiparled Ui the head t»f
the bone could repruduce tiie dialocatiGii, aa wjl3 die case but
a few mondia before.
Ca&E CCVn. — Snb-coi-Qcoid Dialocatiotin probably 2n-
campltit. — A WgE, powciful youug man, who BHid that be
waa but Ifi ye^Tv^ of tij^e, r^llhou-^^h apjinrently ueailj- leii yiam
older, presented him*(elf ut the Hospital with an injury M'bicb
he had recniied fifteen days before, having fallen from a height
upon the deck u^ his ship. He viiM* uituble to uae the limb
initch, Liml eoiilrl jutL rui^e it. lie saiil llierc hud been but little
poiit und no numbness, nnd that the blow had l>een received a
little below the most prominent part nf tlie shoidder. At the
point indicated, or nither a little hcluw it^ wa^ a slight di^eol-
oratlon. On the inside of tlin limb, in Its loner two^-diirdti, >vii9
an e:itensive eediymosta. Under the aeromion, tlie bead of the
bone euidd nut he felt, and the roundness of the shoulder was
lOBt. Tbe deltoid mn^i'Ie, liowever^ wiVA not on a stretchi ns
IS acen in caaes of ordinary dij^locatiou. On elevadng the limb.
and exphiHu^ the axilln, the heail was felt, ultliou^li mtlier io-
diatinetlyf and ns if eo\eicd up by somu plastic inateriul. It biy
directly under tbe eoracoid proctss. The patient was advised
to submit to an attempt iit reduction, and w^is told, that* if
be did not, the use of the limh woidd he impaired for life; but
being very stupid, a[id suffering no pain, he declined to have the
trial TiiaJe.
This case appears to be one of those iu \\\i\'A\ the head
DISLOCATIONS.
357
I
of the bone Bcome to hove been driven agninet the front ^i^irt ot'
the aouket, breaking; flwivy ita aupj^fjrts^ and a\\o\v\u^ the licaj
to rest juel in front of its naturnl po&itit>n, forming there a new
docket nearly on llie ed^e of the oM one. Thia injury is indi-
cated, Srflt, by the want of tcnsiou of the dcltoitl, w'hich u^iiuHy
e\idtfl when the head of the humerUB i^ eaiight unJcr the edge
of the socket ; aeeondly, by the nuinbnees met with, in most
cnsa^, from the pressure of the heiid of the bone upon the
oxillnry nerveSf w})erc tlio disloeation ie coin|>]cte; and, finally,
by the j^reAt eechymoeis on the in^iide of the limb, occasioned
by the niptured veascU iibout the injurad soL^ket, nnd whiiih we
do not often see, so fur u^ my exjieriencu ^ogHt in L*aBe^ of sim-
ple diiiloentlon of the shoulder. An attempt at reduction^ in thia
cnee, tvould ppoliably have i-eaulted in the breakiu^'-U]* of the
adhesions which hod formed ; thus admittinfj of the replacement
of the bone in its natural position, where, however, from tlie
want of support, it woo!d require the aid of mcejianiea] appli-
ances to retain ic until a new socket should he formed about it.
Case CCVJII. — Dislocation of the Hend of the Hftmenta
Jbrwnrd, icith probahh Frachirc iff' tfte Suiket. Jif^d'tcfi^n^
— The following case cxcmplilicB two fiicts. The first, of wbicsh
I have befiire given one or two instances, is, that when a blow
ifl received on the shoulder, the iirm beln^ at tlie i^ide, and not
extended, produnn^ a dUWatjon of the humerus, it is generally
ncfompiinied by a fraeture; second, when a patient presents
himself with a doubtful injury to the arm, tlie necessity of ex-
amining carefully the whule upper exti'emity-
A short, powerful Irii-hman, about 5,'j years old, apjjlieO for
advice at the ilospitol. Having requested the ward-tender
to prepfire the patients hefuroluind for examination, as there
were a great many afipliuants, his shirt was removed- I iit once
perceived an unnatural condition of the shoulder; and, on ex-
amination, found the uau;d signs of a dislocjktion forwards. The
padent said that he hiid frdlen, about 6ve weeks before, striking
on an ii*on t^i-aliiig. producing a severe contusion, followtnl by an
ecchrmcais on the out^tide of the anu. T a&ked hhn if he had
had surgical advice. He at first said no, but afterwards stuted
us
KE
\y\e act uf rutation, imJe^ a jKUt oi ic$ eu[>p<>ns
heen dettroyed^ Tbe pulleys were ag^n ftiljustcd, the baite
retumod to iw *ockct, and the arm secured to tbe sitfe hy ■
banda^. The recovery w^ good, but prolonged.
Case CCIX. — Cite o/ Dialoeation of the ShoutJer back-
^tjoriff, from yfuftcular Contraction, Jt^duction^ — This dis-
locntiort i« one t»K great raritv. Sir Astlcv Cooper gives two
CMEA aa having owurre<! in his hospitftl practice In the coarse of
thirty yenrs ; whith, however, he speaks of a* being diBloeAtionA
on the (|j)r<«iim of the ecapula- M, Mdgaigne has ci^llecTnl
twenty-nmc cases, eight oP which were the reault of consul*
aionH, !ike tlic present euse. Out of a huntli'cd aiifl fifty-ninu
eiiHCB cj[' wapulo-humeral luxation recorded at the MiikUcsex
lldupitsil, three are useirrncd to this variety. Thi^ case is the
firnt (if a Jisliicatioti of tlic shoulder backwjii'ds that I have seen
at flic llospilnl. M- Malgaigne Joi^cribes the dislocation under
tPlSLOCATIONS.
3511
the licad of onticnrrls and fjnrkwdnls. He alao speakfl of fl»e
dilficiilty of retiiiuing tlie heiwl oi' the l)one- In one of Sir
Afltley Coo|>er*a cases, it wna found thnt the fliib-s[^a[)ulufia luus-
cle wtiK torn nwny frum its iii&ertioii Into tijc siiialk-r Uiljerusity
of the humerus, i^tA that tlic piw-tmiii" [imtfcies *lrew it bM^kwanls
fts fiooti iiti replaced in ihe ftocket.
Tljc Hubject of the preaeat c\iss was a. man ajred 40. He
enlfiTd the rro!*|ut«.], fTiine 2il, 1860, Before he removed his
cluthe^f imding the elhovv ap[i1JL*il to the i^tde, arid nrjt stLittding
out froLii tlie budvt as in other dishiciuionn of ifie (ihouhlcr, T
doubtLil lu beiti^ i]ir4li>c;itJoo. On examinution, tlie following
3p[iearance» wan' pre^i?ntyil : —
The coraeoid prnt'esa of the sr^iipuln, vrns so prominent aa to
apppjir at first like the head of llie bont. t)n tlie oiitakle of
thid, the g^lenoid ciivily wh^ f^een empty ; the acromion [jrojei^ted.
Behind the acromiun, and rair^ed n Utile above its external
angle, wa« tlie head of the binie, firmly fixed In ita position.
The arm aeenied tti lie n little Ion<fpr than the other; but it \VJW
diilieull to deoide this hy measurement. The fore-arm and hand
retained their movements ; the arm itself eould he <^nrried olf
from the side only for a short distance, and ita anterior nnd poi^
terior inovement^ were very limited.
The accident had occurred fleven weeks hefore, dnring nti
attack of coaviilsions, follnu'ed hv an apoplectic state ; and,
on neeouEit of thif; eritieiil rondilion, nttention waa not g^ivcu to
the state oF the shonlder until some time afterward?. It was
not known whether he received nny blow on his nhonlder during
the eoavnlsions ; hut a slight ecehymosis was still visible at the
hend <if ihc' elbow, and at the upper and anterinr part nf the arm.
Tlie patient being etherized, the arm wfis rotated freely,
to hrenk up adhe*iionft ; and, the scapula being fixed, an at-
tempt wns made to force the head of the bone into ihe socket,
hy cjirrying the elbftw barkwards^ and prying the head ftir-
wanla ; hut it cGohl not he stirred from its situnlUm, Thii
movements of rotation were noiF repeated, followed by powijrfid
estensian; and, on a repetition of the aame process ns hefore,
the head was detjiehcd from ita positianf iind ra|tTaeed in th<*
flocket. Thia wjis verifiod hy an examination made hy nU the
gcutJeiiicn preeent.
aso
Exmiiurnss.
The arm could now be carried freely in every direction. The
head of the bone wna rjukc iiiovuUic Id tbc si>eket ; and, on
being aclzcd witk the tingera, could be co^ilj displaecd ciUier
forwards or bitekwnrdai Tiiis accmcd owing jmrtly to die entire
loss of niuacular power tar retaining tbc lieod of tlic bone in lu
place; and, posaiUy, from an intlnmmatory action, or the teu>
iog aviay of ihc altaclinitnts* of tlie ^ub-scnpularifi muscle, which
took place in some of the cftt^ea recorded.
TEie pntient^s arm vrm bandaged to liia didct and a Grm \ya/d
applied bebind tlic head of the bone to prevent dieplace-
ment.
Kotwiih Stan ding tbeee precautiona, in the course of tlie night,
the bone a^ain became diaplueed, du that itwaa ncectisary on the
following day Ut etherize bini. and i"cplacc it, which was done by
one of my collca*jLics ; my tetm of ^^ervicc hnvlng expired at the
HospitiiK The right aim wm no:v- confined bchiinl the body
for eii^bt days, duiing which time the bead of the bone rc-
Tnaincd in phu-e, Ucing then brought back to its natural pOAL-
tion, and bandaged firmly, in the course of tlic night il again
bccnmc displaced. It wns then replaeed, and the arm coutiued.
ad before, behind the back ; and he returned home on the I3th,
promising to report in the course of a week.
He showed hiiaaclf once or twice more ai the HoapitoJ. The
liriii relnliied its positioc in the socket, and the motiona i>f Uic
arm were improved.
Cast, CC^. ^- Dtslocrttion of Shoulder of three Tii^rttAn'
stindlng^ Ittdaction^ — May 17, 1>!61, a acarnun entered
the Hoapitali with a dislocation of his shoiddcr of three naontlia*
duration, w^hich had taken phicc ris follows ; —
Wliilc rounding the Cape of Ciood Hope, his eihip encountoi-ed
a heuvy gale. A aca struck the vesricl. while he ^\as on deck,
and knocked hira violently agninat the tail'rail. lie received
tho blow on his nnn just ImjIow the ahouldcr. The nLptain at-
tempted to reduce the dislocation, btit did not succeed; and,
since then, the man hsA been using his arm as much aa the
limited motion would allow.
On the day following hia entrance, May I^th, the patient waa
DISLOCATIONS.
361
^
plJjprizpd, tin? mllK^sinns being first lirok^n iip^ an far as conlU
be» hy roturion of ifie humerus j aiiiJ, nffrr pitenaion and other
inan<Eiivrea, contlnnEi) fur linlf an hour, the head of the bone
WHS reatore*! to its normnl punifion under the iiuroinlon.
Owirjj elrher to (he pnrlinl fiUing-iip of the old eoirket, or
what iipponrod to me n. loss c»f Bubslanefi in the front pnrt of it,
the heoil «f the bore wuuld not remain in place without eup-
port. A pad wns therefun? £ihu?e(l in the axilla, and a relenlive
baodii^ rtpplied.
On the lat of June, the bmda^e wjia removed, and alight
molinr of the arm aJvi^ied. He gnineil slowly the mnseiilar
and nervous power, owing to the ItJog; cime ibat the limh had
been (lieplaced ; but was auMeiently well, Juae 22d, rnther more
than five weeks nftcr the re*liiPtion, to leave the Huipital,
having a pretty goud use of hia Umb,
Case CCXL — Bt^locfilloji of Shoulder, with Probable.
Prat^.titre of Gff'noid Onvity. — June IS, 18«5K About aix
weeks before, while this patient, a man of 35 yenra, was standing
in hU atore, he wiw aei^ed with giddineaa. and fell, striking upon
hit( left shoulder. For two weeks after the nccident, be felt
p;iin and a aense of uneasiness about the shoulder, whieh was
examined by several j>hysicmn8T who could delect nothing ab-
normal. At the end of the two weeks, as he waj pulling on a
rope attached to a limb of a tree, the limb sprang back ; and
the rope, catehing in h!a arm, gave it el severe twitch, thereby
dislocating it- Seveml atrempta had been made to reduce it
before luA entrance int^i the HospitaK
Oo examination, there was the usual prominence of the
acromion; and the bead of the humerus wan feltunder the oora>-
coid process. Kiiving been ethevizeti, the reduction was easily
effected ; though, with slight pressure, tlie bone would slip back
to its former position.
In Ina first fitfl, rbe juttient prohdiily broke o(F the nntorior
edge of the glenoid ruvity- This would exjiLiiu lUe trouble be
had after the first injnrVi the fragment acting as a foreign body.
By means of a bandage^ ihe hciid of the bune was ke|)t in its
place ; and patient made a good recovery. It may be remarked,
44
363
EXTREMITIES.
that, in these cases of oJd dislocation of the shoulder, the ft
tm-e of ttc socket ia supposed frum the miinuor in wliich the
atxiident occurred. Secondary die placemen la would Cake place,
from obvious i-casous, if this fi^cturc wns present. In a recent
mac of dialooation, tJie praotidcd surgcoo cjinuut mletnke carti^
IngLUOUB for bony crepitus.
Case CUXII- — Lateral Dialocation of ik& Sfbotc
Thia Qccidcut u c^ccaaivclj rare, and the only cjlso of cumplcte
lateral dislocation tW I can find ie one described and tigurcd
Nov* 23, l*i63. The patient wna a tall, nniscular mun abo
25 yeara old, and, in wrestling witb nnoiher man of about
own fltren^th, vrns thiown violently down, hid nrm comin
UJkd(^r him, Ou rir^in^, tlic arm wns powerlcaa, and lie ^apposed
tbnt the joint lutd been tractured. Ho was brought to
bonac in a state of groat eufforing. Supposing that it was
case of a common dialocittion of the elbg^v, I felt for the p
jection of the olecranon throug;h the alothcs, but could not diati
guiah it. Xcitficr was crepitus produced by aitcmpta at rotntio
The clothes being removed, with some diiHculty, as the ni
was in great pain, the condition of tbc limb could be observed
The fore-arm wae very eligfitly tlcxcd on the ixm, but less
than in tlic div^locibtion buckwnrd« and was not eo much lax
The back part of the elbow waa completely Hattcned, and no
of the proceaaes of the bones which enter into the joint we
anywhere prominent. The breadth of the elbow was about one-
third greater than natural. By manipulation, the arueulating
process of the radius, the olecranon and the internal condyle of
the humerus could be distinguished in the maaa i but the who
anatomical condition of the parts was of the most perplcxiu
nature. By cxtcueion, HeAion. and rotation, after two eftbrla
tlie articuloi' surfaces were restored to their natural posili
The cose did well.
Case CCXIIIp — Fracture of the Arm just above the Cot
d'/hsy ofKuen w*ee^a* standotg^, imitating Dinhcalian of tl
Fore-arm backwarde. — 18C6, I have lately had flu oppoi
DISLOCATIONS.
363
ntty of ggeing Q ca-*e of the above deaoription in the practioe of
Dr. Ciibot, one of my collengues nt the Hoppitnl, and, witli W\s
permieaion, give it to show tlio deceptive flppearoncos which mny
be prod need fifter a frfloUire.
The patient, a child of six years, was thrown down by a boy,
and sustained what the surgeon in attendance confiiJered. and
which undoubtedly wasj a fracture of the humerus just aJjove
the condyles.
Seven weeks after, the inflnniniatiofi and swelling having sub-
sidcdT he eiitere<t the flo^pitul to have what, on a cureory exarai-
nacion, seemed Co be a di^lcxiAtion of the fore-arm backwards
reduced-
A more careful inapeetion woe made on the next day, with
the following result : On the front of the arm, there wns a sli^lit
ecchymottis ; the fore-arm (Xjuld be flexed lo about a rif^ht angle ;
and, just in front of the joint, the lower end of the shat^ of the
hnmei-ua projected, not sharp or roughs as described in rcconf;
fnictm-e, nor ao broad Jia we ordinarily meet in dialocation. On
the inner aide of liii:^ portion of the hunierua wna a rounded
process, which felt very much liko the inner condvie. On
the ouUide of the elbow, the hend of the radiua coald be felt
behind the humerus. By carefid manipulation just above it, the
outer condyle was found, upon which it moved freely. Tlie
olecranon could be easily distingiiisbcdf displaced backwards,
and on lis inner side it |>ortion of bone was felt-
Flexion waa ^uod lo only a limited dep'ce, and there was no
lateral motion, hut the arm could be com|>lctely extended; (he
two latter points conatitutin^^ tlie chief difference between frac-
ture aad dislocntitm of the elbovv.
The diagnosis made was that of fracture of the humerus just
ahove the condyles ; llic upper frn<jincnt being forced di^svn in
front of the elbow-joiut, and the lower fragment carried up
behind tlie shaft of the humerue, to whicli it had become
nttached. Under ether, after a moderate amount of force had
been usee], the motions of the arm were somewhat improved.
The appearances hitve been given in detail, from (he fact, that
tlic diflereniiid diagnoaia between fracture and dislocation is gen-
erally made when the injury ia recent, and before the process of
repair lins been ect up. Af\er tlie bf^nes hitTe iinitcfl. In « fnuv
ture iienr tijiiiuti witli scjiiil- dinpliiccment, it is otlcn v€rv iIilH-
cult, anil bometlmea iiiipusriibk', to dacide vt^telher we have tu
deal with £Lu unreduced dlslocallon, or a fracture witlt tlm bouea
liULtcd at an ^ncrlc.
Ca&E CCXIA'"> — BiiWntiftn of both TJntjhg: one, tukt
the I^oramcit Ora/e; iks v/hert on tits Dorfinm &/" ihc liifim,
with Frttctiim nf the Cervix J^sruorifi, JiffhicCion, — The
putienl was brought intu the MjiM^iichu^etts Oenentl Iloj^ptud,
Laving been cmolied hy the ^ivln^-way of ji wooden hi>ijjte which
he WHS eii^^ai^-d in jnoving, bt^ln^ 8lru<^k iipi>n the back a^ Ik
was mnkiii^' an atteiii[it to cf*cape, Tlie rl^lit leg first attnu^tcd
attention. The thigh wria fixed, «li<jhlly rtexed on llic biHly,
iitiuiding off from it; tiji^ tiiei^ pojntin;^ ni^rly forward, die liuib
apparently elon^^utcJ, A deep holhiw voja felt in tlie re^on
of the trochanter, »hidt hjLd it^tsLi'di^uppcured. The man being
etljtni^ed, [iml the imllt^vfl ailjuslcdT a ^Trnduidly inrreajst-d furce
wrta applied to cKtcnd the linili. A aheel u;ia |ihu'i^) nndur the
upptT pjirt of it ; and an nssistiint, Bt^inding on the tiiUo, dii-ectcd
to lift the linib. A sli^lii rotation W[H then mmie to diM^ngngc
the heiid of the liune, untl it ^^ enl into its plucs without U4iy
pereeptible noise or fiotlou of the mnacles,
The ri<.dit Iliiih l>eing ]>'plaee<l, it \v«3 now perceiveil tliwt the
left lindi nuh distorted, and presented all the mgns of £l di^lo-
catinn upon the dor^^uin ilii_ It was firndy iiKe<l, shiiriKoed, the
toes inverteil, and resting upon the upfK-r jiart of the other foot-
The troehiinfiir wua proinincnr, and [Iniwn np from its place to
within iibiiLit three indke?^ of the t^rent of the iJiuui. Oa iiiakJno
an efTurt to move the liuib, an indiHtinct, htit very deddiHl,
crepitus vraa perceii'etL
The pnlleys hein^ adjusted, nnd ether administered, the limb
was slowly and with nitieh difficulty dra^vo down ; n relight rota-
tory moiiun being given to it, when ihi^ heud Wii.s on a le\eJ with
the socket. It went into its plure with a lend enick, which was
\i&in] by all the aj^ai^tHnts. The limh now nppeared, at tir»E, to
have regained its natuiiil condition- A-'* the etfect of the ether
upon the muaculur syalcni suL^ded, the limb jrratlnally eon-
4
DISLOCATIONS.
3fi5
Imcled, t\nd the foot became slighily everteil. An e^cftminntiun
now being made, by relating the limb, and [ilncing the iingcr on
the trooha.ntcr, it wna porfectly evident it> nil present, ihiii thei*e
WAS a frn-cture of the thigli-bone pastsin^ thrjugh the trochanter.
The two limbft were tlietetbre confined; the riglit one by a
weight attached to it, and o crndle placed over it. To the left»
Deeauk'a splint, an uaed at tlie Hospital, was applied. In ad-
<1iiion to the above injuries, two or three ribs on the left side
were fractured.
The best explanation of the appearances offered by the left
litnh IS this : The violent crnahin^ force dislocated the femur,
At tfte same time breaking the neck of the bone. Tiie Beparatii>n
of the parts was not, however, sufficient to prevent thoin from
bcinj^ repliiced ; but the Bigns of complete fracture of the neulc
of the lemur were at once prtxluced, on the bone bein^' reinmed
to ltd socket.
The eubeequent history of this case i» not wichaut infereet.
The fiuficnti from the time of his ndini^dion, hnd com|»1nined of
hiri chest, where his fibe were broken. One night, flome weeka
after onlmnce, great difficulty of breathing oarae on j and, upon
ciamining the chcril, it was discovered that a congestion of the
poi^teriur part of both Jungs had taken place, Kuch as Uas before
been observed at the Plo^pital in patients wlio for a long period
of time hiive been confined on the back without movement, after
cerions in juries to the lower limbs. From tliis atiection he
very gradually recovered.
At the etid of two months, he left the Hospital well. Tlie
motion of the right limb wiw natural. The left leg was a little
shorLened. The motions of tlte hip-Joint were limited ; on ex-
nminafion, the trochanter was found irreguhir at the point of
fnicttire. As it hiul been thought possible that (he heml of the
femur might have been left on the dorsum of the ilium when
the complete fracture of tlie linih took place, search was made
for it ; but it could not be found tliere.
Case CCXV, — Ca^e of Dislocation on Dorsum Jiitt tBith
2*robiible Fr(xr*.lure of the Socket. Hsducticti. Fre^neni
Rtcufrence of the Dialocation, — A man was bronght into
366
EXTKEMJTIES.
the Iloepital witli a dislocatrim on tliG dorsum Oii, ^rhTch was
Ciiuecd by a \vn;:;on peeing over hiiu, the limb being at & ri^^hl
angle with the body. Ether -wns pfivoiij the pullcya applied,
Aud the dijslocation reduced. On rniJ^in^ ihc limb sJi^itly, to
eKamine it, It at once elipped out of plncc, and was ngiun
reJuee*.!, This cxpcrJtricnt was once or twice repeated, with ihe
same result. Dr- S, D. Townsciid, who bhw the man, verified
the laet. Slight, thoufjh not very nmrked, ercpitiie attended
the mi>vcraenta of the joint. From icar of displncemcnt. and
with the idea of a fraeturo of the edge of the upper and back
part uf the eolylmd cavity, the limb of the patient was kept
rigidly eonfined in Dcsnult'e nppnmtua, and hi<^ desire Il> re-
turn home resisted. The prceautiona taken in this tmsc wcic
flftervjifd Ghown to be not without reason. About three wecka
after the aceideut, durin;; my absence from town, the patient ^ot
oiit of bed, and, while re*?tin<; on tlic injured !imb» ottemptwi to
tnrn around, thus giving n slight twist to iho hi|>-joinC, The
bune immed[jilcly slipped from its eoi.'kct. This accident after-
word, ill the couree of the next week, recurred n number of
times from simple motions mndc by the pntient while in bed. It
was then determined to put on u permanent qilint. and nilow it
to remain for several months* Thid had the desired ettect, and
the patient was seen by me some months nfter leaving the lloe-
pitid : the joint was then slowly i^egnining its inobihty.
During the treatment, the patient was very desirous to return
to his home, but waa persuaded not to. Hud he done so, and
had the difiloeotion been reproduced (ae it was very likely to
have been), it might easily have been urged that the dielocution
Lad never been redueed.
Case CCXVL — -Dislocation of the fHp-jOiiit, wiffi other
JiiJHricfi. — December, 1851» A man, about -DU yeara old, was
Liiried under a bank of enrth ; and, on being dug out, was
brought, about four hours after the necident, to the Hospital,
On examiuation, Jt was found that he wjis laboring under a
fihght concussion <d' the brnin ; that the right hip was dish>cated,
tfic limb being inverted, and shortened twt> and a half inches.
Tlie left testicle had been torn out from the scrotum, aud hung
fluepcnded by the epermfttic cord. It wna covBrcd wilh grnve!^
and the cxtcrnaL tunic svtis bo di^ from exposure as to crucklc like
fmrcbmcnt. Aci the vc^acld £tiiJ continued lo pulaaCe. I dotor-
mincd to make cfibrta to j)reflorvc it. It was ikereftire icjupora-
rily tnvclofKtJ ia a cfxoprwa, wet with warm water ; nlier which
the paticot waa pkct-d antler the full influence of chloric ether,
with a. view to the reduction of the clislocation. The furce of
the pulleys bcin^^ applied, although a [rarfact state of tolE(Sfl,tion
from the cfTcet of the anrr^thctic a^at eccmcd to cicUt, it re-
quired continued effort, for ten or fifteeti minutes, before the
the muscica concerned in the dialocatiou began to yieJd. The
limb vraa gradually brought down ; and, when the liead of the
bone came opposite the socket, upon n sliglit rotntory niovc-
iDcnt, h alippcil in with a di^^tmct rcp^i^. On mciving the limb
al\cr the reductmti, nn uncommonly hxid cartLluginous ercpitiH
could be heard ; and thia ayinptom, in a modified fonn, con-
tinued for five or six weeka after the necidcnt, cvcn'when he waa
eutftcicntly recovered to wnJk aljoiit the ward.
Attention wne nest ^^vcn to the tealicJc- The acrotum having
strongly eonlractcd, it vfaa found to be a matter of some diffi-
culty to return it, but it v/ne finally effected by seizing the scro-
tum with the fingers, aad then forcibly crowding in the tcaticle
through the wound with the thumbs, confining it thua until two
or three fiuturea were made in the integuments.
The patient, when last seen, two inonrh^ after the accident*
was recovcrmg the ufie of the injured limb. The wound in the
flcrotuiu had iiealcd well, and the teaticlc aeeined to have aufiercd
but little from the expoanrc it had beeu euhjeeted to.
The application of the c^ttcnding forcc^ mode from the aukle,
was found more convenient tlian by the ordinary method from
the lower part of the thigh. No subseijuent inconvenience was
experienced by the patient In the kuec-joinC. He had some pain
and awelling in the ankle-joint for a number of days after the
injury; but whether it resulted from the accident, which was
a complicated one, or was in any way connected with the man*
Dor in which the e:itendii]g force was applied, it was impoa-
aiblc to determine.
f
366
EXTREMITIES -
Case CCXVIT. — Dislocation on the Dtirftnnt Hit, nf
iw^nti/~thre€ dayt' standi/iff. JiedacCwu. ^\ iiian 3fi ywirs
old, of etrun^ miipicular dcvelupmcntr was AttcmptiDg to raise
unkftlier who wtis lyjng hctuha a. niUroad trsick. Ou makmg die
elTiirt, he fi^ll ; the weijj;Jit uf (lie liJted man coming aj^niinst Lis
pelvis ami Itft Uiigh. He was uniiUIe to n^e, anil was taken to
a neigl I boring liiiiise, wliere Wis hijf wiia exaaiinetl. Tin? injury
wjifl sujipustHl Uy be it ti-prtiin. IIo remained m bed fur twenly-
tlir«t d'AVn; atid» as the limb dtil not recuver, he wiin ixihist^} to
go to die Ho»|)lt;il, Doing «n, he wjilkeil a mile nm) a qunrter
to the niilrfKui station- He ciime hy the tniin to Boston, ami
entered thtj Uoajjital, Miircli 13^ 18(52. On mitking an exaitii-
nution, I at once perceived that the limb was not in its natund
poallimi ; and that the Hymji1orii8 or a. cliHlocattion upon ibe dorw
«um ilii existf'il. The limb wa^* shortened about two iiichea ;
the trochanter being about that distance rearer lo the cnwi of
the ilium than tliiit of the opposite side, and the toes invei'led,
bnt not lyini; aeroHS tlio infttL*p of the other foot; there being
thia peeuliarily, timt tJie legs stood off from tiie tingh, Furiuing
an angle with it, and giving hini n kn[H.'l(-km?ed appearttnt-e.
The w\iii]ii limh wii8 much more ntdvnble than I hrtve genemtl/
oh»4erved in a case of dislocation. Tliia may gioR^ibly have ariseii
from tbe elfoTts whieb he bad maJe to produce Tiiotion, under
ibe impresfiiiiEi tlntt it was only a sprain. On turning him on
bi« faee, the natca of the injured Me a[i|>e>ired mnch broailer
and roumW than on tlie other aide; and, where tlie hollow
usually exists behind the truchanter, an elevation was per-
ceiveil, whi<:li on exiimlniiLion iippearwl to be the bead of tfao
hona, which rot^iied when die iicoessury movementa were given
to the femur.
The patient wnB etherized to the point of total relaxation of
^e museleSf and pnllevH were np^lJedr and the limb drawn down
to the same length as the other. An attempt was now made to
turn the head of the hone into its av>cket ; hut although, at tlio
efforts at rotation, a tearing sound was heard, as if strong adhe^
sions were [)eing broken up, yet the bone could not l>c forecd
into its socket. An oflbrl w;ia then made to reduee it by Dr.
Seid'a metlntd. This also failed ; the only effect being to cariy
DISLOCATION'S.
369
I
tlie liead oF llie bone around the aocket, atiil Indite it in tlie fom-
mcEi t>valL^. Fri3m tbia prjgiti<)n, it wsis casUy brou;jlit back tu
its original gitusicion on the dorsum. The pulle}^^ were now re-
adjusted, and the Jlinb ap;:Lin bmughc slow]}' down* eo as to bring
the heM<l oppo.ajte (Ke acetabulum ; anil, the pulleye bem[* ro-
kiGil, a siidUen twist nnd lilt waa ^iven to the bnne, which
went into its proper piaffe with n jcrlc:. The limb at Gret,
after the reduction, huA rather an iinnatnral ajipearnuce, bijiniT
aeemiTijfly louj^er than the other, so that 1 thou^'bt that poapibly
it mi^ht have again slipped under the socket i but, on moving
it, I found those free motions whi(?h can tinly be pivon by a bone
in its natural position. The apparent length of the limb arose
from It deviation of the peLvie, it having been three weeka in a
strain cd position.
»
Case CCXVJII. — Diihcation o/ the Hip npon Dorsum
Ilii. — June 16, \^^\^. The patient, a stout man of 23 years,
while standin;; on tho inn.4; <»f a milroad, was struck fi'Oni bc-
himl in the pelvi<; iv^don by a frei^^lil-L-ar, thrown down Ujiua
the track, and dra^r^etl eonie distance. On examination, the
dislocation was evident ; the right ler^ being shorten&i two and
a half inches, drawn up and thmwn over the left, tlie foot in-
verted, and the head of the femur easily Uiatin^ished on the
dorsum ilii.
The dislocaticn was readily reduced by tlie '* flexion method,"
and the patient made a rapid recovery.
Ca8E CCXIX. — Perineal DUtocation of H!p-jotJtt^ with
JSver^icn of Foot, — A tnan, 35 years of a^'e, while etiindiug
neurly erect, was knocked down by the cnving-in of a bkiiik
of earth, and was seen by nie two hours ailerwnrds. He was
thrown forward on his left kneCj with the thi^'h much ilcxcd
on the pelvis. Did not know what the position of the foot
was at the time of the accident.
The left thi<>h was found to be Hexed on the pelvis, at an
angle of about 70*, firmly fixed, and about tw'o and a half
inclies shorter than the other. The foot was everted. Near
47
370
EXTK>:UlTlEft.
the luWr hchu was ft projection. 'Hiere was coDsUemble awd!-
in^ iilioEit llie hijt-
TEie pnticnC lieiog eilierizeil, eiten^don waa mmle bv pullevB,
«t fiTPt iu tlie a£L« of the fhigfi, anfl the limh roiaied, but with-
out eflt<?t_ Extemiitin being ajriun made, i\i& knee was J**
prewedf unJ the upper enil of the boDe lifted forwanU lo th<
socket. Thi* ninntriivre brou^hc the iip|>er end of the boue
forward upon ihe |>elTb alMive the M>eket, und st niigbteneil tbe
thigh, the friot being evened nnd ihe limb ehorieneil.
Strong exteiWon was next mnde in the axU of ilie bo<1v, tli«
tliigh roratwl inwiinl';, and, nftpr ^hpping h_v the aocki^t many
times, ibe bend of ibe femur hnji[i|ic>d into Uf< pinee. Atler some
eccli^tnosu nnd Hwelling, the eo^e lerDiiiiated favorably.
Case CCXX, — Ghlofttd'on on f/ic Dorsum of the Xixum.
lipdiicttim, — An intonWte^l mnn wjva brtmght into the Hos-
pital, in the firei week of pTime, lJ*r>tl, hnving been caught nnder
a ti'sin of can backing into ihe ^tntion-hoiise. The tiL^hi femur
lay ner<j^ the opposite tliigh, 6o thnt the iatemd part of The
light Vnee touehcd the let^ patelk ; the teg waa u litt}e bi?Tit
upon the ihifrli, and llie r>ot, eliglitly inverted, rested on the in-
step of die other. Tlie trofhimteT was feJt a liide above rhe
neetsbulum; and the head of the bone, a little above atid b^
hind it, WQS indistinetK' felt undiT the muscles. The thigh vr^tA
immovably £icd, so thnt it could be seized near the knee-joint,
find the patient almost turned over by it, without prodiiuing any
motion of the limb.
Having fully etherized the ninn, I first attempted to redaee
the dislocation, by Heid'e uietbud j viz., by strongly Hexing the
thigh, and making the knee describe a segment of a circle over
the nbilomen, thus sweeping the hend of the hone partially
around the socket. The wJit of the dislocation was altered, but
tlie head of the bone waa not reduced. The limb was now
Heiied gently hy the ankle, and easily drawn down, till, when
opposite the flockei, n noiao was heard as if it might have been
reduced, but not of that docidetl character to satisfy me thnt it
vaa 80- Every person about thought it had been returned to
ita place. On letting the limb j^ro, it seemed tii have the natu-
iol directiop, but was evidently a litde shortened-
DISLOCATIONS,
371
Tlie Yimh wm then agiin eeizi^l ; anfl, firing drng^l down,
I put my hand Miinil llie tronhanCer, giive it a Jitlle Wt't, and it
went St once, with nn ijniiiL4talcablR report, into ita ptnce. Mo
tion iMJuld now he given to the limb, in every poHrtible direction,
without throwing it from it^ fiitiuuion.
Cask CCXXT, — PerhtPftl TtUli^cation of tlie ITrp'joint.
Rediiei ion . "-^ \^h\ ^ A yonnj^ miin^ nliout 20 years of nge,
was struck on tho outside of ihe Oiigh, and ihrown down, by
a huTidle of hay whirh fell on him from a. loft. On hia being
taken up, it wjw df^tvivprpd that the ri^ht hip-joint was Jialo-
Cdted ; and I wa^ rcfjiiested by his phyaii.'ian to see him.
I f[jund the patient tying on his bnek, tii^ tliigh etanding out
laterally from t}ie trunV, and forming a Hghr angle with it- At
the spot usually opcnpif>d by tlm tvot'hanter, n deep hollow cs-
ibted. The heatl of the hone could he felt on the aact^ading
bmnch of tlie i^hium, and inigfit Jtt first eimily have lieen inid-
iftken for the tuber iscldr. The patient wonld not allow any
examination to be made until he had hern plaeed under the
indueuce of ether, ,
Aftpr the patient was etherired, the pulleys were adjusted, and,
on the first etiijrt at fraction, the head of the hone slipped aronnd
tha socket, produeing llie appearnnoe of a dislocation into the
ifiL-hiatie notoh. The f-kree of the pulleys was then intrreased^
and the head of the bone Wiw quickly bronght over, and went
Into its pla(!e with a dirttinet repnrt. On the removal of the
extending power, the limb was found CO have recovered its
proper length nnd motions.
A few years before the above, I had the following case : A
gentleman, RO years of aire, fell from tl^e third story of his store,
alighting on his knees among some bales of goods. The effect
was to produoe a dispbicement of the right thigh, nttended by
phenomena like those observed in the preceding instance. The
patient was etherized, and the Kmb replaced by manual forte,
without the aid of pulleys, the eystem being deprctjeed at the
time by the accident.
372
EXTREMITIES,
CiSE CCX-Xn. -^ Appearance of n DUloerrtion of U
Hip-joint^ after nf^arhj forty yeare. — This cnse ia odc of ui
commcn) interest. The subject of it wna a gentleman, ahoiit 31
yenra of age, who, in the latter part of the year 1^21. npjilicil
to Dr» J, C. WDrrtii on account of an injury to hia hip-jyinl,
wliich, ho 6tntc<J, had been injured twelve wceka before in tl
following' nimincr. He wne riiling a spirited horse, when tJie
animal suddenly reared and tell ba<;kwari:i5 upon hinif the weightj
of the horce being reeciied on the left thi^^h ; the patient havinj
fallen on lila backt aa he aaid* a liutc inclined to the leli «id<
On attempting to rise, be found himself crippled.
After It careful examination of the caae, it woH declared
be n dislocation, and the patient was not encouraged to ho]
much from an operation. lit peraiHtcd, however, in having
attempt at reduction mode; aud^ after n consultation witli tb
other niedieul ol^cers of the Massachusetts General lloapital,
WHS a[^ed that tWis should be done. The eflbrt failed, oflcr all
tlic ordinary means had been resorted to* About a week iifter-^j
wards, the patient appUcil to another surgeon, who gave ns^f
opinion aimilar to tbnt given by Dr, Warren, and mndc another
attempt at reduction, but without Bupeess, Finally, he w
induced to apply to a proJcssed bone-setter, who mitde a thii
attempt, with the eamc rcfjult. Immediately after the accident*
he had, it seems, called in two practitioners in the neighborhood
who made attempts at reduction, and supposed they had sm
eeeded in replacing the bone-
About a year subsequently, cnntrnry to the advice of Ds,
Wnrren, a euit for malpractice was brought, by the patienti'
against the two surgeuna who were onginally called to the case.
After one or two triala, the suLt wna withdrawn, the jury having
disagreed, priueipally on aceount of a eondict of surgical tesi
mony.
In September, 1858, 1 received a letter from Dr. Greeleyj
of Ellsworth, Me., the physician of this piaticnt, stating that
was at the point of death j that his friends were botli willing
and desirous to have the coac investigated, and tliat he himsi
had always expressed the wish thnt this should be done. Ol
the receipt, a short time afler, of the telegraphic despatch
DlSLOCATlOKd.
373
nouncing his death* Dr. IL K. Oliver, at my request, prf>ceeded
to Ellsworth ; antl, nfter taking note of tlie external iipi)eflr;Lncefl
of the hody, separated the pelvis and the upper third of the
thighs, nnd, by permisflioa of hia family (it being imtHva/^ible
to make a &u.tiff]LCt(>ry iiiveati'^'^atloii on the spot), brouglit the
portions ihua remove<l to Bojitou. Here, he made a careful
di^eection of the eofc paitSi on the afPcctcd sitlc; and fluba&-
quenlly, the^e tissues liaving been removed by niaceralioai made
a thorough eAamiutitloii of the houy atructurca.
The following is his report of the examination of the body,
the diaaection, &c* ; —
*' T}i4> bofh'n Willi miiaciilar anil adiponi^ ET.tAnes well iavelopeil* WOB
lying on JUq bi^il^ ihi; ^fioatderj^ iteiug uli^litly raiai^d. The loner ex-
trcniiliea wero od a liac with the body ; Lhe heeU boin^ together, and
on tba SEime level. The hmbe were tliersPoro, to Lhe cyoy of equal
length. Tlie riwht side of the pehU nppeflre<l lo be aomewhAi luwer
than the icl\. Tlie light foot vnrltd but r^li^lillj from the perpcoiljcu-
}or ; tbc Icfl lurucd out aL tin aa^h of 2~i° or 30^. The li:l\ kuuc was
raisedi £o that tha Lhigh made wiih lUa piano af tha bed aa angle of
aliotiL \a°. The rii;ht kuue Wiii^ raised ro tlie IcvpI of ihe left» a
dif^troDce of two iachea in the length of dit tiuiba was noticeable. It
was diEBcull, on account of the ^eat amonnt of adiposo 1ii^Q«, to
compjLiG Iha lenglb of Ilia limbs by moiisuriag from the auEcrior su-
ptrior tjpinnu'* processes of iJie iila. The movemenlB of [be left thigh
were limited^ und confined exclusively lo flexion and cxteusioa; no
niolLon wlmlovor being perfcivod in attempts at ubdiit^tioa and adcliio-
lion. KxEenMOTi uf the leg wha impo^sihle, ^ven aller iliinKion of the
tetidnim of iha Hi^xur musi.-lea uf llie thigh- Tli^re wim iimsequeuily
A pcrmniieat fiexioa of iho ihigh upon iho body, and of the leg upon
the Ibigh. On Itie uppur and inner part of tEic thigh, a large, hanl
mnfifl coulJ be fi>lt, not eKLSting in the correqpoadioj^ lotraliiy on the
ri^bt aide. Tiiis waa ^ubsequeiidy Touud to be iha new bcinj scckel.
The body being turned ovefi the flalnesA of (he lef^ hip, a9 compared
M'ilh lb* right, was very markt-d. On emminalion, a. hard, round-
ed body^ BubMH|uen[ly fuund to he tho irochaaicr major, wa^ felt
lying rather Jeep below the l«vel of the trochanter of the nght
■ide.
^* Id the disseetion of Lite leR hip, all the muaoks, large and amnn,
belonging lo this region^ wuro fl-nad^ hut nolir-eably h'^s full iu sub-
etUDce, atid oC a lesa healthy color, thna tho^e of the ri^ht side. Tho
374
EXTREvrrrEa.
cliimge of directTon taken by ihemi brougLt tibout hj the clkAagfi
tlic point of insctlioQ, — namely, tlio Iroi'liaiitor mnjor nud the up*^
per purt of tbe thigh-bone, — was of course Jipparect, The gloteiu
miuiiiiLis, lit* it pH»sud ovi^r wlmt rvmaiued of ihe acetubulum to renck
ilfl poiut or iu=«riioa, was (irmly bouod down to ihe li^fltnent whk-li
covoreif tiie cr^vity by Htraog hhrotis liemio. The obturator cxteruiu
appeHred to be ivduc^d to a I'l^w tibrc^f Hrisiag from tho ramu^ of iltft,
uchium and pubea. Tba carlibii^IiiouQ, nud, apparcutly. pari
the oflseouB, rim of iho ftcciftbaluin was nb?crbcc]. Sir«tch«d <^^
what rfmRiiii>il of Ibe onvity was what npponr^d Co be n part
the old capsHlar lignment^ Mitl pHriUlly Gtn-loaing the oeck of il
d i, "t placed buuQ. Deuealb ibia Jigamutit, and filliitg up Ibe {metabului
WAd a dense iiiJL»a of adipose Btid fibroua li^uc. Kacoinpivj^diiig lh«'
new socket waa a lough fibrou* hiyer, whieh, as it surrouoded
ih^> neck of thfF bone, na-iumod hII the don^iiiy nnd strength of a tru4
capfluk, with pcrhnpfl eveu grt'fl*er Ibiekutartn No Uhb of divisioul
bctwcou Iha nc^v ntid tho old <:ap^uhir lignmcot juM referred to could
be dfiteotpd. Upon dividing the CBpaulaj b'gameot, a ligameulum
terea was found, dT^itjg tbe hetul ftnuly to ibe sotltet, And rei^iTing
Iho uutrieut vcA^i^h iLrou^li a iiotoh in lliu same relative postliou,
□amcly. In the on(t?rior part of the cavity^ as in the true acetabubun.
The nrticular eariilage of tbe uew socket wa» wanting in that smooth^
shining appeiirwiitu, ebftracterwiiir of nrtieidHllug Biirfac« general-
\j. Thai of ibe bead of the bone wa^ much less uneven. Besides
the rouod li^umenrf a few small fibrous blinds wera seen attacbiug
ths bend of thu bone to the sookel anteriorly. Upon exuminatioa
of the interior of [he pelvi:^, the thyroid foruiiien wm fouEid lo be
ncarty obHEcraied by the rounded biL9^ of the new socket ; but it still
rc^taiDcd ilB iincjnbrauo £trctehed over the intruding bony eup^
" Sinfe niHCefHiion of the soft lisaiioa, Ibe following points ar«
to be remarked in the Iwiiiy ^Irndures: —
'^An ndvcDlitioua soc^keL for the head of the [higb'bone is formed^
below, and a. little ia advance of the acelnbuliim on ifae left nid^
This soetet fiUfl up tho greaier portion of ibp ihyroid foramen, and il
bounded us Ibllowft : Superiorly, by ihe body i>f the pnbes and the aco-
tabulnm^ the cavity of the liUter being encrom^hcJ upon by the adrea*
tiiioua BO(?kec [o the oEtout of one-half of hs area \ posteriorly, by Ibe
body of iho isL^hiuiu, upon wliidi ilie socket rests wiihont leaving any
prkrt of the ihyroid foramou viaible^ iufeficjHy, by the rami of tlio
iethium ond pubes^ leaving no port of the foramen visible there ;
anteriorly, by an irregular, crcactnt-stiapci portion of Iho foramen,
DlfiLOOATlONS.
375
one and three-quarter iQches iq Icn^th^ by qd Average brendlh of
onc-quartor of ua inoh. Tlio nmjar purt of the soiket is at ooe
pflpe ; but Ibertt Jire four eepnrote piefren of bene of diffi^rent sikm,
the }aTg^t of wliidi mut^urua two iocbes in leugtli b^ an uv«m<;e of
oDe iD<:h in breodlb. Tlic^e looaa pariioiifl bciiis; liUcd in Lbc places
where Ihoy opponr lo belong, the aockel h&H uti average oulaide diam*
ercr of three iitrbe^i and n depib of iwc mdiea. The subBinnro ofiEs
padetus is quite Arm, but irregular *md rough externally, ftod aome-
ivhftt roii^^h intornally- Tlie opeiiio;^ tbrough wlikh the nutrient
veftgela pae^ed rroiii Ihe inlerior uf [be peh'i>f into the CHVily of Ibe
joint is «een &t the nuierior porEion of tbe fundus of the mx-ket.
'* Wbero llitT Bf>t-ki:t if uaitud vi'iih the i^chinm and the nxxnl of
the iachjum and pLil^r^^ hcuy niallor hiiB Lcou depotilL'd in limilcd
umount, so Ihut a liirrow vxK'UiU from tbe otd nc-etiibuUim pislcriorl)',
round lo [be lower jwiriion of the LTesccni-Mbupcd opening Hurt riorly :
but, upuu the superior aspcrl* whoi-e the weight of ilie body vaa lo
be mipperled) the interMil LrcLwceu the socket iiDd (ho adjoioio^ por-
liou of the p^lviM i» ^ulir^dy tilled up. Tlerf, in fad, 14 «eeti n tirnif
ntroDg huliress, ihrowu ncrosa frtiiu tlie budj uf the puben and ihe
ptibic portion of the ilium downrtnrdu and outwards, aprending oyar
the wholo superior surfuc^e of ibe eorket quilc to ile outer od^. Ou
exumiDiug the iuEerior of the old aeetubulum, Its cavity, nnlenorlyf
is seeu to be pa]i!«idt'rid>1y euLT0ii(:ljei1 upon by ihe posterior border
of ihfl butlresa just deniTibcd ; and, poBlcriorly* by « second but-
tress, much emulJer thiiu the ono uiontionGdi thrown down upon 1b«
aocket from ihe ponteiior poninn of tbe flrelobubim.
'^ Tbe heud i>r ihc tell femur ts uiurh lurger tlmu j[s fellow of tbe
opposite aidaf uud ir^ surfnec quite roii^b. Its ^renlcat eircumlcrctic«
is tiis itiehei. From the hi/nd of Ihe bene, nloug Ihe ooek aDterioHy
flnd superiorly, \si ihrown a ridge of bone Eenrly reu<;hmg the iroeban-
l(-r iniijur. This oihls uiulerhilly to tbe ciruun^rvrtucB of ibo necV.
which is itvQ and ona-ci^bth lachort ; that of the ueck of the opposite
side being four inehea.
" The mom caroful prruliny fails to defeet ri^s of prt^vious friwv
lure anywhere, either in tbe pelvis or in the ft^tuur."
lie /iiarlit, —The moBt Importftiit point which Dr. Wnrrco
was caJIcd upi>» to decide in tliia case wqh whether a Jif*locatioD
of the bone e^Etsted or not. Hb opinion was thnt a Ublocntion did
exist. The dofcadant in the amL, liowover^ obtnineil a disngrec-
mcDt of tLc jury by the teatimony of a diatinguiaheJ surgeoa.
S?6
EXTREMITIES.
who expre*i.He<! a de^Jd*'*! fniinion rhiit there wm not smd never
htui W-n a iii.s|o<'aiiij|], hut Ouil the ori*;ln»l injury wae a fruc-
ture of the pelvia. It will be wen that no signs of any fnictupe
having occurred arc to he found In the ^^^jectLneir* but iltat lW
inJEiry wa« wbai Dr. Warren BUjiji^jsed it to be, — a simple
dislocnlion.
The question was made very prominent in ihe trial, whether
tlie ejicciea of di^lucalion of llie hip whiuh Dr. Warreu &upj>ofc<l
this to he, — rHincly. lIowIl^x-:i^]rl and baekwarrjs, ntih tlie beud
of the bone lying on the ischium, near the le^aser lAcbintic noldi,
— ever exiateil ; and the work of Sir Astley Coo|ter was hnui^ht
forward In pruof tliat such a JIdlucatiuii. although [ni^ntioneU hy
•ome authrtritic«i could not take j>lac«. Dr. Warren, however,
did not utider^lund Sir A^dey to Ji^ji^trt that this ilisEoralioo
couid not take phiee. Moreover, lie It^lt, that in any case the
evidenct? of hi^ own iten^e:^ should rather be his guide ; uid, na
he w<i» aho of the belief tlijit there was no depression at any
point about the acctabuluin in whii'li the he^itl of the boiie could
not, cxeeptionally, be lodged, he [lersintcd in his o|tinion tbiit the
dmlocation baekwarda and downM-ard^ wa;4 wilhin tlie boinidA of
poaaibilit^, and that the dij^Iocalion in <|ui;5tJon wa^ of tJiat
deacriptii>n. In ihj^ belJrf, he hnd the nmatenanee I'f the coii-
milting snr^eoQs of the Ma^saelkusetta General Huspitat.
Sir Astley, at tliat |)rnod, did not acknowledge die exifiteniTB
of thia apceies of dl^plaoeinual of the hip-juint; yet, in later
editions of hia work, pnhliaheil by Draueby Coo^ier, one or two
cases arc related as having ajWrw^ard^ ocenrreil U'i him : and, ill
the edition of Sir A»tley Cooper on Dif^l oca lions, puhlisiied \>y
the MdMUchuseltfi Medical Society, two eases of this injury nre
dcacribcd, the Hpceijuena of vihieh I had tlie o|)[)ort unity of eee-
ing abroad ; one, through the politeness of Mr. Edward Stanley,
tlie distinguished aurgeon of ^t. Bartlioloinew^H Hospital ; itud
the other, by the kindneea of M. Kobert, in Paris. In tlie
latter cnac, the dislocation was partial, with the head of the bone
reeting on die sockets The dislocacion downwards and baek-
■wnrda w, however, at the precent day, Tery fully acknowledged,
and 1 have eecn it in my oivn practice; while Mr. Erichsen, in
the la«C edition of his valuable work, has placed it among hte
I>IS1*0CAT10K8.
377
four forme of dielocalion , conBirlcrinrr the dielocntjon upwnrde
&nd backwiinle into the iecluatLc notch oa dimply n Jitli^rcut form
of ihe dislocation upwards on the iJium,
A few words as to the Teasoiu! which influenced Dr- Warfen
in his deoieion aa to the kind of di^locAtjon will be of intci^ct^t
here. The limb wua len^thenod ; the diaplncement waa tliere-
fore downwards. The next point wiie to determine whether tins
dl^plucemcnt ks£ downward^ and forwards into the foramea
ovale, or downwards und backwards in the vicinity of the Jcsser
iachiatic Dotch, The iachniilion of the foot ojid leg were such
as to suggest to Dr, "Warren tlie poasibility of a displace ment
into the ibramen ovale ; but the phenomena were not so marked
as to impress thia species upon his mind to the excluaion of the
displacement downwards and backwards, since he was of the opin-
ion, that the position assumed by tlic liinl) mi*;;hc be varied by
drcumstances, being inflcienced by the de^jreo and direction of
the dlidlocatintr force, as well as by the subsequent condition
of the capsular Ji^ment.
In this condition of things, the head of the bone having been
diligently sought for at the inner and upper |MUt of the thigh,
and not detected tliere, but a. hard, round body being distinctlj
felt below and behind Ihe acetabulum, the head of the bone was
thought by Dr- Warren and his confrdree at the Hospital, to
be lying behind and upon the lower part of tlie body of the
ischiuiu, in the vicinity of the lesser isehiatic notch.
The dislocation as it now appears it not as it waa described
by Dr. Warren ; but the socket for the head of the bone lies
almost inuDcdmtely under the old acetabulum, perhaps a little
forward of it. The cause of the deception, it will be surmised,
,1hi in the fact, that tJie head of the bone found its resting-place
tlmosC immediately under the aoetabuluni, at the poeterior part
of tlie thyroid foramen, and in contact with the body of the
iichiuni. Such a position of the head wotild render its detectiou
anteriorly quite diHicult^ even in very thin persone.
The specimen, beautifully prepared by Dr. Oliver, may be seen
in the cubmet of the Warren Mu^um of Natural History, Its
appearance is faithfully represented in the annexed en^aving,
oopied from a photograph* Above the advcntitii^ue eoeket lied
48
378
£STREUlTiE9.
Hi
what remaine of the ncctabulum. Anteriorly ia seen the cres-
oenl-shaped portion of the thjrokl fonimen, mitl fhe twitch iIp'
scribetl aa admitting the nutrienl veaeolfl of the joinC. The
larger butd-esa, described hy Dr, Oliver, ie perceived above tlie
new flocket, and nnterior to the oeotahiilam. The change in
the Appearance of the head of the ihifrh-bone of the affected
Bide ]fl very faithfully deliiien-lcd.
The flpeciraen, OBide from the interest na coDnccted with the
trial, is exeeedinglj inetrucHvo in several re^pecte. It la most
curious to observe, that, in the depoeilioD of the bony milter
in the fonnaticm of the new aoekel, a. distinct interval is left
for the entrance of the nutrient veescla.
The firm, Hlrong biittres3e& which nature hsvB provided are
found just at the points where tliey are needed in the support
of the btxly. The depth of the new aockei is quite remarkable,
and will explain in a mea^uro tlie imposfiibility of abductintr ^r
acidulating the limb; the edges coming eo far forward on, and
oncompoaeiag ao closely, tlie neck of the thigh-bone, elb to make
any such action impracticable.
Case CCXXUl. — DUlocation of the Thi(fh into the Fo-
t^men Ovale, fieduction. ^ In the early part of May, 1859,
I wafl called to see a man who Lad received an injury of the hip^
DISLOCATIONS.
'did
joint, nho other injaritg, hy the fiill of the wnll of a house.
When I orrivL'd, he \v^ lvii>;i on his bnck, witl» hia Icil leg
flexed on tho pelvii^, untl eimidin^ ofi'tVom iho uthor at an angle
of nbont 45**. A slight hollow wiia peruciTcd nt the scat of tho
trocJmntcr, nnd tho foot waa slightly everted. Taking hold of
tlic nficctcd bone, I found it in a great degree fixed i and, tha
foot being evorCcd, I &t once recognized n dialocatioii into tho
fiti'itmen ovjde without further cxriminntiiMi, kuowin;^ that no
other injury cuidd lUVfiCiit thc^c evmptomj*, unWa it were a frac-
ture of t};e neck of the thigli-bonc, in ^vhieh case there would
liftve been tt (certain decree nl niobjlitj of the injnred Umb-
farther exnmiiintioQ also wa8 imprncticiiblo, the patient haviii;^
his ciotlios on, lying In the street, and inaliinfr the ^rretLtest out-
cry on tho elighteflt attempt to determine the nature of tho in-
jury. In addition to the above di.aloeatt£m, ho had a fracture of
(he liiwer eri<l of the radius of the loft arm, and n deep cnt on
the right temple-
He WRS plaoei^l on a Hltert and conveved to the Hospital,
whero I almost immediately fullowed. He wns etherizeil, and
the dislocated bone, with very slight manipulation, slipped into
itfl plaoe. The patient vas kept in bed about tlirco weeks by
hia other injnriee, bnt, on gcttini; upon his foot, rceovored rap-
idly. The fractured radius, whieh wos much displaced, was
ti'catCfl with the splint contrived by Dr. Dond, of Philadelphia,
for that injury, which, for comfort and efficicney, is superior to
Qtiy one that I know of for the treatment cf this troublebome
ueeident.
Cabe CCXXrv. — Ditlocaiion into the Foramen Ovale of
yhur veekif' standing^ with other Injuries. HeUuctiott. —
Oct. !l, 18(jl. A younp man, lil ycnra of age, was brought
into the Hospital, having, twcnty-ecvon days before, fallen from
the forevord of a ehxp, while at sea; strjkini;; first on tho roof
of the cabin, and from thenee slipping ofl^, and strikin;; the roil.
By the first blow, the hip was dialoeatcdj and, by the second,
the right arm was broken in three places, vi^fi., tho head of the
humerus, tho oloeranon, and the wrist. Tho bones of the arm
ha<l united when be entered tlic Hospital ; the joints being rigid.
380
EXTKEM1T1£S.
anil the shnft of the hunienifi nkiicli in a[1viLn(.'6 of the lieml <jf
the b(>ne. The pittiout wa« in rather a feeble *ityle, and hiul
gone through mueh AufTcHTig at eea; for Tour days af^^r tJie
injury there being a siippreflaion of urine. Tfip left, tiiLgh vaa
out of ita place, the knee was Lent, the shaft of the feiuur pro-
jected forwards, forming an obtuse angle with tiie body- The
toea presented almost directly forward*. The troehanter was
not prominent, as on the opposite side ; but ihf re waa no hollow.
At the upper and inner part of the thighi a prominence could
be felt, not perceived on the other side ; and this could be dis-
tinctly felt in the rectum, and was undoubtedly the head of the
bone.
The patient being fully othorizod, the thigh was seized, and
cffoita made to break up any iidliesionft winch might have beeti
formed^ by making motions of flexion and rotauon. By the*e
manipulatioua^ the head of the bone ^vas dislodged from its
position, and slipped up on the piibia, but would not enter
the socket- On further eftbrta being made, it slipped round
under the eocket^ imd finally lodgi^d on the dorsum ilii. In (he
course of the reduction, tlie appearances presented by nil the
diderent dislocations of the hip-joint were imitated. The pul-
leys were now applied ; nnd the limb being gradually drawn
down, when opposite tlie socket a movement of rotation waa
given it, and it slipped in. After the reduction, a rigidity of
the muscles on the part of the thigh still gave it an unnntural
look, as if it might be ont of its place ; but the lef^iomtion of
an equal length to ilie other, and the free motions which could
only take plat^e with the head of the bone in the socket, diH[)elled
any doubts.
The feet were then bound together, and the patient was put
to bed. When seen, an hour after, the hml) aj*ain proje(?ted
forwards, aa before the operation ; and it was enid that it Kad
a^umed that position after some struggles made by the patiect
in coming out from the effects of the ether. A little force, being
opplie^l lo it, brought it down to a flat poeitjon in bed. While
under the ctl^er, flexion was given to the stiffened joints of the
upper extremity.
The patient complained much of pain in the upper part of the
DISLOCATION B.
381
tliigh, an(] required aixty drops of clisir of opium to m&ke biin
fiJccpi
Go the followiug day, there wtis a suppre^aion of urino, aa
hod occurrcfl &ller the &ccidenti He gruducUl}' but compJotclj
recovered the uac of all bid joinLa iu nbout a month after the
reductiou.
Case CCXXV. — DidocaUon of Thtgh, -with Fructrtrt of
the Acetabulum^ Death* Aniopst/. — A strong, robust,
though mtoiapcrate man, 36 years of age, fell from a nx^f,
eCriking on hia right side, and waa carried to the Hoapital. The
tollowing ia the report: "On entranee, the patient lies on
the injured side. When placed on hia back, it waa found that the
right Ic^ wna shortenctl, the knee aemi-floscd, and the foot in-
verted. The patient being etherized, the thjgh couhl bo Hexed
at a ri^ht jinglc ^vjth the iibdomeu* Crepitus could be heard
nbout the head of the bone» By continued exertion, the limb
waa extended to within half au inch of the length of tjic aound
limb, and Dcsault'a apliut applied."
The day following, the patient died of delirium tremena. At
the autopsy, the following apppnrancea were presented: There
yas li great cfIii»on of hlood into the tiat^uts nbout the ^at of
injury. The head of the feiour projected a ehort distance be-
yond the edge of the great sacro-iechiatic notch, haviag fd-
lowed the groove left by the dieplsiceinent of a fractured portion
of the acetiibuijin and bone behind. The latter waa about an
inch and iL half squnre, and three-qunrCera of an inch in thick-
ness at the ihiclieat point* The fracture alao extended through
the acetiLbuIum and the bone. The head of the femur waa
deeply indented, and the fragments of the bone and cartilage
were separated.
Case CCXXVI. — Dulocaiion of the IIip-jiAiU back-
wards^ and pro6tti/lij dowitroa/tlff^ Reduction. — A little boy,
aix yeara of age, waa eitting on n long lieiivy pi^-ce of limber, ou
March 18, 1800, when it rolled, throwing him down, and passed
OTcr him, bruibi[)g different parts of his body. When taken
into the houee* he aeemed ao much iiijui-ed otherwise, that hia
KXTKEUlTlEfi.
mother diil not pny pirrticuliir atCenliun to tlic injury of the hip-
On ihc third day alter the neculcnt, Dr, S. A. Green, iK^iitg
calTvd In, iloteclcd u dir^luculiou of the left hip, and udvjeod hia
removal to the Hospito-J.
^^''hcn I firat saw the boy, he wna lying on the ri^ht side;
the Joft thjf^h bein^^ drawn np ntarlv at a ri^fht nn^le with ihc
body, and placed rather iteroeo the opposite limb, ns in eorne
cased nf hip-di&eaee. On lifting hi«i, and lunkin^ hira Etfin<t on
the sound limb, iLt the same time dra^^'lng down the di^pW'ctl
ore as for lu it would ^, the {not pointed forwunld, inetcud
of reatin^; on the top of the other fotjt, ne in disloealjjii ud
the dorauin ilii ; tijc pelvis was driipofcd down somewhat by the
llinb, and llierc was g^at tension of the mu^lcis running frum
the femur to the pelvis* ae ie aometimes seen in dieloeatiOD
into the furamcn ovale, whioh it somewhat rcfternbled in this
respect ; hut one •^>i the prinuipal si^zne ol^ that dislocation, the
deprceaion of the tro<*hniiter, was wauling. Thu di^loention, in
fact, rceomblcJ more what htis usually been eulh'd the disloca-
tion downwarda and backwartU, in wfijt^h the hi?nd of the bono
liea a little behind and below the aookcti I totrk pains to try to
obtnin eome measuremonte aa to the dift'ereneo in Icngili of the
two liiuba ; but found this inipmcticnble, in consequenec of
the bent position of the thi^h on ihc pelvia. The head jf the
bone eoidd not be felt, on account of the swelling whieli had
taken pinee from the length of time eince the displacement.
The ehild bein^ etherized, I tiret attempted to reduee tho
limb hy the method of sweeping the tbigh over the opposite
limb and pelvis, protiucing a rotation of the bone. Tlie litnb
waa then eeizcil by the ankle, njriidually dm<;ged down into u
straight poBihon, and then, by a alight rotation outwarda, the
head of the hone clipped, w^ilh a very dlatinet aouiid, into its
socket, ^lotion could now be maJc of it easily and frcoly in
every direelioup
Case CCXXY 11. — Fmct a re of Upj^r P<trt of Thigh-
bone^ imitatii/g Dislocation of thf Hipfoint. — A powerful
man, aged 40, a seuumn, entered the llocfpitalf Juno 1-1, 1865,
for an injury of tho bip-joiatj received seventeen months be-
PISLOCATlONfl.
383
r<ir«i whidi he ^uppofleil to lie n. dir^locstLion. " IIi^ waa guaH*
ing a gavemment warthou^ at Alexandria, Va-, when he
diflcovered tliree ^eriUaa in tlie third atorj". He discharged liis
musket at one of them, killing him inetantlj ; the ^etoiid took
to liis hnela; it struggle then ensued hetwecn the patient apd
the thud onu. which entled lu tlieir grappUdg each other, and
both rolling down u hatchway, landing on the ground-tloor, a
diatttuce of eome thirty-five feet, the guerilla underncathn The
latter receivetl two fractured legs, Hud a eenleiice of fifteen
years In the Alhuny Penitentiary*" Tlte seanistu wna carried to
a hu.Hpi(jd, and etheriaed. He waa aftcrwajxU infomicd, that
hia thigh waa dislocated, but had been reduced ; and, at the end
of BIX monlha, was disdinrged. Ilia leg-, however, never aa-
Bumed its original length, and lie hud the iJiipreflalon tliat the
di«Wation vkim never reduced.
Upon eKunination, there waa found shortening of one inch*
but neither inversion nor everaion. He could walk ; though,
owing to the shortening and stiffness of tiie iilp-joint, he carried
a cane. There waa an irregular [irojectiou (bony) bdiind the
trochanter major. Patient was stout, robust, and in cicellcnt
hcidtli. Upon inveatiga(ion, it was decided that the head uf the
tlijgh-bone was in its socket j and that the shortening was due
to a fnu'ture received at the time of the fall, the precise nature
of which eouhl not be ascertained, Itc was again examined June
21st, under tlic iuflueuce of etlLcr, in the preHcnce of all the via-
ttln^ Aurgeous of ihe Hospital. It woa decided that tite head
of (lie femjr wkh in it» pro]>er position, and the shortening was
tlie result of thp old fraclui'e.
The stiiTncss of the linih, ihe projection behind tlie socket,
and the want of history in regard to the fracture, at first led Ut
the suppoNitiiiii that the patient^s impre^r^ion iv^ to a dislociUioa
esisLing might be a true one. Under ether, however, the mo-
tion of every kind which could only be given to the head of a
bone in its socket, showed tliat die a]jpearances Wei's caused hv
fracture, whiitcver the original injury had becii^ wliicli possibly
might, fnim the italure of the accident, have been both fi-actunj
and dialocution.
384
EXTHEMTTIEe.
The fullufving is a Buznniary oF tte dis]i>catianH of the hip
tnsatctl in i\\Q Mar^ixhasetU GcEieiul Htiaplud, Jrum Dec^m*
hev. 1821, to May, 1865: —
DDTAiiin Ilii SS
Forsmea Ovale ...... 8
S8
89
Of tlieae, 36 occurred in mnles, and 1 in a fciuaic- In 19* die
puUcjB ivere used ; in 20, no pulleys- Two of the uaauixeoflrii]
CMe« were complicated uith tVaciure.
AMPUTATIONS.
The queelion of poiiita of election for the performance of am-
putation has been re-opened within the past few ye»rfl> and the
nile of practice lunterially changed from that even now taught
in oome of the a[jpruvcil European (e^t-books. Tbe old rule of
amputating the leg witliin a few inchee of the knee — for an in-
jury, perhaps, of tlie ankle — hats given place^ in thia country at
Icaflt, to the much safer, and in crery reaped better, prnctiee of
saving as niuch of the limb as possible. This reform ifl due
almost wholly to tiie inveittion of tlie improved conical docket^
no-vf no univi^r^ally employed iu modern artificial liiuba, iu whicli
the weight of the body ie eustaiiied by tlie accurate adjustment
of the tapering sides of the etnmp to the corresponding cavity
made to receive it, while the senaitive cicatrix i^ efiectually rc-
lieved from pressure.
The advantages of immediate amputation are pcrhnpH now
more fully recognised tlian ever before. Even during the pe-
riod of JcprctisioEi or sliock, where it would formerly have been
thuiiyhl uecenaury to wait for re-iictiun, we now feel justified, in
most caaea, in proeeedlug at once to the operation; having
learned by experience, tlmt the inhahttion of cdier ia generollj
attended by a greater and more rapid reatoralior of the vital
forcea tlian tliat which followa the esihibition of alcoholic sdmn-
lantfl. Cy operating at thia time, many patients may be saved,
who would otherwise die from the gradual loaa of blood, and
from the ncrvoufl irritation dependent upon extensive injury.
AHPUTAT10X3.
385
The kinds of operation ■which have gcnornllv been preferred
in this ^'iijinit^ arc the circular for limbs with a single bone, and
the flop for the fore-arm and le^. The opetntions of Syme imd
Pirogoff, for sr^ving lu niuch as possible of the lower extremity,
and oa eubetitutea for fimputittion in the leg, arc woU worthy
of luloptien in suitable cnsC€.
Tlie operation by daps of skin alone id now looked upon with
great favor. I have often [lerforrned il with much satii^faction.
One amputation — timl at the hip-joint — may bo pai^iieularly
mentioned, on necouat of ita etriking want of eucecBe. Out of
twenty-three operations mentioned by Maclcod ns having been
pertbrrued in the CnineaT ull proved fatal ; and, during the
late WOT in this country, the euceceaful casca woro very few.
It has been thought safer, therefore, to leave □ niaUf with a
compound comrainuted fraciurc high up in the thigh, to the
clmneea affordeil by nature, rather tban to perform tJie umpu-
tatioo now under consideration,
I have had an opportunitj^ of twice performing tliia amputa-
tion in Boston, One t'ase was in a child whose limb was par-
tially torn oS by a railroad oeeident ; tbc other was for a largo
tumor of the femur, which reached hi^h up into the groin. The
first patient died at the end of a fortnight, without evident
cause, when apparently in a fmr way of rccoi'ery ; the other
recovered. The method adopted in the lost ease was hy making
anterior and posterior i[\i\is of integument; tying the femoral
artery before making tlie section of the muscles.
In cosec^ of rc-ainputation for diseased stumps of the legf and
for tumi>rjd high up on the ]eii;, where it is desirable not to go
above the knee, I have had the following experience : —
The tlcpa of akin bein<^ made, and the tibia and fibula sawn
tbrtnigh ju3t below their heads, the popliteal artery is upt to be
cut ofi' ut its division into the antenur and |>odterior tibiu]
arteries* At the same time, the stump almost immediately is
retracted by the muscles into the [lopliteal tipaee ; and a trouble-
some hemorrhage commences, whidi it is ditRcult to arrest with
the patient in hie ordinary position on the back, and embarrasa-
inent is experienced in finding the vessels- Much blood also is
u»ua]]y lostf if the surgeon has trusted the vessel to digital com-
la
3S6
E^TREMlTIBfl.
presftion. DMring the flpnng of 18r>fi, Imving hnil a niim1>er of
tlictic ernes t[» deul wilh, I JoiinJ ^<:ut cuove[uence i[i (liming
tlie patient at once over cjd \us face, in whicli position llie ves-
sels were eiieilv sei^iited. In these caaea, the simple (laps uf
flkin have healed luach more fnvorablj tlmti by the old msihtu]
of iDLiBCiibr £&pf<, as rccommeiKleU by Liaton. For imiputation
of the thigh. Dr. John Green, formerly of Boston, i\*tw of St.
Loul^, in ihe June.* noiuher vH the Boston *' MedLal anil Surgieal
Juurual '' for lf^63, has gnen nn eAcelleut r^^itm^ of ibe he*t
melhuila now in uae for making n good «lump, which liave been
Buatained by hia exi>erienpe in the army Juruig the Jate war.
On account of the ilani^LT of pyivnn;i in a]n]>utittiuas at the
pz-eaent day, it luis been projjofied to opcnite at the joint, as le«e
likely to be followed by this occurrence, tlmu where the bone U
diviiicd in ita coutiuuity*
LUfcanc'a, Chopart's. Pirogoff*fl, and Syme's operation*, I
have hail occasion to pcri'orni. In elviL practice, howevetT the
nature of the iiijurj" for whicli aaij»ulatiun is peiTornied ia such,
that tile opjiortnniiy icr these opcrjitlon^? is comparatively rare-
They are peeuliialy ajipjicahle to the leaiuna produced by fire-
araiiH.
Case CCXXVllI. — Aitipniniion of ihe Arm above the
Slhow for OftJigeuital Cancer offht F'o^t-ami. Ditiih, apf.r
tfOo years, Ji-oni Internal Oanfrfr. — A child, 11 nionllia
old, wafi brought to tny fiLU^gicEil Lafirniai^ hy !ta pareiit^^, on
Sept. 9, 1843, having a large tumor involving' the whyle uf the
left forc-ami. At birth, (he tuiiior uas about the size of an eggi
and regularly increased with tlie growth of the child-
The mother waa delicate, but none of the funtily hod been
affectetl with cancer. The child was, hi other resjiccts, appar-
ently in iine bealthi The ti[Luor evidently Avoa earcinoinutoud-
It was of a firm coii^iatence, flomewbat irr^fgular in ita outline,
and in one part slightly discolored. Intniediate amputation waH
advised.
The parents did not bring the child n^nin uutd the 7th of
October, nearly a month afterwarde. The tumor wa* then
larger, mid had Hoftened at the diacolored portion- Atnput&-
tioD was performed above the elbow.
AMPUTATIONS.
397
The opcrnlion waa borne well, nnd in a few weeks the child
recovered perft'otly. The Euiuur, bem^ cut open, was found to
be encepbalotd cancer, eoftening having commenced in it- I did
not henr fi^oni thia cliild Jtgain until the month of June, 1S45,
when I wne culled to nltend the nuiopey \ he ha\-ing died under
the following cirf^utnetonces. He had been in full hciilth until
throe months before, when a phyeician wna cnUed to sec him,
Hnd found him laborin*; under a eli^ht coufjh^ and distress in
the ri^ht side of ihe ulieet, which wiia alighlly enlarged. The
cou9;h and jtaln gmduaily increased ; the cheet end abdomen
becoming enormously distended, ae if from an internal tumor-
He finally died in ^eat eufferinc^-
Thc cavitv of the thorax waa occupied by an enormouE TnafB
of encephatoid diseaae, which bad token the place of the lun^,
eome traces of which were found in the back part of the chest.
The diseased masjs forced thft heart over to tlie left eide ; it dao
projected throiiirh the crura of the diaphrarrm into the abdomen.
The flubptance of the left lung waa etuddod with enccphaloid
mo^^ea, some of which hung, ae it were, dependent from ila
eurfncc. The heart wqb healthy. The Uvcr^ although net de-
cidedly eancertjua, Mvas evidently much changed in elructure.
The kidneys, fpicCQi and other organs, were normal. The
etutnp of the nrm ampitt;itcd was in a healthy condition, na well
ne the axilla of that eide. The o:ctroaiitica of the nerves were
much cnlariHxL
Case CCXXIX. — Amputation at ihs Shottider-joiiit, for
Siippurafioii af2er a Bttnt, — A boy, foui' years of (lo^, wne
brought into the IJoepjinl in the middle of February, lybU, with
his entire arm, part of hia face, and cheat, burned by the explo-
eiod of a buming-tiuid lamp. The burn of the face and cheat
did well \ but almost the whole auffn.cc of tlic arm suppurated,
and for a long time it waa supposed the child must auceurab, so
profnee was the discharge. He was only kept aUvo bv the use
of largo quantities of stiumlanta, taking from b\s. to eight ounces
of brandy tn twenty-four liouvi^, Finaliy, about the thiixl week
in Morch, the arm bcgiin to have a gangrenoua p.ppearanee, with
patches in difTcrcnt parta, attended by hemorrhage from one of
36&
ExxiiEwrriES.
thpni. yirhich wna arretted by tfie percbloridc of iron- He had
alB<>, iLt tliirt lime, beiuurrliugK from hia nose.
Aa floou ti6 the cliilil liad raLlii?d eufficieutly, it vna proposed
to remove the arm, tlie Bti^nfU from which was hardJj aupport-
nhle in the room. Tlic parentft, who were of tLe nmsL iji^norant
flnd d«;rnided eort, at firat declined to have iiny lliiDg done, hut
finally consented- The daily dicHj^ing of tlie wound caused the
raost violent outcriea from tlic patient^ on uccouut of the excels
sivE pnin.
Thehiirn extended quite up to the ahoulder; anilt with ihe
exception of fl ^mnll dRp of wkiri beliind, there wiia uo iutegu-
menl left to cover the wuund. In removing tlie liiub at the
joint, the head of the bone was found to be so incorponited with
the capftule, uml attitcJied to it, a* well as ao noftcncd by disease,
that the knife at firat cut deeply into it. The vei^sL-ls were iui-
Diediately seized, compressed, uutl tied, ao that very little blood
was lopt. A couple of fluturea brought together the inegular
edges of the wound.
The irritation caused by tlifi limb being removed, the patient's
pulae rose at once. He almost immedialely began to take
food, reeovereil his appetite^ mul very aoon h'ta health.
Some time afterwiinla, lie was seized with attJioks of uocon-
aeiousnes^i lasting at first for a short time, and ultimately filed
witli cerebral ayraptoms.
Case CCXXX. — Amputation at the Shmildtr-joint Jitr
Injitrif. — An Irishiniin, 32 years *if age, waa hronglit to the
HoMpitid on May IG, 18p'>1 i his arm having been drawn in, two
hours before, between the cog-wLeela of [Kiwerful uiacluncry
used for pressing heiiip. The limb parsed in up to tlie shoul-
der. The bonea of tlic liniid were fmmd to he cnished, the ra-
dium and ulna not broken^ tlie lower two-thirds of the humerus
comminuted; and an opening over the hnichial artery, tvro
inches below the axilla, uElowed the finger to be pajsbcd in and
up to the joint. The limb wu^ removed by an anterior and pos-
terior flap. Some diffieulty waa exiJerienced in d Ian rtieulating
the hcatl of the honieru^^, from the fa^t, that, the bone being
broken below, im purchaj^e could be liad by wliich the head
AMPCTATIONB.
389
could be lifted from its sockctn A powerfiil pair of forceps had
been provided tor thi^ purpose ; but the diripiucomciit wiia cf-
fcclcd without having recourse to them. Tiic patient did wcll-
Thio wBfl the fii-st case of ataputntion at ihc sliouWer-joint
occurring at the KospitaL
It will not he out of plncc to mention here a contrivance
which I bad auhapqucntly arranged to replace in & dcg;reo the
amputnlcd arm. Finding how free and powerful the actions
of tlic muftcica were npon the scopuJa. I bad a inrge solid leather
cot or covering made to fit the stump. This was kept in pUco
by two stmps ; one passing over the oppoeite shouldnr, the
other and stmnger one round under tlic opposite osilla. A
strong hook waa inserted in the end of tlie stunipp With this
appendage, the lOfln fleaurcd me, thnt, after eomc months' pmc-
titc, he was able to do aa good n diiy's work in sawing wood
OB he formerly eould with the lost arni<
Case CCX:XXI, — M^tUgnant Tumor of the Rirfht Arm^
requiring Amp^Uilioii at the ia^houfdc^'-joint* — Thi a patient
WA0 a tall, thin man, 30 years of ngo* He had olwa^'a been
heiilthy until Aprd, 1^50, when he had Ui^^hm-gefl of hlnod
from the kidneys, unattcndeil with pain, continuing for one or
two weeks. In June, the tumor nppenrcd aa a email hard lump
under tbc ekin of the arm, near the insertion of the deltoid
musclcn This grwlually increased until it nearly encircled the
anuT extending under, and raising up, the brachial artery and
nerves. The motions of the limb were not much affected by itfl
pretipiire until the winter of 185U-51, when it increased rapidly,
nnd the nctivo portion became somewhat painful. Hie phj'Hician
coneidcrcd the cose a critical one, demanding the removal of
the tumor or of the arm, and directed him lo me. After a
CRrefiil examination of the tumor, wliioh W!i6 r|uite firm nnd
movable, it was agreed that the piitient should be etherized,
the tumor cut into, and, if found to poasctfa the efiarnetera of a
mahgnant groirth, that tbc arm should be removed at the
ghouldcr- joint.
The operation waa done on the 15th of February, l^bX ; and,
when the tumor was incised, it was found to ho carcinomatous.
I
390 EXTREltlTIES.
The bleeding from it, wiiii^h was qiiitn free, wne therefor©
stnndied wiih u bil of Hjmn^, :im] die removal of the arm pro-
ceecle*! witl*. Tliis waa doue by an anterior not] a postcrinr
flnp; the former \niln^ ninde from without iini'iinls hv menns of
a ac!ili>el» iti uriler to hnve a more regular woHTid, ami the better
to avoid impinging on the tumor- The suhdnvian artery, as it
pa^t^ea over the first rib, was so effeetually comprpsfied by Dr,
H. W. WilliiLins tliat scarcely any blood wiia lost.
On Feb. 20lh, iie bad a discharge of bloody urine, after ft
severe piiui in the loins. He seemed to atEach but liltle impor-
Umi's to it ; and, lit fact, it soon ceased- He rapidiv rppovered.
The tunmr hml a litrdm^aius apiJi'-anuKre, and, under tlie mi-
croscopcj showed fibroua tisauet in which, after much investiga-
tiou, CEncer-cella were distinguished.
Cass CCXXXn> — iVecrosi* of Humerus. AmpiUatton-
— The patient was 21 years old. Tliree years before, after
getting wet, he wn*i seized with an inflanimalion in the riciuity
of tlte elbfJW-joiNt, imd supp^iRifion ensiiEtl. After !i time, bone
wftfl dwcharged- Other jrarta of the arm were flubaeqiiently
attnoked, and iiiiicb hone remove<l. In the course of the dis-
tant', tbt r*bcinIder-joirit and the elhow-ji>int becume ant-hylosed ;
leaving the hand fiied in strong rotation over the pubes, only *
Bliehl lateral aeiion being permitted hy the movement of the
scapula on tlie Iwjdy. Very large sequestni Htill remained ; and,
from the [jofljtion of the hand and los^i of use of the joints, it was
thought, that, even if uW the dead bone was removed, the limb
would he left uselt**. Anipntalion was therefore de<;ided on.
Some difticuhy wiia experienced iti fixing on the point for re*
moval. If the: section wu» made above the apertures in the
bend of the hnmeniH, It would be difficult to get a flap fmm the
tn.'ide on account of the size of the new bone, w^ncli wa« foreed
eloae upon the ribs, obliterating, as it were, tiie axilla. On
eonankaiion^ it wnt* decideil to ntnpnlate n few inches below the
sbuulder, removing the tiei:|ueHtrum afterwards. Thl^i was dune,
and a large piece of dead hime forcibly cstracted. The nxillfirv
artery, from the confinetl position of the wound, waa aecured
with some difficulty, as had been apprehended.
AMPUTATIONS. 391
The patient left the Hospitiil about four weeks after the operft-
tiuD, mudi improved io beolthr with tlie wound m a hciUthy con-
dition.
Case CCSXXHI. -^ Same's Operation on a Girl afecfed
icilh Talipes Varus and Spina liifidn. — A girl, 13 years
old, en1er<id the Hospital, April 13, 13ii0, on account of con-
gemtftl talipes varus of the left foot, with ulceration below the
anklCf Avhieh had c>:istcd for ^ix years.
She hnd iJso a Epiiiii biliJiL over the sacrum, about four
inches in diiiuicter. It was ductuntin^f, eliialic, jind painful
under strong pressure- She had ineontinenee of urine, nnd, nc
tiinee, of feces- Her mentnl faculties were impaired. There
was a fetid di'schar^ from the tilcer, and dead bone cculd be
felt with u probe.
Afjril 2Ut, Syine^B operation wilh performed &t the ankfe^
Joint. There wns more ihnn u^ual suppitrniion in die wound;
and. May 4tb, free hemorrhage occurred, which wns stopped
wirh difliculty. SubsetjuentlyT she did well, and was dis-
charged May 2lJth.
Tiie disease in thb case appears to Imvo arisen from impaired
nervous energy, probably owing to the tumor implicating the
Gpinal cord.
Case CCXXXTV. — Amputation for Caries of the Bonea
of the Foot. Double Talipts Varttt, Spina Bifida. — A
young Lailv, 17 yenrs of ogSj applied to me for advice in April,
1849, Slic bad w fi]iina bifida over tlie last lumbar vertebra,
which in infimoy wns about iKe tizo of a bean. At the time
I saw her, it was divided by a deep suIcub, one side direftiy
over the ?pine ; being about as liirge ns n mcdium-»ized nppte,
Bof\ and Huctunling, and protected by a thick, tough ekln. The
Other side, ibout hnlf ns Inr^e a» the first, bulged out on the
right, and was solid. Tbis tumor ga\e rise to no abnormal
eeneationa; nor did it interfere with the moiion of tlie lower
eittrendties* unless! wiien injured by n bloWj when it was IbtloM-ed
by temporary numbneHa-
Soon after ghe began to walk, talipes vEirus of the left foot
392
EXTREMlTlEa.
npppftreil ; nnij bo gi^nt was the defordiity. ihtit slie refiled en-
tirely iipun the outside of the foot. Tho tViuiiim utiil pressure
gave rise to an ulcar, whldi reMistcd trentment, anil gruduall;
tixtcmled over tlic wliole of flit- hldo of llie foot, Pruip time to
time, portions of bene hod been didch&rgeil, and (iniJIy ih& llctle
toe BQpa.riLted in a gjLi^trrenous condition. Necro^ied bone eoultl
Btill he deteefed throu^li three R^tuloua opeiiingj^ in tl^n ulcer.
After a long nttnck of flicknees in \wr eighth year, the right fool
became ileformcd in a Biniilnr manner to the left.
The ]e(t leg wns one and a half inches shorter ihtm the right,
the knee tw<t nnd ri half itiehes hiru^er round. The shortening
was mu^rd hy the los?^ of pc^rtioiis of the fibuhi and ttljju, whidi
were dl^elinrged through iiHtuiaa whose cicatrioes rem&ined.
There vrns an abseeas over the external malleolus on the oul^ide
of the riglit foot.
April Tth. She was etherized, and the lefl foot amputAted.
just above the ankle, hy ihe lateral^fliLp method. The etlge^ of
the wound were brought together hy a single suture and ndhe-
flive pla^ter.^ She did well ; the wound uniting partly hy first
intention, and partly hy granulntinn.
May 4th. The tendon of the tibialis antieus and the tendo
Achillis of the riglit leg were tlivided ; find, n few days snlwe-
quenlly, an nppanitiw wne applied to siraighten the foot,
June .'50th. 8he eonld rest her weight upon the wde of her
Tight foot, though it was not entirely straightened, and was
atill weak.
which restored completely the power of walking-
She afterwards had an artilicial foot for the left leg.
Case CCXXXV. — Pn-Of/off^tt AnipiUntion at AnHe-jotut
for Railroad Accident. tSlougklnfj. lie-amputation. Re~
cavnnj. — A young man, about 20 yenra old, wns brought into
the Hospital on the 23d of June, ISfif), with bis fool crushed ;
having, the night hefore, stepped upon the top of &n engine
while in motion, catclung bi^ foot in tiie machinery. The
phalanges and tnetatsu^nl bones were comminuted, the integu-
ment covering them destroyed, and the skin torn npwanls over
the flwtrntralus. He inj^isted that nothin^r ahoulJ Im? removed fhiit
was not nhsolutely crushed, though T informed him of the daci'
AMPUTATION'S,
I
»r of elon^hin^ of tho eoft pnrta in ncciiknts of this dGBcription
whidi vilftlity diil nfjt appear di^stroveJ nt the time. It waa
lecided, thcivfore, to |>crforni Pirogoft'^B operation.
An incifiioD wtxs axade in front of tlie internal mnlleolua,
CATTiod under the foot, (ind terminated rear the external mal-
leolue. Tlie iutcf'umcnts of tlie heel wei'c then diui^ected a
little From the bones, and tho inoietoa carried acroea the
■fi>ot in fronts no iw to expoac the joint. The Qstr:i^>'itlua waa
[dis!irtj'!idutcd ; and, in dissecting it out, in order to get at the
ffl calcisi care was taken not to injure tlic poaterior tibial artery.
The 08 cal^'is was then eawn through obhquely^ and tlic foot
xemoved. The intepiments of the lower part of the le;* cL»verIng
he joint were dJefiected bnck a. liti(c ; and the external and in-
;teruid mnllculj, together with the nrticnlnr ^urfaec of the tibia,
■ere i-eniored with a saw. This was done with some djffieul-
flv, owing to the ^>riinary ineisicme having been made in front
f the malleoli, as described in the books; whereas it would
been much better to have be*:un farther back, wliieh
liave been easily done without endangering the vBs*ela
that Bupjdy the flop. It being found that the oe cnlcis Inter^
^red Bomcwliat with the easy npproximntion of the li|>B of the
^ound, a flli(:e was removed from it. The enda of two or three
tendons which projected wera cut ofl' with aciasore, aa waa also
I About an inch of the plantar nerve. The bone ccmc woll into
place, and the edgca of the wound were ftpproximatcd by a
large namber of euturea. A bro:id atrip of adheaive plaater
waa applied so aa to keep the bone steady, over this a towel
folded itn;;thwitc, and tlic whole secured in a hollow padded
flplint to eouiitcract nny rerriielion of the inuaelod of the cuif.
He was ordered a lar^ opiate nt night, and alcpt quite well.
The next day he cc»mplaincd of pain from tlie prceaurc of tho
eplinl, which was then removed.
On the ^5tli of June, the weather being very hot ond the
smcU of the dreasinga quite offensive, they were removed, with
the exception of the a^lhej^ivc plaeter ; and a cotnprc^, wet
[with a weak eolution of tlie permanganate of potash, was applied.
"cry flhortly, iia I had fearetl, a elough commenced in the centre
»f the wound ; and* na it eeparatctl, repeated heroorrhngca took
00
394
EXTREBiUTtES.
plftce, finrtlij followed by g-nngreiie and erypipolas of ilie lower
part of the fitunip. It being impodsible to amputate the limb in
that condition, tbe tiapa were dcpumted, atid the bteedinp; reaeds
found and tied- The limb subsequently required amputation
higlicr ujj, which wqh done eomc weeks oflerwarde, by one of
my eoilcQgiiee (my florvice linving expired), when the patient
wad in a proper condition to support it; and be did well.
The operation of Piro^off at first guve every indication of
eucccea ; but, as we arc continually ob&orvin;; in roiln^mU acci-
dents, the injury to the muscles, veBseU, and nervee, wae much
more extensive than would at first be auppoeed, and neee^aitnted
the SLibeequent amputation of the leg.
Case CCXXXVI. — Rt'an}piilat.lon of Lt^g, Recovery.
— Mnrrh 22, 18fi(l, a man 4fi years old ciiterei.1 the FToHpital for
painful atuinp of right leg : twenty-eight years before, when at
eea, whaling, b!f^ right foot waa torn oil' at the ankle* by being
caught in a coil of rope which was "nintiiiig out" witli ip'eat
rapidity. A few days after tlie injury, the leg was amputated
juat above the ankle- The patient stated tliat no flaps were
made, but that the l!mh was cut *' square off/^ The slump wan
long in bealin^i and afierwanla there was much pain of a neu-
ralgic chnractex in it. For tlie tliree monthe previojs to his
coming tu the IIoBjiital, he feulFered from an indolent ulcer on
tlie end of tlic >tuinp.
March S4tb. The patient being ethmzcil, re-ampul ration
was performed, by flaps; a long [Ulterior and short posterior
one, chiefly of bkm, being taken. Tliere wns much veuoua
oozing after the vesaela were tied, which, however, subsided
after the stump had been expo&ed to the air for two hours. The
flaps were then brought togellier with seven sutures, Jind cold
water-ilreatfin^ja applied wilh a nu>dera(ely firu^ bandage- On
examination of tlie amputated portion, the poaterior tibial nerve
was found to be bullxius nt ita exti'einity ; and from it numerous
nervouB filaments were distributed to the end of the bone. The
flaps united almost by first intention, and in three weeks the
patient was discharged well.
AMPUTATIONS.
395
Case CCXXX.VI1. 'imputafion cf Lvg, h\gh up, ^cilh
Cutaneous Flups^ — A[irit ii^ 186G, a man aged 46 entered
the Hospital wirli a large ulcer of a cancerous appes.rH.Tice en-
tirely encircling rhe lower part of tho rifrht, leg. Its edgea were
cflllous and elevated. It begsin three yeairj^ before, end he had
done DO work uince. Tbe kj^t six ntontha, he had been unnble
to walk on the leg, whirli was bent to a right angle with the
tbigh.
Amputation being decided upon, the question was, at what
point this should be done. There was imegumeni enough for
a long stump; but tfiis was objectionable on account of the
fle::ced positii>n of the knee. It was iheivjlbre determined to
divide the bones just below the head of the tibia, as making a
better t^tump than the cotidvlen of iLe femur bj the knee-joint
operation -
The popliteal artery, being divided just after its bifurcation,
retracted, and the stump, at the same time, was powerfully
drawn backwards by the flexor muscles still attached to it.
This stjito of things rendered it very difficult to get at the ves-
sels; but, by turning the patient on his face and dissecting up
the tissues, they were finally reached and IJed.
In the present instance, two flaps were made of skin alone,
instead of employing Liston*s method, the diTision of the miis-
cles being made by a circular cut. The two arteries, lying in
contact just after the division, were now easily seen, and tied at
the hack of the wound.
This amputation, with two flaps of skin and a circular cut in
the muscles^ is the most satisfactory one, in this situa^ioni that
I have ever done. An amputation, lower down, performed
recently in the same way, has also resulted better than usual.
The ulcer, on microscopic examination, proved to be epithe-
lial cancer. The bones, though perhaps a little enlarged, were
not implicated in the disease, Tbe patient did remarkably wellj
the flaps healing almost by the first intention.
Case CCS^SJiYJIl. — Ambulation of the Thigh at the
JjOKer Third^ for Disectse of the Knee-joint of eighteen
years^ standing. — The following case of disease of the knee-
■AW
BXTHBMlTIEe.
joint la ore of those bo freqncntlv mot with, more parti<^ii]arly
in womeDi where the pnticnt ia kept under trealrnent lor many
years. Vkith alternate iiiipro\cuicnt and r^Lip^ee ; the di^endc
ultimntelj requiring an nperalioCi On in^pcetion of the joint,
the Eurgeoa is eurpriped at the great extent of disease, anj
that the operation has been ao long deferred.
A woman, 42 years of age, mneh emaciated, and of a very
livid complexion, enmc under mj cflrc in the Hoppital, in
ApriJ, 1^0-5, Eighteen years before, she had fallen down ataira,
Btriking upon the right knee, ■which became swollen, and eon-
fined her to lier hcil fur five or six wccka, 8inee then, she had
scarcely ever piidscd a year without having an attack of InKam-
matioD in the Julnt, coniimng her to the hou^. In April, 18l!4,
it became more inffamed than usual; and an iibecesa formed,
whieh pointetl in the popliteal space-
The limb was aomcwhat flexed, and the tibia slightly dislo-
cated haekwarda upon the iemur, and the patella apparently
fixed to the outer condyle. The husband of the patient wished
her, ae alic said, to submit to treatment tor several months
more before baling any operation performed ; but she preierrcd
to wait no longer. The question of excision was considered^
but not urged* on account of the slate of her general health;
and siie decided the innttcr by declaring for an amputation.
This was done by the circular method, with the losa of but a
fctt" drops of blood ; compression being made by a tourniquet
in^'cntcd by Juhn Whitton, the ingenious ward-tender at the
Hospital, which compressed the artery only, without interfering
with the Tenous circulation- The wound was closed with two
sutures; and the only dressing used was a compress, wet with u
weak solution of peminnganate of potaah, with the view of pro-
venting infection of the wound by Hospital gangrene, which
was prevalent at the time- The shock of the operation pro-
duced considerable exliatistion ; but. by the use of stimulants
for several iioura, she recovered from her dcpresflcd conditioni
The case terminated favorably in a few weeks*
An examination of the joint showed llie tibia displaced back-
wards upon the condyles of the femur, the cartilages completely
destroyed, and the epiphyses of the bones cxteoaivcly carioua.
AHnruxvoa>~$.
tbe pt^Jkead Fpare ; and i^ pat«Ila in^ finnlT fii«d to
Case CCXXXIX. — Comp<m$^ /Vm^wv i»to fie JTm*^
ThL*
fint
by
me %i b, F,M,
Ixri^
compound cownnmnteJ fj«etuie of tbe koec-joiui la
B half before, from the flake of an aadtor filing upon fam. A
wound exifled oo eadi aide of tlie joint, ao i^At iIm ia^cr omU
be parsed &om <nM iide to dte otber, encomitcri^ tbe t^afca^
fr^menta of bvoe. Tbe injured part wia quite iii^<tt«ible to
tbo examuiation. There was a moderate but eon$i«iit 6i>w of
blood from the wounds. Tbe pul^ waf I^O, trre^riilar, feeUe;
patient A little flightr. Stimulantg were given ercrr fitteen
mioutee for two boure, but witb do imptMrement in tbe pnlee;
tho dischar^ CFf bJood gradually iDcrea^inf: from tbe woumU.
Under tbeee cireumBUneee, the que^ion vrhicb pre*ented it&df
was, wbetber to proceed 1o imineduitc ainputatioti, IVom fear of
tbe paticrnt loEing hie rfiaoee bv hemorrba^, or to apply a tour-
niquet, and wsiit for nn iniprovemeDt ia tbe ^vmptoioa.
On con»uItaLion with tny colJea^e^ at tbe Ho&pitaJ» tbe laller
course was decided upon. On tbe following tQoming, (be ap-
pcarancee were much the same; puJsc 120- The leakxpf^ of
ven^^'Ufl blood continued. On further consullalion , it waa
thouv^ht unsafe to defer ]ong;cr tbe removal of the uijvircd pait.
He wne lhcref>re etherized, and the nntputation f>erforrae<U
The atae tcrminsitod favorably. GencmJIy gpeakiDg, en^es of
Urn doecription have done well after immediate amputation,
Bince the Introdiiction of etber. The want of vitality in the
preeenl cbsct however, seemed hardly to justify it* even with
the adaistaocc of this asent-
Case CCXL, — Amputatwn of Thigh for 2^tcrc*ia, —
Mr. F., 28 years of a^, applied to mc in February, lJ5t>l, on
nccouot of a necrodd of the femur, for which he requested to
have an amputation performed- When be woa fitlccu yeara old*
398
EXTBEMITIEB.
he received a ahock la the lirab hy jumping froin n wull, which
waa follovrcd by severe inHainmatSon» cnilinj^ in ubscefie, which
opened ot the lower and inner part of the thigh, jjet above
the knee- la the eouree of it jcar* abstce^ce fi>rmed aloog the
whole length of the limb, coniroanicatin^ with the bone, aome
in front, and aomc on the outer aide, aa hi<^h hb the trochanter
ninjor; ihroiij^h thcac npcrturea, smalJ pieces of bone were
occaeionrdly discharged, Jn the lirat vear* while bearinjf »onie
weight on the leg, the femur gaivc way in its lower ihird. but
united again, with ahortening of three or four inchea, and w4th
a decided bend outwardSi From 185(> to !HG4, he suffered
much at the ongioal ^ite of thi; diaeaae ; the iuflanmiJiUoii
exleodiug to the knee-joint, which became nearly atiff. For
neurJy hrtlf of ihie ]>eriod of thirteen yeai-fi. he w*ih eonfiued hy.
fiucceaaive attacks of inflammation; and he finally decided to
submit to an operation* when he saw t)iat ]m future ufiefubifiss
and comfort were likely to be altogether destroyed, A consul-
tation waa held upon the case nt the Ht^spital, whidi resulted in
the deelfiun to remove the limb at the level of the highest Gstii-
louA o^ieninj^, which waa at the couimcncement of the u[]per
third of the femur: and, in caae the fiequestrum should be
found to extend higher, to attempt itfl forcible extraction h^
means of forceps, wliich I had before successfully accourplished
in a mmilar euae, where it wiis iiiiportaDt to preacfvc aj< long a
bttimp as poasibJe. The exact amount of bone di^ea^ed could
not be accurately determined, owing to the severe ]>ain and pro-
tracted couHtitutioual disturbance which had several times ful-
lowal tlie attemjjt to probe the lower openings in the ijopliteal
region, and which waa c^iplained on disaection by the prosimity-
of the sequestrum to the great ischiatic nerve.
The operation waa performed Feb. 27t]i. A flap was first cut
oui on the front and outer side of the thigli, having ita bu&e nt
the upper aperture already described, which waa placed rather
on ita iiiuer aspect. An inner and iwslerior flap waa then made,
and the bone eawed ofl' just above the point of junction of the
ffapa, which proved to be in the aound boDC> tliree-quartera of
an inch nbove the upper extremity of the sequestrum- Thia
was about four inches long, and lay looacly eucaeed in a caiity
AMPUTATlOPfB.
399
m the back sind lower portion uf the femurs whii?li was open for
Xhe uioflt part, but was croeseti, at about the middle of its length,
by a bridge of new bone of about half an inch in brefldth. Ths
nerve, as above stated^ ky directly on it. The aeqiicsinim was
so loose that it could have been entirely removed, if it had been
possible to reaeh it by any justifiable operation. The knee-joint
had been partialty disorganized by in Ham mat ion ; two small sur-
faces, however, reniiiining on the conJjlea, siill covered by ear-
tilage, each about half an inch in diameter, and corresponding
to the articulating surfaces of the tibia, which were concerned
in the slight motion rpmaiiiing. On the curved portion of the
bone, in front and opposite to tlie sequeetrnm, were marka of
the very oblique fracture which had taken place during the firet
year of the diaeaae. The speotmen is now in the Warren Ana-
tomicftl M use urn -
In speaking of this case, I would remark, that I have seen
very few cases of extensive necrosis of the femur which have
been relieved by o|ioratioD- The recoi'dfl of the Masaachuaetta
General Huepital show the game tact. In one eaae, I remov(Ml
half of the shaft, near its lower extremity, with perfect relief;
in another case, of twenty years' duration, whieb was one of
necroais of tlie whole Icnrrth of the ehatt of the hone, the o|>era-
tion wiiH followed by so long and exhausting a suppuration aa
to compel the amputation of the limb just below the trochan-
ters, to save the patient's life. This man afterwarda died of
an extensive cancer of the etnmp. In the present instance,
even if tho removal of iho dead bone had been practicable, the
patient would have been lef^ with a deformt^d limb, three or
four inches shorter ttmn its fellow, and with little or no useful
motion of the kne&-joint.
In this enae, as ia ii^ual where there has been much previous
iuHainmittion in the anipututed limb, the bemorriuige from the
smaller vea$ele was very abundant*
Tho convalescence was alow, and interrupted by n acrica of
abscesses in the slump. Although no exhdiation of bone took
place, it was several months before the patient was well enough
to return to his home in the country, but with his slump only
partially healed. In October, 1864. I f^aw hicn in line hcidtli
H
400
EXTREMITIES,
nnd hin;h spirits, 1u*j stiinip entin3ly licak-d. atid hnvio*; gained
thinv or iorly pounds ct' ticali. This iucrenee in weight, na is
well known, is not unusual ia per^utts who have subiuitted to
nniputntion after biiviur* ^odg through with a toug suppuration
from a diseased liiuh.
Twx) yenra afterwarda, he was seen, quite we]I, and still in-
crefislng in weight. Ilia fi^^re, instead of bcin^ distorCGd, oe
btforc tlic o|>ei'ution, was erect; and he walked weJl with a
Palmer leg.
Case CCXLI. ^- Ampr/ttr/wn of Jlti^h for Anchtflo^itt of
Knee-joint, ^ecroniit of Tibifi^ find othvi- X** *ert#f . — May 3,
1866, a jonng man of rathor weak and sickly ftppi?aranec, 20
years of a<pe, entereil the Hospital For an amputation of the
thigh- Three years before, ho fell, strikiiii; liis \q\\ knee, pro-
ducing a swelling s^od inflattimation of the kuec and Je^ which
contined [lim to hia bed twenty-two months- A year after, \
lar^e portion of the I'roni of the tihiiT in a necrosed etate^ waa
removed-
On investigation, I found the aflocted knee larger than tLo
other, stiff" and painful. Above it were the cicatrices of two
idcerg ; buloWf a depression, marking the position where the
bone had been removed. Close to this, a sinus existed, mnniog
upwurdti and outwtirds to the inner condyle of the femur, wher«
dead bone CDuld be felt. The foot wjia inverted, preeentirg llie
appearance seen in tjdipes varus, whioli, the patient said, took
place when he attempted lo walk after the operation for necro*
sis. There was not only invoraJon, but exlcn^iion lo such b
degree us to givG the np[ieitrance of tulipea equinus : the le^if was
shortened four inches. The limb, being entirely useless, wi
amputiUed, Jlay 5th, with an anterior flap of skin ; a t'Jrmilar
cut bein;^ made behind, so as to bring the t^i<-aLrix on the back-
part of the stump.
The patient did pretty well until May 31st, although il
was some suppuratiou in the stutnp and retraction ijf the flapSt
when an abscess tormed on his Idl Inp, which was relieved by
an incitaion. In this, as in some other cases, wliere a retraction
of the llaps occurred from suppuration in tlie stump, a very
ABIPCTATIOXS-
401
rapid cicatrization took |>lftoe, from estension mnde on tlie ia-
legn^ments with adhealve plnaier and a weight. On tho IfJtli of
June, he wos well enough to ro home.
The IblJowin^ la the dc^criptioti of the amputated portion :
The tibiii nnU fibula were dUWated on (lie hack part of the
femur, and auchylosed lo iC and to each other; tlie ^mtellu was
anchyloBed to the extemal condyle. On the front piirt of the
tihia, a [ohet and deep sulcus exlsiedf from which had been re-
moved a sequeetruin of the whole cahbre of the bone, nine
inches long, which the psitient carried with hjru* The foot wna
in a complete state of extension, combinetl with slight evcrsion,
BO as to thna an Fdcnoat continuous line with the tibia, and in a
aiate of false anchyloaie.
Case CCXIAI. —Ampulndon of hoi h TM^/i 3 for Hail-
road Iitjfi7-t/. Utifilh lw^7itif'lJtrEB dayn after. — On June 2,
1864, a man was brought into the Hospital, who, two hours
before, was thrown from the railroad track by the engine. He
Bustaiued ft compound comminuted fracture of botli bonea of
each leg, with deep ragged wounds near the ankles. When
brought in, he was almost in a state of collapse, having lost
much blood. Stimulants were freely givon, which were fol-
lowed by some re-action. Ho was etherized, and both lege
flmputulcd juet above the knee-joint by the circular method.
But little hlcjod was loat during the operation. Fuur vessels
requiKHj iigaim-es in the left, and three in the right stump.
The pnticnt wns so depressed during iho operation, that it waa
necessary several times to suspend the us^ of the ether, in order
to ascertain hi« exact condition. He ralhed, however, from tlie
operation well ; and, being put on a nourishing diet with suffi-
cient stimulant, improved until the ITth, when he had a severe
chill, followed in a dny or two by sloughing of the integuments
covering the ends of the stumps. From this time he gradually
sank, and on the nit;;ht of the ^5th died.
Nature seemed to have made a great cUbrt, in thia casc^ to
sustain itself agninst the great shock of the injury, and also to
Tej^air it. But in spite of all the naturnl efforts, assisted in every
way by art, it woe unable to occompLeh the process. For two
61
402
EXT&EHlXIES.
weekc, he proniboti ns well as any case aflcr a simple operatton.
He woe then seized wilk a chill, iis stated above, and slowly
eank.
Case CCXLIIT. — Amputation at the Hip-joint for a
tariff} Ojtieo-narvoT/iatous Xftmor of the ^emur^ Jlefovertf. —
A young mnn, 16 years u\i}, of very light coniplexioa ftod
redilifih hair, entered the IIospiiaK March, lJ*59. He waa bora
10 Maincj iif healthy parents^ *dJ» ^'> f^r a« was known, with,
no aerofuln ia the family^ HJa euiploynient for a year hMl been
tliat of ehuemaking. About seven months before he entered ihe
Hoapitnl, at the upper ord front part of the tlii^h a dcep-eeatcd
tumor made its apjieuranoe^ immovable and filigbtlj pnipful. It
inereafte<l elowly in evorv duMiction, until he w;ifl brought to
the IIoi^piEnl in the lEist week of Mua^h, 1859. At this pe-
riod, ihe left femur, whieh was the seat of the disease, waa
«li^htly Hexed on the pelvia ; and the upper half of it was oeeu-
pied by a lar^^, firm tumor, making a very ditallnct projectioa
in froiLt, but more indefinite behind] where it mounted up^ and
was lost in the nates. The front part of it waa somewhat
nodulated, and wuh in immediate eontact with, and partially
pressed up, Pouparl^a ligament. The fckin waa everywhere
movable on the surface of the tumor, except on the outer mde*
where a slight rcdnees exiated, caused by the application of ft
bbeter. There waa a moderate degree of mobility of the joint^
auffiaient to show tijiit the articulation had not been invaded by
the disuaee. The patient could use the limb a little, and was
able to wolk out with support, thoup;h very lame. The i^landu-
lar flVfitem generally was intact. The appetite was poor. Ho
had no fever. The pain in the tumor required the use of an
opiate at night. The eircumference of the limb over the tumor
was twenty-two inehea ; the measurement of the corresponding
part of the opposite thigh, fifteen inches.
Having made an examination of bis case, I told the brother
of the patient, that all applieationa were ueelej^^ and the only
remedy lel^ was amputation at the hip-joint. The case being so
important, on the following day I called a consultation of the
iiu^eona of tlie Iloapital, which resulted in the followbg con-
403
I
I
clusiona : That the diseoae w;ia probably an osteo-aarcomatuufl
aficction of the foiiiur, wliii?h, if left to itself* would very aliortly
terminate the patlcnt^a life in a most pfijDtiil manner ; and the
onlj thing to be tlioug^Ht of was the rcmaval of tJie femur
at its articulntjoTi witli tlic hip-bone. On the other hund.
from the size and situation of the tumor, thnt the operation
wiu an excccdingiy hasanloua one, more so than in the onJlnnry
cneea of Ita perforin tince ; that tlterc wa^ o, posaibility of hia
dj'io^ during the operation, or widiir the auUequent ten days ;
and, even if he recovered from the immediate shock, that there
might be n rc-jippcarancc of the discaac : that these conditions
bein^ projicrly placed before the patient and hia friends* if thoy
eoncludcj to take tlic risk, tlie operation ought to be done.
Thia question having heta fully weighed by the patient and hia
brother, they decided to have the limb I'crncvcd, rather than
run the riak of aubmilting to tlie lingering course of the dJaeoBe,
The openLtion was performed in the following manner, on
Monday, Murch 28th, the fifth dnv after his entrance into the
Hof^pitaL The oi-dimiry nicthud by trandfisiiin being impmcti-
enble* and in \ievr of the possibility of a dissection of tlic tumor
from itrt attach II lent 9, a large flap ol' skin was raJt^cd from ita
front part ; the incision commencing at the root of the flcrotnm,
ond terminating ju?t above, and in front of the great trochan-
ter. The flap waa dissected up quite to Poupart^a ligament, the
faacia over the femoral artery openc<], the vessel exposed, a liga-
ture pasiicd around it and tied. An inoiriion wiia then made on
the back part of the thigh, corresp<mding with that in front,
and a tlap of r*kin partially ral'^tzd. With a short, strong knifOi
the musoles niiniing from the pubee to the inside of the tumor
were cut through, and thoac on the outaidc treated in a elmilnr
manner. These incisions loosened the thigh, which hud bctbro
been eonfinccl, and allowed it to he depressed and rotated out-
ward. It was necessary to do this to a great extent, on aecount
of H lobe of the tumor projecting over and obscuring the arlicn-
lation* The knife was next applicfl to tho capaulc, which waa
divided, the roiuul li^^amcnt snapping ofl' at the fliimc time from
the powerful foi-ce applied to it. The bone was then diaarlieu-
jittod, the great muscles of the thigh cut through bclund, and
404
EXTREMITEB8.
ilie limb removed, A vory Inrge sponfje was thniBt into tbe
wound, 10 prei'ont bleeding, wbilo the &iimller vessels in die flap
ftud trunlc were secured. By the skilful compression of the
abdominnJ aortjv by Dr. Gay, the immediate seizure nnU eom-
pression of the tJaps by Dr. Cabot, together with the previima
lin^ntiire of the feuaoral, scarcely any blood was li*el. The ves-
sel's in the llaps were Buccossivcly tiod as they were u[]covered
by the removal of the spotipe : it was also found neeesBary to
secure the great femoral vein.
The lips of the wound were brought lorrether by a nuinber of
autnres; a compress was npplied, mid a very large apon-i^, to
make gentle compression, and fill up the deep cavity in the side
of the pelvis ; o^er this a lowel, and the whole limdy fiecurcd
by a banda^. The openition was nocpsearily protracted much
beyond the usual time f>f an ordinary disnrtioulaEion ; yet utter
its termination, and jnat before the remi^val of the patient from
the table, his pulse was as goud as before the operation was
commenced,
A section made of tlie tumor and the femur, which were
sawn longitiidin^vlly through the middle, presente<l the following
appearances: The tumor was beautifully variep^aied, and pre-
sented the ordinary aspect of oi^teo-sareoraa. Jt had its origin
between the pcriostonm and the bono, and extended from the
middle of the femur quite* to its neck. The periosteum cover-
ing the greater trochanter had been peeled up, and the sac of it
filled with that yelJow oleaffioous fluid whieh is bo frequently
seen in tumors connected witb the bone. The parietes of the
bone were somewhat thiekcned in the centre, ihinued toward
eitlier extremity, and the [nedullary cavity was almost obllt^
erated. The substance of the tumor itself was quite tirm. hav-
ing the ordinary appearanccH of carcinoma interspersed with
spiculie of hone. A microscopic examination of it was made by
T>T. Ellis, and verified the diaguosie. The head and neck of
the bone seemed to have completely escaped invasion- The
nmjscles covering the tumor were paHi^illy atlherent lu it, but
none of them so completely incorporated with it as at firt:t had
been feared. The tumor seeraeil to have been eutirclv euude-
r
ated ; and. so far as could be ascertained^ not the slightest trace
of it was left beliind.
AUFDTATlOTrS.
405
In the aftcrnof>n of the day of the operation, the patient
fleeTiieil to be in a j,rood condition, and comphiineU only of the
tigihtnesa of the bondage rtround hU bodj. This wna looacncd
by CuUing it away imrli:illy, and compLctcly removed on the
following mornin^H He passed a pretty good night, under
tJie effect ckf a draohni of the eolation of tlie sulphnte of moj"-
phliL^ complaining print^ipnlly of an exceeslTC thirst, ^htch no
ainounC of drink &ccnn^d to sntisfy, and which I attributed partly
to the ctl(cr» On -Alai'ch 30ih, the thirst waa aome^vhat alle-
Yi&tedi but lie waa still without appetite, and eomplained of n
little eoretkcaa in the groin ; pre^^^iire gave prun in the Jotvcr
part of ihe abdomen. The pulse wa& 100.
The following day he took an enema, which emptied hia
boweli^t and 5ecmcd to linpruve hi^ appetite, eo that ho chewed
a hltlo beef; alao took brnndy and water and milk puneh, to
wliieh he waa much avcrec, iie\er having taken spirit in his
life.
On Saturday, April 2d, the wound began to be rather oifen-
sive ; and at the aug^^i'rrtion nf the vonemblc and diatiuguiehed
ProfeaBor Muoaey, who waa present, the drcasinga were removed,
and a yoast poultice applied I the pu]ee was rather over 100;
the appetite ^till doubtfub On Monday, tlie 4lh, hia pulae
was 1^0 ; there waa prufusc Bweating while Bleeping ; he began
to take his food more regularly, and hia pulec t[> have oonsidem-
blo firninc&a, lie waa allowed bread, tea, and baked apple for
hrcjikfast ; breads meat, and baked apple, of which he waa very
fond, vegetables, with bnindy and water, for dinner^ for sup-
per, the game an nt breukfu^t ; at bedtime, and to drink tlirou^di
the night, from Imlf a pint to n pint of milk-punch. On the 8th
of April, he was reported as doing well: "He makoe no coio-
plnint, the puhe ia about 100, and he may be i^aid to be in a
convalceeent condition; the boweU are emptied every other day
by enemaLa^ nnd he hne taken no purgivtivc medicine since the
day of the operation."
The patient went on improving till the third week after the
oporfltii;n. The wound healed well, leaving an aperture at
either end for the escape of ligatures. About the twenty -foiirLh
day, on waking in the moruing, he felt a pressure at the inner
406
EXTRE2niIEg<
part of the afutnp ; and^ eliortly alter, n atrCMwn of blood elowly
tnt^kled down. Dr, Ezra L>yer, the hou^c-surgeoa of the Hos-
piCol, yvim immediately fliimmoncd, nnd by menna of a sjMJiigo
applied oi'cr the ajjertLirca from which the ligatures iseueil, and
a Blror^ comprc&ain;; bandii^, euccecdttl in arroetins; the bleed-
ing. Tiie bleeding recurred o^ain in about two hours* and waa
Aireetcd in the Bame wny. When I saw the patiect, at 9,
A.M., he was rather pale, hie puUe mpid, and hid Byetcm hi^d
evidently rceeivcd a severe shook* He was not mueli ulnrmcd ;
but, on thi? and the following day, made great complntot of ex-
ceBfijve thirst, as he did ufter the opcrutiou : dliowing; tlint it was
the loifs of l>l{>>jd, and not the ether, whieh prev^iou^ly caused thi«
eymptom. From the free escape of blood at the lime, and it&
arterial eolor, it wnt thought [irobable to have escaped from the
great yesael, in eouecf|uenc!e of (he ligature hnvinp pnrtiidly de-
tnehetl itselT; nnd for this reaaon it was deemed pradeat not to
interfere Aviih the wound for tlio nest two or three days. No
new blecdin<; having occurred, 1 then bad all the dreB«ings re-
moved. The two lin;fltureB at the outer part of the etump were
flcized by the firjjera, and withdraxTn wilh very slight foroe. The
four li^itures at the iuterniLl part of the stump were then sep-
arated, and dragi^ed upon singly ] and nil of them were removed
without dittieuhy. The two Urge ones, whieh bud been attached
to the femorjU artery and vein, had probably been for j^ome tiaic
dataehed, anil lay coiled up in tho wound, cauf-ing irritPtiim and
anppurationj and probably the hemorrhage wliieh had given tho
alarm.
From that time the wound rapiilly healed. The pnlient left
Ilts hed ill nboitt a week, and in ten <lave was able Co go out of.
doors. Mar 10th, he returned home quite v/qU.
Iie/l/ftrk^l. — Thia eu^e ii* worthy of notice from hnving been
the tiral of amputation at the bip-Joint thut hus flucceedetl ia
Boston. The following statistics, from Mr. EricbBon. in hii^
valuable work on Surgery, may be interesting, as showiniT it»
mortality T Of 1^6 oaaes, 76 died; of 47 cases in which it waa
done for injuries* 35 died ; of i2caBea operated on in the Crimea,
&11 died. During the late American war, as nearly as I can
learUf there were 23 ea^ea of amputation at the hip-joiDt* of
AMPUTATIONfl,
407
which 5 recovered, ncd IJ^ died. Of tlieae, 10 were primary
Opcrationa fur gituahot wounda, of vhich 3 recovered, and 7
d!c^; a.ad 13 eet^ondary operations for the sriiao couec, of
which ^ recovered, &nd 11 died.
Tlie flops in thia case, beiDg prlnclpnlly composed of akin,
mntle the wound much leaa appdiiiig and more manng'cjiblc thjin
where largi; muacLihtr flapa are \c\\, as in the ordinary opcnitioD.
Tlu3 nmy be considered worthy of imitation, even when not re-
<|uired by necessity, aa in the present eaffc. The previous tying
of the 3u^ry, together with the compre^eion of the aorta,
aJiowcd the o|>eration to be pcribrnicd in a perfectly eomforlahle
manner, tvithout the alighteat burry* and with almost a dry
wound, if the expreflsion may he uaed*
This patient lived for aome months in very good health : but
the diacoao returned intcrnolljT and he died within a year of the
operation p
Case CCXLIV. — AmpHtaiton ftt tht Hip-joini. Death
thirteen Jar/rt rtftr-r. — A child, SIX years old, was brought
to the HoapLtal on the I^th of June, 1858, at three o'clock,
having been injarcd about two hours beForc, He was sitting on
the curbatone of the sidewalk, when a truck wheeled round
n^inat him, crushing his limb against the etonea. His injury
at first WAS not detected : being lifled up by somo pftsscr-by, and
piftcod upon hia feet, not being' able to eupport himaclf, be fell,
and rcecived, in addition to hia other injuries, a violent blow
upon the forehead. When brought to the Hospital, his state
was as tbllows ; ilc was quite faint, eountcnnnce livid, pube
aranll. The integuments of the thigh, near the hip, were nc^trly
cut through by a scmicirculnr wound; and on the outside a
deep wound in the muaelca communicated with tlic bone, which
was fractured obliquely, and denuded nearly up to the joint.
As the blood was Rowing from this extensive woundj the caec
admitted of no delay; and annpntation was at once performed.
The boy wiis first slimulatcd with aa nmch 3pirit aa he could
I bear, and ether w^ls admiriatcred, whieh quickly brought up the
cireulation. The limb was then separated at the ftaelured part,
Dr. Shaw comprcflaing the artery, Dieacction was next mode
40S
EXTREMITIEa.
at the Bide of the booe, which waa dUnrliculnted with diffip[iltT»
doth from ihc aciitoitiical relation of the pnrl^, tlicse being
obscured by ragged muscles, and more especiallj' from the
remaining portion of the femar being loo short to he easily con-
trolled in effeoilng the disarticulation. The capsule was, how-
ever, opened, and the bone dUseoted out with but little delay-
The boy at tbi^ moment becnme clewlly faint, and was only
restored by using frictions of brandy and ammonia; the Inner
being opiilied also to ihe noslrila. He waa likewise su^j^nded
by the remaining leg'fio as to throw the blood to the brain ; and,
nnder this treatment, soon revived, although at one inonient he
seemed to be dead. The vessels were now tied* and the wound
temporarily drcs.^ed- Just as tbia was finished, he a second
time eame in peril of his life. As h often the case with patients
recovering from ether, he eeeined dispo«?<3 to vorail ; and, ir fact,
a basin was held, and he threw np a large quantity of liquid
substance. Immediately nAer thig* he fell back as if exhausted,
a cold aweat came over him, and the respiration and pulse
ceased. The frictions, and other means for resloriiig suspended
aaimfltion, were at once again resorted to; and I proceeded to
pass the finger into the mmith for the puryajse of raiHing the
epiglottis and making a pa^if^agt for the air into the windpipe,
when it encountered a mass of solid potato-like substance, with
which, on further investigation, the whole mouth and fancea
were found completely blocked, so us entirely to eKclude die air,
and almost sutTtvcHte tlie p^itient. The teeth hud allowed the
liqnid contents of the stomach to pass between them, but had
acled as u ntnuncr to retain the solfd matters in dte mouth.
The niuuth heing uow cleared^ kud artificial respiration set np,
the child ^'nidually coiumenfM>d to breathe, and. In the course of
half an hourf was in a safe state. At 9j P.M., the limb was
drt^ssed, and be was taken to bis bed in the ward. The patient
lived thirteen days, and received during this time the moHt un-
remitting care from the nurse in ehar^ of him, and from Dr.
Dyer, the house-surgeon of the Hospital. The stump, during
thib time, became quite sloughy ; and one ortwoabHceE^t^eti formed
in the groin. The whole wound, however, finally assumed a
healthy appearance ; and, when there seemed to be every ]>ros-
409
pect of hoF iKrm; ffcae ssfeK liirciiu^ uas aKwi dingg-opf pan
of die laoftL, be flDddecJr £iL!i&i sad dkid, nearlr & fcirmi^ii
Hie foflcnrboE ixblt r^*'^"^?t« tLc T«enlif of il>e of^niknu for
ampmmcA of Bnitf u uw Miinmninn'T'f GenenJ Hofpital,
irooi J>BD»T, l^ir£. u JKiiQsrj, 1?^~, — A penod fj£ fonr-
foar
:«>
a
3t.W
:«k
n
1»J*
u
ir
ItwS
4£
1
li^tt
I
]
Ml.
14
7
K.,»
«l^ lE^ S %
Tlx ex'T^on of di^«&M^ jcrmU. ft£ m rab^^jTiite for unpnta-
tioii, irbk±i iTM rerivwi ^'.-ii^ rear* »;to bj Mr- Sjroe, — mort
puiioilwjj f^r ill* *:]U^ir %:i^ 'ih'juldtT. — hks fincf bem pr«c-
tbed tm iD'j« 'jf tLt W;rw j'-'JJi^ '-^ ^ tod^, «Dd haf pft«ed
inUf fOT^ry jl^ 'jtk 'jf tL^ ■ti>iJLh'I>JM'J r>pCT«£ioiu- The excisaii
of the k&<9t. In psnirruW. lui^ U^^n mucli id'jt^ {requesdr per-
funoed tLui tliaa of ujt oiL^r lur^r^ ^jini : tLe difieue« whkL. m
ciiiJ pTK^iw. require «ur^':raJ inteHVmice, being more fivqooit
in the <»»e of the kseie than of tlie elbow. Bv tbif opentiow,
manj )lmbf . wLj':1j «ou]'i oTber«'i«« be t^jod^mned lo ftzapoubon*
are uvei], &u>i made u^iefd. Exd«)>jn of iJbe knee if, of
GouTttf appli'^jle ouJr tt^ '^-^et in vhidi ibe limb u ocb^ww
souDd. ukI tL*: Diov«v>ei]i£ of ibe hip ukd ankle oniiBpaind.
^isrforwtd upon wlulu, il already ooiiau a great niiinbcr of
X2
410
EXTUKMITIKfi-
most ndmirable result* : hut, in tho cnse of yoiirg Hiildren, n
very graie objection has ariritn from ihe face, tlmt, in se^'ei"al
instuDcea, at firat reported ns 8ucc«SHful, the growth of the
Jimb has been an'ested ; leaving it, at In&l, niiiny inches shorter
than its fellow. There 19 no doubt^ thnt, if the e|nphv3efl of
the hones are wholly reinove^l, the aiibseqaent growth of the
limb U impaired. It ia therefore proper, in children, to pan;
off from the artindnr Riirfiu-ps as rhin n flHi'o ns is L-onei stent
with the rcinuviil uf ihe di^^eaaed b^me and the wliole iiriioular
cartilflfre. One case in my own [>nictice, given below, in
little girl of ahimt cig;ht ycsirs of age, an entirely uselesH am
bent-u|> limb, the rcrnilt of st^rofulous white swelhng, was mada
eervieenble by remoTing- tbt ecdd of llie bones, bad stmigliR'ning
the joint, 1 siiw thi?; pntienr, at the end of ihreo years, peifof'tly
well^ and walking wiih a iilight Ump. The liuib was shorter
than the othr>r; hnt the pe]vi8 Imd so adapted itself us to nuike
the losfl of len^h le^m evident than might have been EXpec:ted,
I hflVQ performed excision oF the knee-joint three times, for
cnriea, with moht gratifying sucees?*. In a fonrih caise, — thai
of an adult femide, — whleh, fruni the first, seemed a less prom-
ising one fur the operation tlian the others, atitputiuion was
ftfterwfirda nece]iJ^]iry,
In two or three eiclaiona of the shoiilder-joiot for eariea, the
results hove all l)een anecefisful-
Tho iidvnntages uf excising the hend of the hiimerua and the
articular siiriaces entering the elbow-Joiot are undoubted.
Barton's operntion, remuving a wedge-shaped piecti of bone
for a contracted and distorted limb, iJa one well worthy of imit&-
liou, I have introduced btjiort' two cose^ in illnslralion of it.
Case CCXLV. — Ej^a'gion of E;rff^rufjt Condt/7e 0/ I^iifht
Htanerus^ — Nov. 27, 1854, A man, 24 years of age, being
on the cnrs while they were in motion, stepped off, and was
thrown ftgidnst a rnil, which penetrated ikis arm nbove the* elbow,
tore open the integuments, aad broke the exieinul condyle inlu
the joint. He entered the lloi^pital the same day. I saw him
fii-at on the 29d;- The arm was then flwollen, and there was a
moderftts discharge from the wound. The condyle waa com-
EXCISION OF JOINXa,
-m
pletely loose iLnd dpimdod, so thiit it was di&seoterl out and
rpnii>ved withcut nay j^'reut difficulty, unci the wouml icW open.
On the foUowin;^ d.iy, u ycaet poultice waa applied lo the el-
bow. On tlic 13cb of DccGLiib^r, a smnll itl>80G3a farmed on
the elbow, wliith wn« opened, and disclmr-jwd freely- In order
to 6iip|>orL it Willi wa little pre;^*iiro us pus^ible, tlie lU'ra was laid
on a bladder partly filled wiili water- Jan. lOih, another ab-
ficeea formed on the nuinide of llie wound, which had then nearly
healed up. On iho i^tllh of January, he left the Iloepltal, the
wound entirely healed, the joint posjfesein^ but little motion.
About »\x months aftenvard^, he pr^eeiUed }umBelf, having
recovered a good motion of tlie joint*
Case CCXLVI, — Excmon of the Shanlder-joint for
Curies, Recover^f. — 1S5^, The patient wiuj a man, 60
years of a;^- Three years before, the dideuae 6rut Tuanircj^ted
itself by a pain in the shoulder. In 18^3, ewelUnge appeared
about the middle imd outer part of (he arm, whieh were opened,
and gave iesue to \\ Jnr^'o (piautity oi^ pua. The inner part of
the arm was soon after al!b<]ted in the same manner ; aUo, over
die pectoral muscle r>n the thoras. The opcninp;a left by theae
abaoeaaes were pr^ihcd, but no dead bone could bo diacovered,
The motiona of tlie ehouldcr-joint became almoat abuhshed ;
and the difohar^c of pus wii3 so large ^ from the fi3tul^>iie 0|)ejiingB
in the arm, arf to j^^oally weaken the patient. An inci^^ion was
therefore made from the opening nearest the ehouldcr-joint
towards the head of the bono, which waa found to bo carious,
though not extensively so. The wouad waa kept open in the
hope tlkat anchylosis would tnke place^ and thus avoid the neces-
sity of an operation,
^^L A month Inter, no improvement having taken plaee, the
^^V patjeut was etherised, and the eld incision enlarged The os
I humeri tind glenoid cavity were found to be aariocjs to such a
I de^e that an oporatiun wns absohitely noce^tBory ; and it wat
^^B performed aa follows : — ^
^^P A triangular flap was raised from the shoulder, so as to cx-
W pose the head of the bone. The strong adlir^aions between it
^^L and the socket were then cut through, wliich, with v, little dis-
418
EXTRELMTTIEfi.
ecctioQ, allowf!^ the head of the bone to be turned out nnd
enwcd off. The eocket, being carioua, waa next rcrat>ved by the
cutting forceps* The wound waa closed by a few auturea, and
GOmc strips of ailhcalve phiater upplie<l>
At the tiEue wlien he left the Hospital, the disebnr^ from the
varioua ainusea vfos dccrenaitig rapidly; and the large cavity
left by the operation had been quite fillwl upn His heollb waa
eseoJlent.
I 9aw thiB patient again in 1855. His coutlitlon waa ae fol-
lows : The left ehouider, front port of the cheat, and intecfu-
menta over the ecapula, were covered with puckcrctl cicalrioDSj
the rcault of tbe numerous abacesscs caused by the original dia-
eaac. The upper part of the abaft of the liuuiciuH was a little
in front of the old j,denoid cavity. The mctiona of the fore-arm
and hand were perfect) ao that lie waa able to work at hia em-
ployment-^ atocking-weaving — for tea hours a day, winch re-
quirca the conatiint motion of theae parta. To facilitate the use
of them, and to relieve the sboulUcr, a aling was suspended from
the ceiling, in which the arm woa placed ; and, by thia mcans^
he suffered no inconvenience from the constant atrain whioh
othcrwiao would have fallen upon it. He had the full commaod
of his hand and fingcra, and could graap tilings with nearly aa
much atrength as with the other hand. He could not raiae the
liand to the mouth without inclining the liend a little forwards i
nor conld he cjitcnd the arm to ita full length, directly before
liini. With these c^ceptiona, he could movo the limb ia all
dirccliODH.
Case CCXLVH — Fzcteion of the Knee-joint. — D. L.»
32 years old, a handsome, frcah-looking man, five feet eight
inchea in height, entered the Mnsaachuactta General Hoapitoli
March 23, lti5T, for an affection of hts right knee. TUrco
years before, ho had wiiat was euppoaed to be a rheumatic attack
In this joint, wlueh lasted three weeks. Five montha previously,
the knco became painful and swctlcJ, and he was confined to his
bed for thrco weeks with it^ but afterwards waa able to walk
withoaC crutcbes. When ho entered the Hospital, tlie joint
meiftsured three inches more in eircumforcnee than the sound
EXCiaiOPf OF JOrNTS.
413
or left laiee. There was grenl thickcninj^ of the enpP^Jo, which
gave the impression of its hnving undergone a long inHara-
matory process ; there wns aleo fluctuntion, hut no pain except
on free morion.
A ffiittfl-percha splint, eicenJing from llie hip to tho loee,
waji moulded to the hack of the limh, ao aa completely lo pre-
vprt the motions of the knt^e nnil ankle jjiioCa, Coiinter-irri-
tntion wii5 ms.de hy the free uhp of ihi> tincture of imiine. Under
this ireatmetit, the knee-joint, in four weeka, had dlminidhcd an
inch in drciiraference. As the absorption, although grnduidly
progressive, did not spem to hp p"oing on with miffirient artivity,
two deep iBsuea were mwle, on Mny 7th, ithove the joint; and,
on the 20ih, two more below. The improvement from these
a[] pi i nation B was very prcat, so that on Jiinp Ifith, at hij* own
request, he was discharged from the Hospital, niueli relieved,
Thta patient kepr about until June 2, 1^58, when he again
entered the Hoepitai, by my odvioe ; the ditieatie having hh-
Bumed a more rroubleaome form. The lcnci<^ was quita painful.
At Ciniea awollen, and almost u^elesH. I^Ie was unalile to hend
it, and was obliged, in walking, to Mwing the limb forwiird
between hla crutches. It was his wish to have ampiilntion per-
fonncnl ; hut, on wniMnltJEtuin, it waa deriided in give Inm the
cliant^e afforded hy excision of the joint, and he readily con-
aeniDtl to folkiw my nilvice. The operation wiw performp<l on
Jnne 5th, in the following manner: A ^mihmar incii^ion waa
made, commenelng over the inner condyle of the femur, ex-
tending down to the tnbercle of the tihia, and terminated over
the outer condyle. The whole f!ij.p was dititLecteil up, and the
joint exjiotied. 8ome atlhcHionn existed, nnd an attempt at an^
cbyloAis bud been made; but the cartilages were in a great
measure destroyed, and the bones eroded. The patellu wua
firmly fixed to the feninr. and did nut participate in the dj^eai^e,
eo that it was determined not to interfere with it> The condyles
of the femur were sawn off, as al?ii» was the head of the tibia, by
a narrow saw, like Butchers, which wtis iirmnged to cut on tfie
iDuer instead of the outer edge, the saw being reversal in
the handle. This was engaged under the condyles of the femur,
find divided the bonet^ witli the accuracy of a kaife. A couimoti
414
EXTREMITIES -
Baiv would not have been avail:tble, in consequence of the pTf>
leetjun of llic patdlEi. ; unJ, but fur tlila luniuijument. a chain-
Huw wcuM liave been required. Od itie top of the tiblii, a
tubercular deposit stUl reiiiaincU, wlilcli woa cijiiipletelj' remnved
bj a gcuge, leaving a cnvity nboui a quarter of an inth Ueep-
The head of tbe tibia waa ao cut as to leave its edgee a little
more dej>end«ut thitii the centre, in order to favjr tbe eacujie of
fluids* The bony suHace^ bein^ carefully phiced in apiioaittoii,
tlic tlfip waa secured In Its aituatlon by nunieroua sutured, and
tbe wound covered with a litile scrajicd bat soaked in blood.
There waa very little hemorrhage, and only two small arteries
vrere aecured* The limb was tlieu placed in a gutln-percba
Bplint, nicely padded, which had been carefully prepared before
tlic opcraliun, and moulded exactly to ita abapc. The splint
reached from the natea to the foct, so tLat the whole of the lower
extremity was perfectly confined.
For the three days subsequent to the operation, the pnticnt
slept well, without pain in the knee or fever. On June 8tht
when the le^^ w^ib raided from the epllnt and dreeaed, the wound
waa found to have united, except at the outer cdgCi where there
waa a discharge of pua. lie waa remarkably comfortable, and
espcricrccd but little pain from the dreesiag. He was allowed
house diet.
On the lltli, the limb was again taken out of the apllnt* and a
collection of pus Avaa found on the outer, but none on the inner
eide. Tlie appetite was not veiy good, and be waa therefore
ordered the compound tincture of trcntian. On the 14th, the
limb woa again dreeaed, and the wound was tbuiid to have dia-
chai'ged aomcwhat more than nt the last dressing. The incUion
below the [latella had apiiareiitly united by the first intcntaoD,
and only tbe ends were open to allow the esciLpc of tbe pua-
Uia appetite was much better.
Tlik patient continued to Improve, and lef^ the Hospital In
about twi) monlhe, not hiivin;,' hnd a bad f*ymptom from the date
of the operation. In November, he was present at a meeting of
tbe Boston Society for i\(edical Improvement, having walked
nearly a mile from hia residence. At ihia time, he waa partially
disabled by a nail growin^^ into the ficah of one of the toes oa
EXOieiON OF JOINTS.
415
tTjc side opcratc^l upon, so as to require the use of tvrc rnnca ni
wnJIciiig. BoHv union accnicd to Imvc tiikcn pljure betrt'cen tlic
femur und tibia, Tlio wound hud apparently heakd ; thuugli , [it
a eiiiuii epot, it ot^caeioaally opcQcd, and diEScbarged slji^lttly.
The recovci'v of the ii^e of the IJmb in ihia ease was qnitc
rapid, and [\g was out as doon as n patient after an ordinary
ompiitutioii. The aiipcriarity of the single over the double fljip.
wlien it can bo made, botli tis regards LippeariLncQ and position
of tbc wound, iicud hardly be iusietcJ on.
Case CCXLYIIL — Excision o/the Knec-johit for Vfiria^.
J^ECOvsry, — A p;iri, 14 years of fli^e, of ii^ht complexion and
red hair, entered the Hoepilal on April ^tf, ltiJ3S)t durin;;^ my
eerviee. About eix years before, ehc had an aftcelion of tlic
ri^^lit knoc-joint, tlie origin and courac of which she wiis utterly
unable to deJ^criLc, whidi left bcr htuic, and the limb tll^litly
Guntmctctl. Nine months before eoiuin^ to the HospitiLt, sIiq
entered a factor)' in Low^:!!, wliei'c, for a ^od part of the day,
ehc woB obliged to keep licr knee in a bent poBition ngainat tbo
nia^Juuc at wliieh eho worked. Tlila hrou<;ht on a rccurrcnco
of paia in the joint, flouic ewclling, and further iiontraetton of
the limb, bo as to disable her from walkin;^, und ret|Uin; local
applications to relieve the EcnJernces of the joint. She came to
the lIoRpital ^vjth the idea of having the limb rcniovod, if it wero
thought adviiiable by tlic euri^eons.
The right knee-joint was about uue-lblnl larger in circumfor^
enee than the other, and tlie natural d^pree^iona about it were
obliloratod. TliO Itg wua bent on the ihigh, so tlint, on ttandinj
up, the toea did not roaoh the door by nearly two inuhc^ ; the
diriciwed knee beiu^ prefleed againat its fellow, and the inner
e<ige of the foot coming to the ground. The surgeons of the
Hospital agreed willi me, that the case way a very favorable
one for oxeisioa of tlio joint, and that tliie operation was to be
preferred to removal of the Umh.
On the 30th of April^ she was etherized ; and I mailc a horec-
ehoe incision over the knee-joint, which woa found to be oloricly
invented by a den^e eovoring, coasisting of the di&orgnuiKod
synovial membrane and cellular tifisue : the cartila;^ wero
416
ESTBtEHlTlES*
eroded tit mnnv points, and the condyles of the femur and head
of the tibia were necrosed. About half an Inch was s?iwe<l from
the fpmiir, ard a quiuter of an inch frum the head of the tibtft;
a]\ t\\c diseased Ix^ne was removed, and the pntellu dissected out.
Tlierc WAS very little hemorrhage. The f<*iimr and tibin were
brought into proper apposition^ pare lieing taken that the ext^spd
endfl r}iou]i] not be too tightly hrought together ; the Hap vraH
confiiieil by HiiiiireB ; and the hmb pliiced in a [rutIa-^»erchiL splint,
and lundageih
She pflfised a comfortable night, and did well, except liat
twiee ibe n<-tion of the femoral muscles drew the tihia out of
po>!;i]ion, Ltekwards and upwards. The patienti being of a
scrofulous hnhit, emaciated, and of jroor vitality^ her convale»^
eence w!w slow ; and the limb required fi good deal of miinnge-
ment, hy splints and dresaings, to keep it in a goi>d poBilion. and
promote the healing of tlie wound. She waa taken out uf doora
early, and every means ueedT hy food and Ionics, to invigorftt«
the system- It wns not, however, until September, that she
was sufficiently well to leave tlie Hospital, when the joint was
firm. A slight superHcinl wound Etill remained. She waa
taken to her relatioiis in California, and her future history is
unknown. The case promised to be of Buccessfiii issue.
Case CCXLIX. — Er-cision of the Knee-joint fir Be-
formed and tihno^t C'nfiies:i Livih, C\ire. — A girl, 7 years
old, horn ir China, was brought to the Hoitpltal in April, 1361,
for the purpose of barinn; either tbe knee-Joint excised or the
limb amputated. Her parents were still ahrond, and no satis-
factory account of the case could he obtained. The knee wils
bent at nearly a right angle, and the patella was fixed. On
nttempling to walk, ^he came down npor tlie toea with a most
awkwfltil and hobbling gJiit. Her health was otherwise good.
Kxcinion was performed on the 24th of April. A eemietrcnlar
flap was made in front of the joint, exposing the articulation.
As delicate n slice as possible wsu* then excised from the ends
of each of the bones, by means of Butcher's saw. The patella,
becoming dctichcd, was removed^ The bones were then ap-
proximated, tlic limh l>eing straightened, and the flaps nicely
EXCiaiON OF JOINTS.
417
adjusted by sutiirca. The limb was then pinccd in it gutta-
percha «pliut, which hud been prcviimi^ly mocddcd to the proper
EhapCf fluil acciirod by a baridii.<ru cKloiiditi;; iroin the toea to the
pclvJs- She wofl not niucli dcprcsBod by tho operatiun, but
poised a restlese nl^bl, and fi>r two or three davt* was in an un-
comfortable stale. On the 27th, the wound bnd the appeoroKCO
of having united by first intention ; but, on the SOth, there waa
a alight discharj^e of pus. May 21th, nearly all the dbchariTc
hnd eeas&I : and, on tlic :^8th, it was found that the boned had
unitctl. June 24th, a aturched band^i^e was applied, instead of
the pitta-peix^ha splint ; aud she wad taken out daily into Iho
yard, and exposed to the «nn. By the middle of July, &hc was
able to wnlk, and, at the end of August, was diachur^'ed well.
1 &aw this patient about a year after the operation, and exam-
ined licr t-arefully- The knee-joint was slightly Hojtcdt from lL«
weight of the hotly ; and the Urnb uppcared to be iibout two
inobee eborter than iti fellow. The pclvJe, however, had yielded
80 aa to compcnaato for the loea in length in the limb, wbieh
appeared to be due in pari to the want of nutritious the limb
having ^own less than tlic other* She walked with a rery
eli^bt limp ; and the chaTigc prodnccil by the operation waa very
6triking» a aerviceallc JJmb being aubetitutcd for a deformed
and uiielesa one.
Case CCL. — £!xcuit>ii of Wedgc-shnptd Piece of Hone
J'rom luiee-joini for Anc/tifhaifs* Dtatk from Pyemia. —
A boy, aged 14 yeara, of large size, and good muscular devel-
opment, in mhh received a wound from an. axe, on the right
knee, which penetrated the joint. The injury was fullowud by
severe and Jong -eou tinned intlamaiation of tlie joint, fimdly
re^ultiug in an anc^hyloais, wiib the Icg^ bent at a right angle
with the fcuLur. When I tirt^t ^aw him, he walked on the tip
of the toca of the right foot, th* left limh being- thrown, in a
bent position, forwurdfi ; so that a pcreon seeing him in motion
would auppoec the whole o&scous system more or leas distorted-
Being consulted in November, 1851*, as to the poeBibility of
Gtrnightcning the limb by any mcohanieal force applied to it, I
At onee dcoidcd in the negative ; the patella being lirmly fixed
418
EXTin
in it& situation^ jtud all motion of the jt>int, eo f&r as could be
perceived, deslr^*yed» The onlr ruetbod of relief I could pvty-
^ny&G to him was aa 0|kcratioD like that Brat HLig^ested ity Dr.
Bftvton, of i-emoving a wet]ge-*Iiaped piece of bone from ihe
joint, or ita viciiiUyT ^vhicli 1 had onee before practiwd with
eiicceea i thut removal of the limb, even, wiia more dceirubJe
tha:] allowing him to continue in hia deformed and painful cod-
(lition. Hiti friends and phj^ician, having taken the subject inlo
full and dtlibtrate cimeitleratioQ. decided to have the o[>enjtton,
which I prupoaed, performed; and the patient vraa hrought
down from the country, and placed under my chiirge at the
Iloapitnl-
Tlie operjition was done on Oct, 29, 1859. Previous to tta
perforniancet it waa observed tlial the liamatring tendons in
the different naotiona of the limb were powerfully coniracfed;
and, in fuur or five cases of excision uf the knee-joint which I
have performed or witnessed, I have observed tlml these tendons
funned an obstacle, at the liiue» to the straightening of the limb,
and were ^c^y troubleaoinc afterwnrda, during the treattneat,
dragging the leg backvvni-da out of apposition with the femur*
The o|>enitioii woa coniraenced, therefore, bv the eubcutaneoua
division of these tendons* The patient then Iming placed upon
hifi hack, u. flcmicircular inciswn waa made just over the knee-
joint, commencing at the lower part of the inner condyle of the
femur, extending around across the spine of the tibia, and ter-
iniojiting at the outer condyle. The flap of skin w^ thea dia^
seeled up, and the remaining soil parts divided to the bone.
Tlie anw was next jilaccd on the femur, Jviat above the anchy-
loscd patella, and the bone sawn a little obliquely downwards,
so as nearly to traverse its thickneaa. The saw was then placed
on the upper ^urt of the tibia, juat below tlie point where the
old articulation was supposed tc have been, and an ineision
uuide neiirly at a right angle with the former, so lis to remove
a bolid bit of bone« with the patella attcidied tu the top of it.
lYith a very little motion backwards, the rcmaiiiin*^ shell of
b<me was uow fractured; and tin: size and shape of the pieee
removed were so exactly what had been intended, that it seemed
oa if there could be no difficulty in placing thu limb at once in &
EX0131OS' OF JOENXa,
419
BtP!ii*'ht position : but, far aomc rengon which could not bo ex-
plainrxli jiiid which wt\e- u neon nee ted with museiiUr Qction, it
W)ifl found iuipoBsiblii to do this, — a result I attriLutod to tho
he;td of the tibia having be^n pnrtiolly dieplnccti bt^hind the
femur; and thue, wbiJc tho whole circumference of the femur
had bcon romo^'Cfl, only ft pnrt of the head of the libia iiad been
incluJed in the incisions. The Ic^j beinp; bent forcibly back-
ward!:', 80 aa to proCriidc aa much ua puedblc tbc ends of the
bone, mjd the intervetiini^ bit of booc being cut awavt the ends
of both bonoa were Fairly exposed, and a elicfl removed from
each of them. The limb cmilJ now be brought out atruight,
and the everdion of the foot corrected. Lititon^s apiint woe
applied, and the ed^e^ of the wound nieely adjusted by sutiiree.
The hcniorrha*je, during; the lirat incieions, was much more fre«
than in any cxctfiion of the knee-joint 1 have practiced. It was
partly owin^ to the age and muscidnr development of the pa-
tient. The bony atructuro itself was aho cxeoaeively vaaculnr.
In the atlemoon, the pnlient, having recovered from the
effect of the ether, and having taken twenty drops of laudanum,
was quite free from pain, There had been an oozing nf blood,
which wet tlio banda;^a in the vicinity of the joint. Ho passed
a moderately quiet night, and on the following day mode no
complaint of pain, hie pnlse being between acveuiy and eighty
in the mornini;* Towards evening, considerable rc-aclion took
plnce, attended with souio heat of the limb, and fever.
On the next day, he was quite comfortable, complained of no
pnin, nnd began to take nouriahmenl* The bandages, being
foul, were removed ae far as poeaiblo without diatiirbin^ the
limb.
On the fourth day, the limb wna taken completely out of the
B|dintt entirely cleansed, and frcah dreeainga opplicd. The pa-
tient took eider, broth, and cutfcc, and expressed himself as
getting along well. With tlje exception of an nperture on tire
inner pide, at which the blood bad Cf^capcd, the wound had
united throughout by the iirst intention. A little rcduees
existed over the outer side of die Condyle of the fcmiu: ; and tlio
patient having rolled over, on the first night after the opcratioDi
partly displaced the bone, and kept up undue pressure on it
420
EXTEEMITJES-
throiiirli ihe niijbt t the displnecmcnl waa dieooveretl, and ad-
JTisteil oil tlie ensuing d:iy.
Every thiag appeiired very favorable nntil the sovenili dny
after the o[>oration, when he begnn to show »ome unfavora-
ble aymploma: the pubc became more rupifl, n. laiigiior and
heaviness ft|jpcnroil, a die|)Osttion to aleep* anil more or le^ loss
of Hpjietite. At the enrae time, tiie dischnrge from ihe wound
became tiffi-naive. He wns inimedifitely [ml npim full dosea of
braudv rind (|iiiNiije, siod great iitcentiou given to iho wound, hy
frequent dressings and iiblutioiia, to frtc it from the foul secre-
tiiin^ Jis tnuuh ha jirnciipiiblf^. During this time, the limb above
and below the wound looked woll, und the circulnrion seemed
to be perfectly nurmnl. On tlic followinjr day, au injeclion was
madii into the wound, tbrce times, of clie tintturc of iodine.
The eymptonift of purulent fibsorptiou rapidly be<?anie more de-
cided. The patient wus i^ery listless ; the ptdse 130 : he mride
no eomplaint of nry kind. By the next day, the skin over a
portion of the Hup covering the former joint hnd a sloughy look ;
and towards uveuing, in addition to furmcr evinpfoin*, ho bad
difficulty ill o[iening his jaw'fi. He Bank, and died on the fol-
lowing davT being tliG twelfth frouj the operalion.
The body bein^»' immediately removed, mo opportunity was
afforded of making an esaminalion. The aymptoraa were all
tliLiric whieh would be caui^t^l i)V ab^^orptiou of a pH'^rmoua
material into the circulation, nnd were met, aa far as cnuki be,
at ouce» when ]ier<^eive*l. The part at whieh the operation was
done was inspected, and the bones had all ti^e ap[)cnrjince5 of
having been bathed for a number of Jnvs in fetid secretions.
There were no abaces^ea or collections in the vicinity.
Case CCLl. — ^ar/oJt's Opeytrtion for Stmt if ft fining
the liiiee-Joiiit hy Excision of a WedgC'skfjped liyt of J^iyn&.
— A mnu, 25 years old, from Nova Scotia, presented himself
to me in Scptc^mber, 1850, on accoimc of n grent deformity of
hia limb, owing to an anehylosia of the knee-joint ; the leg being
bent at nearly a right an^de with the thigh. He stated that hia
prospects had been destroyed and lii^ life rendered wretched by
hid infirmity : and wished, if any tliiag could be done for bini.
EXC!S10>J OP JOINTS.
421
abort of cxtrome dun^cr to hia life, ihat it shouKl Ic nttomptcd.
The Kistopy of the ojtse, aa given by liim, was tliie : In Novem-
ber, 18'il, he fell a di^ttLnce of throe feetj striking the kiie€.
Three Jays nfler ihe fnll, the knee be^nn to swell, and become
painful. Thia went on for four wccka» whca it was punclurct],
and ft pint of wat&rv Huid esi-apcd. It continued to discharge
for lifleen moiiEh^f daring which (line many sin.-tll pieces of bone
came nwap. The opt'nin^ finally be?ded, leaving ihe joint and
limb in a distorted poeitioi]. His horcdilary tondciicice were
eorofiUous* In the ereut poeition, resting tipon the aound limb,
the lame foot was seven and a half in<^hes from the ground ; but
he could Ihnp ab'iut with a hi^h-heeled boot-
I infoniied the p.ttient, tlmt ihe only operation which &UQ-
gefited itfielf to mc n'lis Bartrm'a opemtioti, which hud ap[>arently
been nlroady described to bim ; and at once lie requested to have
it performed. I advised hirti to enter the Hoapitd for the con-
venience of appnrutuj^f which he did. Some o^ his frieudfl
attempted to deter him from ninning any rUk', but lie said be
was determined either to undergo the operation flu<*yoet«i by me
or to have the limb removed, as he could do longer bear the
pain and mortification of hl^ condition.
On the 2d of October, the operation agreed upon was per-
formed aA follows : A V-£huped ind^ion wne made through
the §kin jast nbove the knee-joint; ttie ba^e of the triangle, two
iudips wide, preeeniing outward, willi the apex at the Inner fiidu
of the limb- The Aap was di^^erted up, and the bone ex-
posed ; the otiier tt^xture^ having become atrophied fj^oni ditoiiAo*
A wedge-shaped jHuee was sawn out of the temur ; the saw
not being carried ijuito throiighj so as to avuid the artery. The
remaining portion of bone woa then broken ; the £ap woe se*
cured In it^ place, and the knee plaoctl on a double inclined
plane, and firndy fixed to it. There vvm no hemorrhage.
Ou tlio following day, the patient ssiid he had passed a rcst-
IcsB nightt but wuti free from pain. The Ihnb w^aa dressed on
Oct. 7th, and pluoed on n splint with a hinge mid screw, eo
tbrtt it cuuld be extended without any shock to the joint. By
the 20th, iJxe limb had bt-en gradually bron*^ht to n strni<rht
position; and, on the iUth, the bones hud united, imd ibc
4S2
SXTBGMITT&6.
wound wns iicnlcdp Some time after thia, he hnd a febrile at-
IjiL'k, in tlic courac of which the union bccnmc aoiiicwhut ioaa
tinn, ami llirenteocd to dissolve ; the avaleni showing ita ftcrofu-
loiia tendency, tie gradually recovered, however, and left the
Hospital.
About a year after hU diachtirge, thie gentleman preaenled
himaelf to me^ well. The limb was very little shorter thaa the
other; nnd. with a |mir of lar^o trouaera» the dilfereniw in
the ehnpc of the two liuiba could ecurcely be didtiiigUL^hcd. He
wftlkcd well with a caiie; nnd the improvement between hi*
upright ap|M?iirnnce in WJilkin^ nnd his former method of loco-
motion would h[ive iiliito^t prevented biru from being recog-
nized OA the finme individual.
In BOoic cn-eea, greater Bjmmctry may be gained by making
the cxciflion directly from the joint, i-ather thnn above it, fta
there is then proecntod a much larger eurfaoe ul~ bono.
The fidlowing table givca n brief r^sum^ of the oaees of ex-
cision of the joint before dcflcribcd, not iDCludiDg the two CAAes
of Barton's operation ; —
EXCISION or JOXNTB.
i83
n
iiriijijiifii
its?
I- 1 -
I
^n
p
Cn.^TTER IX-
AKTEEJKS AND VEINS,
AXEURISIIAI, TUMOnS AND LH3ATUBE OF ABTERtES.
TiiR inlrmJuctioii of tlie method of treiit.ing' anciirismnl tumors.
eklicr by nr)m[iresj'ii>n rm the vessel above thf. tuiuor, or com-
pn^HLtm c^ii ibe tumor it^elfV in tbe [Aucg of tbe severe aud
dan^rous ojieriitioii uf lyiti<r tbe arttii-y, gnve an nildiEioniil
iia|iulse to tl»e trearmciit of lliese dist-ases. Tlic diPtiuguisbed
eurguon, Mr. Symc, lins atU^orntEHl a revival of the old iniera-
tion of opci^iiii^r the h!ic ittielf, and tying the vessel ubot'i! and
below, m apjjropriate eafies.
Tbo following caees ilhistmte^ by one or two examples^ the
treatmeiit of compression of the tumor directly. An interest-
ing uase of fciijoi'al anourism treated hy immediate compression ,
under tbe onre of Dr, B. Brown, wliieh I saw in consul cnrion,
is jniblislied in tlio "Bo?,ton Medicid find Surit;ical Jourrsil " of
March 15, 1866. The tumor in this cose was id the femoral
artery, juat at its exit from the pelvis. The compression was
made by means of ingenlons apparatus, continuing througii a
period of about eight months, and with full auceeas ; subfititut-
ing a treatmeut without danger for the very serious operation of
the ligature of the eiternal iliac artery. One or two cases are
given of the old Hunterian operation, and one where death oc-
curred after Jigature of the Jfirotid artery from the recurrent
circulation. The compression may be made either with the fin-
gers, — in which case it is kept up for several hours by relays of
assistants, — by long-continued and extreme flexion of the Hmb,
or by special instruments contrived for the purpose. In two
cases of very large subclavian aneurism, which I have treated
by the direct pressure upon the tumor of a heavy weight, in the
=>
AXEUR18MAI. TUMORS. 4:?^
*
fihape of ft cftunoD-ball, and where the Tluntcrlnn ojioniiiim n:i:t
impossible, 1 have been &0 fortunate as, in one injiiamv, to i^llivt
the complete oblitemtion of the artorv; nnil, in tlie iithor, 1^«
produce GoaguhitloD of iJie contents of tlio eac, falJowoil by $\i\^
poTfttion and iloughmg, resulting in tlie iierfoet eiiiv of iho
dueftie.
Caae CCLII. — SubcIaviitH AiifHi-isii} fri'oU'tf htf (\»):j-
prcMioH and other Means, liecoven/. — (Phte HO A i>*l-
ored mui, 39 years "of nge, from Maehb*. Mi\, wa* wnt to
me, MftTch 2, 1854, having a large nnouri^iin of the h't\ ^^uN^l:!-
rian nrtery. I woa called down stairs early in tho mornini^
hj the etatement that a bJnck man in a Uying ^I:iU' was lylni^
under the stftircaac. The patient stated that ho li'l\ lilomv^ior
in ftveaael about aweek before, and had been kept out by Mi\^ss
of weather, and finally hod been laiidctl ;it a ill^-'tant fioint. fri^nt
wfatch he had walked to Boston. He was tiut)orin<; nuirli in^ni
exceuive pain in his arm, whieh was enonnou.^ly snolh^n* b;it1
an asthmatic cough, and great dyj^jmiL^a. lie \va:< inuiitHli:iloly
transported to the Hospital, where, being phii'Ofl in a uurni b:tib
ftnd thence into bed, the circulation beeanio more frei* ; :uul lie
gradnally got into a more comfortable cimdttion. Tbe foDonin^
ftCGonnt ia taken from the Hospital roeonis : —
" Hard-working man ; strained Ium?*elf fimrt^vn months ap^
Haa had uneasy sensations about ^houMiT simv ihiii lime. Kirsi
noticed tumor above clavicle in July* IHJj^ ; ^vorkeil unlil l-Vb,
22, 1854, when pain In tumor and arm oh1i<rei1 bim lo ()Uit.
Now, pulsating tumor over chmole, its anterior inlorior porlJou
one inch from sternal end of ch*viclc, C'in'umfereneo of lumor,
7J inches. Hand and arm have been wwolh-n all winter."
After his admission to tlio Hospital, a eonj^ultsjiion of all the
sorgeona was called, and the quCi^tioti proposed a^ to the pn^
priety of any o]>eration being attem|i(<H| tor hJii ri^lief. The
whole triangle of the neek above the elavielo was IiIKhI with the
tumor, which extended nearly to the sternum, f=o that any pros-
pect of tying the vessel on the eanliae siilo f'eonu'^1 lo he iniprae-
ticable : and the only operation whieli was at all feasible was to
ftpply a ligature to the artery, a^ it issued from the tumor, bc-
42*i
ARTEMES ANI> VXIK9-
low the clovicle ; a project Lardly worth attemptinp. The
i'oUowJng treatment wna therefore resorted to : —
From tlie 12t)i of MaKli to the 30th of April, cold applica-
tiofia were made to the anouriem, \flried with coraprcsaion hv
weights. There wojs do diminution in its size, indot'd it rather
increased duiing hits stay in tlic K<ispjtjd ; nor muuh ameUora^
tion in the Bymptoma, except thnt of pain, which was entirely
a^&uiif^cd by means of compresfiioa. The patient's general
health waa considembly improved.
May 4th, Discharged much relieve*^,
On May Ist, being obliged to leave Boston for Europe, I lost
sight of Ihii? patient. Some montlia after leavin^r the Hospital,
he waa admitted to the State Iloepital at Rainsford Idand. where
ha tame under the care of Dr. J. R. Lothrop, physician and
Burgeon of the placc> and now of Chicago, who has been Idnd
enougli to give me the sequel of thie rcmai'kable caae.
"As nearly as I can remember, "Williame was admitted to the
Hospital at Raineford Island in October of 18,J4. Hu stated
that he had fallen upon the ahouldcr of thfl ntfected side a few
days before, and Buffered much pain in conacquenoo- The
tumor waa tender to the touch ; motion gave great pain; and
the onJy poaition which he could boar, was to ho on the sound
aide. Tho ekio over the tumor was tcnac and ehining ; there
was no pulae at the wHst ; Ilia arm was powerless and cedeian-
toua, and dropped, aa can be seen by tho pict^^re. The turaor
bad more the flpi>earaiice of a large abscea* than of an aneurism-
There wae no tremor or pulaation in it, or commuoicateJ tu the
hand; no sound or nncurismal murmur.
*^rn about three weeks the pain ceased, and the pationl was
able to get up and put on a shirt for the fir»l time; ndlying
quickly from the eifccts of the general constitutional disturbancQT
which had been quite severe.
*' In time, the tumor began to point perceptibly nearly over the
middle of the clavicle ; the akin gradually becoming thinner, I
do not recollect the time when spontaneous rupture took place;
but I think it waa during March, 18j5.
"When the opening took place, there was a profuse discharge
of mi:ced blood and pua, dark and rather thick; in quantity
ANEUBISMAI. TUMORS.
427
about two quarts. It continued to flow two or throe days.
gniduttlly decreasing. A purely purulent diachargc continued
for eeveral raontha : in fact, when the pfttient was discliargcd in
June, there was ever then ft Blight flow of pus frono thfl open-
ing. No biiA eymptoma aceompnnicd or Eollowcil the epontane-
oua opening of the Cunior: oa the contrary. Jack woa ia high,
apirita ut nn event which he liaj all along been wishing for, the
gottin-^ out cf the 'corruption*' He h^d predicted, thati when
the 'corruption' waa oil out of it, ho should bo all right; and
be often begged me to ' launch "it. In a short time after the
rupture, he was up and iihoLit.
" The tumor r^-ipidly fcubsidcd, n.nd was followed by a dcprca-
Bion* Tho shoulder fell forward. An opening rcmuncd onc-
holf or three-lburtha of an indi in diameter, Into which opening
piMJeoted a pointed und curious end of the hnmerul portion of
tho clavicle- The eternal portion wna not visible. The middle
portion wne wanting. AVhcn ho Icll the hospital, he had no
distinct pulse at the wrist, and the arm yvas still powerless ; but
his general health hnd greatly improved, and he felt hijusclf able
to resume bid old employiacnt of ship's cook, wliich be JictuoUy
did Eoon uftcr»
"About a your after WiLiama left the hospital at Eainsford
Island, he proacrted liimaelf at the bont-bou^e in Iio»tcin, with
bid urm in a aliiig, but otherwise in good lieakh ; and I under-
stand that a letter has since been received from him, in which lie
stated that hid hcoitJi contlnited frood.''
OfiE CCLIII. — AiiGuri^tn of the Rij/ht Subclavian,
Treatment btf C(finpressiaji, Crtre. — May 14, 1857, a me-
chanic, from Sc^otland, 41 years of age, came under my core,
having an aneurism of the eubclavian artery, occupying ibe
whole triangle of the neck above the claviele. The tumor,
when first noticed, thirteen months previously, was siluatcd
about the middle of tho clavielc. Being a strong, active man,
in the enjoyment of good health, he gave very little attention to
it nt first. He bad been employed twcnty-aeven years in the
niunufaeture of eteam-cngincB, and much exposed to changes of
temperature.
423
AltTKRIES AND VEINS.
The lum/ir presenlod three prr»jc*iti^nj^ ; itn<l, from its ftrigma]
eize of a pigeon s e^^j;, hml exloadeJ the whole length of llie
clovide. As it increased, be began to aiiffer from pnin in it^
alterd^^d witli shofTne-iH of brenlh. On etoopinpf, » eeuentioc
of w&ij;ht, aceompniiiefl with tliroI>bini^, was produced in it.
No operation socmed feasible in this cnso, and it was tliere-
fore eubn:)LttGd to the ftjllowin^ trentment i He was placed on
hia W'k, in bcnl, nnd ke])t on a liiinted diet of a pound of eolid
and a pint of liipiid fi>od everj' twenty-four hourd, without meat.
BflgH of ice wore applied to the aneurir^m on the ITth, And, in
lees than two honre, produeed a very sensible eflet't in rednnng
the puke. On the l\h\\, conipreesion was tried wkli Dr. v\r-
notl'a air-cufihinn, which waa applied through the day, with ihe
exea[>ti<jQ of three intorvals of half an hour each, when baga
of iee were eubstitnted. On the 2Ut, he com|jlaine<l of mor«
pain in the lower Iol*e of the tumor; also some in the two
upjier loheSf and a feeling of numbness in the arm of that side.
Jee wafl used for fifteen uiinutee, instead of half an hour. Com-
prebsion wns dii^continued, from the impractiiabillty of making
it equally over the whole tnmor, on aecount of its iireguJar
sui-iiicc and large f^hn. On the 27th, having oomplained «f
more pain iiL the smallest prujcetion, the ice wuij diecoEitinued.
On Au^. 13th, he left the Hospital, appart^ntly not much r&*
licvcd : hutf in fact, fnnu ibii Lime tlio tumor fp^adually sub-
sided ; nnd, about a year afti-rwrnil?^, he cnme to the £Iospital,
and snid that the tmiKU" hud cunrely dii^ajipeared, nnd he waa
quite well. Unfortunately, I did not see him at the ihne, at>d
waa unable to vorifv the exaet condition of the subelnvian artery
and pulse of that side.
Jietiiarka. — The ice nnd compression, together with rest,
seem to have given an iiiipeuis to the tumor in both f.-ni^ps ; in
iht* one kading to an obliteration of the sac, and in the otlier to
suppuration and a desirm^tivo inflamniation. The appearance
of tho tumor in the fonner case, when first seen bv Dr LoOirop,
some months after leaving the Hospital, being fiiich aa to leod
him li> ftuppose it a large absceaa, and that some error must
huve been mode in tlie diagnosis at the Hospital aa to ita aneu-
rismal character ; so entirely unlike euch an affection did it appear
JUTELFKIRH^L TUMORS.
42d
to Mm nt that time. Whetlicr owin;; lo Ircatmrnt or to nnhi-
ral cniifles, the dtiinuto recovery of two such apparently tbcmid-
nh]e and dee|jorflte casea is wortliy of record-
Case CCLFV. — Lit^nturs of fhe Lt?ft Sitbcfftiian Artert/
for SuLcJavi'an Ajienri^tn, with a lif^mafknble Deviation of
the Vejtaelf and Consequent Vhrtnge if ifs Hciationg. — The
grent mnrlnliTy ntfi'ndirg the ligsitifre of the largrr arteriH!
trunks, nnd of the eiilx'laviuii in jinrliuulnr, yives importniice to
anj operation oa thf>3e veasela. In the Intter tlie danger m in-
creaaed by its deep aituiitifjn, — cansing, in jnany crwes^ !i grent
difficuJly of reaching it, — jmd l*y the impurtanee of the orgiins in
itti immediate neigliborhcxMl, According to the vnlunLJe tables
fnrriished by Dr. Norria, out of <J9 cases f>f ligature of the sub-
clavian artery, 36 recovered, and 33 died, or nenrly one-half.
In ojierHlitjns on the iliae arteries, out of 118 cases, P5 recov-
en-d, and 33 died. From 38 cases of operatinn on the c^nrotid
artery for aneurism. 22 reeovcred, nnd 16 died. In every in-
stance where it has been neeespiary to place a lipafnre on the
fliiWaviim artery, on the tracheal eide of tJie ecaleni muwies,
the rcftnit has been faral-
Tlie *_iiae whicli 1 propose to relate offers some peculiar points
of inferesr, apart from the general one of the lijrarure of the
vessel. Among the prLneipal of these may he mentioned the
fact of a ligature having been applied to the artery for nn ancu-
rii^mnl tnnior jdliiateii nhovc the clnviele : being, sa far as 1 am
awarCf the first ease of tin* kind that Ims had a suceesftfu] result,
because the recorded aneiiri^jmal lumors in that situation have
required tlie applicafiiuL of n ligiilnre within the scalcni. and the
termination, as sraicd above, has been unfavorable. Secondly^
The anntomicid pefuliarities in the rohilion^i of the vessel, to
whieh umr bo nrtrifnitcd tlie possibility iif the ligaiure on the
outside of the scalcni. ThtMhj, The rapidity with which the
collaicrnl cirenlaiii>n was rcsfori'd, tlit' pulsi: having been felt at
the wrist Iwonly-tbur houz's ai^er the o[>eral'Ton, J^intiUtf^ The
length of tune the iigrmire remained altaehed, ninett/-gi:e datja^
notwifliptanding all siife means were mailc uae erf to dciacb it.
A lady, 30 years of age, of delicate eonstitutifin, hiid a ton-
430
ABTILRIES AND VEINS.
genital club-foot of tlie worst kind, and a double curvature of
the spine. For tbc (ormcr of these she was trcateJ, when yoiing^
by Dr. Brovm, aC hia intirmurj ; mid tbc foot, alter the aceticm
of the tendooa^ followed by the ftppropriato trcjitment, was oi>m-
pletcly brought icto ita natural position, bo that she wna cnuLled
to walk with cn»Ct without the aid of ^y mGchanical support.
The curvature of the spine was eubniittcil to a siniLJar trcaticcut,
with the aatnc gucccdJ^lid I'c&ult.
She consulted me in the early part of December, 184Tj for
an ancunsrual tumor eituntcd juat above the Boapulor end ef the
claviete, about the tii^e of & pigcon'<3 egg, of wbleh ^bc gave tbc
fallowing history ; —
Four Djonthe before, wliJlc in alteadance on a ^ick brother,
ehe had occ-naion to draA' the cork fn^ni » bottle, and felt a sud-
den craek ovor tlie elaviclo. Her attention was not attracted
to it at tbo moment ; but, a short time afterwords, a small swell-
ing, having a decided pulenlion, was diitinguidhfd at that fpot,
which ineicascd rapidly iu hzc. It had a powerful pulsation,
and poeticsticd tho ui^ual thrill eharactcrldtic of au anouriiimal
aticTtion.
1 cudcavorcd to discover the subclavian ni-tcry io its normal
eituatiou beneath Uie eUvidc, at the p^jint where it passes uver
the first rib- No largo voaacl, or uny o&scoua protuberance an-
ewprin^' to the tubercle of tho firet rib, usually tnkcn ils tbe
guide til the artery in this position, couUl he found. Ditlerent
parts of the neck were then explored, whieb led to the Ji^cot'ui'y
of a largo ixrtery paftsint; obliquely upwartl^^* parallel to, and
about an ineh removed from, the esternd boi-dcr of the trapcsiua
muscle. Compreeaion bclrg^ made at this point, tbe pulaationa
of the tumor ceased, as well as the pulse at ihe wrist. Tliere
was no question, therefore, in my mind, that this was the sub-
clavian artery ; but it wns more difiieult to determine iba cauee
of thi£ remarkable anomaly.
I now sought for the fii'at rib, and discovered botb the first
and a part of the second rib parsing oblirjucly across (be neek
above the elu\Icle- The insertion of the scalenus antieua muscle
into the fin^t rib was ut len^^^th distinguished: the tubercle,
however, was not Bufiiciently developed to be manifest to tlie
ANEURISM A L TITMOHS-
431
touch. The whole osseous ey^tcm of th(?cliest, in thia cn^e, liTirl
unJergcne a partinl dUplacoraeot, The spine and ribs nltjtchod
had hecTi, OA it were, moved upwards; while the Bterniim wns
carried in nn opposite iliref^tion-
Milking n strong compression on the vessel nhove the tumor,
the arm became extremely pninful, with n sensation of intmbneas ;
and, on B. euhseqiietit and tnore careful examinntion, the whole
braclLJ.il plexus of nerves could be disorlmiuntedf m Luimedinte
con lad with the nrtery.
Ab the tumor wns rapidly increasing, it was evident, thiil,
eonaidering its situntion and the gi'eat danger of delay, no time
was to be lost, if any surgit^ul openiilon wns 10 be resorted to-
The patient, a person of much fortitude and strength cf ehnr-
nctor, agreed at ouce to the course advked. The openitiou was
performed on Dec- 24, 1J^47.
An incision about two inehea long was made, eiteading from
near ihe outer and upper edge of the sterno-maeEoid mnecle
downwards, in the direction of the acapulo-cluvicular artiouk-
tion, and an inch from the edge of ilie trapcziua muscle ; die
pulsations of the veaecl being the principal guide, ns ihe other
flnnroniicid murks were wautinz. This incision divided the skin
and BUpcrficiu,! fascia ; a second cut opcn^ one of the brunches
of an artery gi^en ofT from the thyroid axJa, which was lied,
A nenoua band of some eiae was now encountered^ and at lis
side, and directly over the artery, a large vein, apparently the
external jugula.r. The vein was carried to the upper part of
the woundf with a silver hook, and the nervo to the lower; the
dragging upon the latter cauJded a disagreeabk and somewhat
painful sensation in the arm.
The sheath of the vessel was next opened, the cellular mem-
brane around it cleared away, and the ancnrisin nee<Ile, un-
armed, pneecd from below upwards, on account of ihe difficulty
of introducing it in the opposite direction, from the interference
of the scalenus anlicus, which had its insertion just below. The
needle at once encountered nnd raised the lower nerve of the
bmehial plexus, which was in the most intimate contact with
the artery. By depressing the handle, and urging the point
forwards with careful meinipidation, the eye of the ueedle was
432
ABTEIUES AND VEDJSp
brou^rhl out between the two. The instnimpnt was now ilircnd-
od witli tUe lignturc, nnd nithdrawn. Careful cK|)lorn,tion was
iDEide to aecertnin if nny nerve waa Ineluded : the painful aene^
tione in the firm, cnused by drawinff tlie ligature downvvarda,
Qt iirst leading to tlie Etuirpoeition that this nii^ht be tlic coae*
But, when tlic eawc traction was made directly upwnrda, no paja
was fell ; the former scnsutiona being pro<lLiec<.! by the dragging
on ibe cervical porti«»n of the bnioLiftl plesus, owing t^> their
conucctjon with the veseoL
Tlie ligature wne now tied, and the wound droBflcd, The
puleatione in the aneuridmid eac, us well a^ thoBo of the radial
artery sit tlie wrist, nt once ceased j and all uppcaranee of tumor
vaniflhed. The patient's arm and Imnd were a little cold directly
after the opcritlion, but, bcint;; rolled in flannel, soon rc^znincd
their natural temperatm'e,
25tli. Found her quite comfor table. She had poinded a
quiet night.
2tilh. She saya that the pulse ct the left wrist returned for
a time laat evening: it tlicn difloppcarcd, but returned again,
though faintly, this morning. I could not discover it at the
time of my visit.
27lh- She has been eomowhat troubled by cccmonal palna
in the nrm. The pulse was felt yestcrdny once or twico, being
intermittent. The ^voiiiid ho» healed by the firet intention.
She has sufferc<i occasionally from palpitation of the heart.
29lh. The pulee waa perceived, though feebly, at the wrist,
but could not Ix' deteeted in the axilla* The spot formerly
occupied by the ancunanial tumor now preseuta an obvious
depreaaion.
Jan. 2| 1848. — The pulee is constant at the wrist,
14th, The ligature alill remains on the artery, notwith-
standing the traction daily made by the patient, in accordance
with my directions. A number of largo vefiecls, taking their
orijjm from the subclavian, exist in different parts of the nock^
One of these, apparently the 8upra-s capillar, paseea directly
over iJie sac, and pulsates so Btrongly aa at first to con-
rey the impression of a return of puliation in the aneunsmal
tumor.
POPLITEiL AKEL'HrSM.
433
March 3Qth, Once or twice in the course of the Inst two t>r
three weeks, finding that the li^itur^ ^va^ ni>t dotiiohed, I have
aebed it wiili the furcepa, and, boldirg (he artery furcibly down
on the rib, Imve twisted the thread with considerable force.
Thia wa9 Uuno tbr tlie tliird time jcEtei'dayi when the Ligature
BOparated, nineti/-gix daya afler the oper:Ltioii,
The vound almost at onee closed,
I esiw !h[e patient on Sept. 14, 1S4S, far the ]aH time. At
that [K?ri<>d she wha quite well, hnd recovered the tiae of her
arm, and was iii no wny incommoded by the operation to which
she lind t^ubmitted. The ntLeuH»^mnl tumor Ivul in a great meiiH-
ure disappeiircd ; but it «tilJ conveyed the impression ot' contnio*
ing a Huid, Directly on its surface, and incorporated with it,
wiis a very larpe arterial trunk ; euppoBetl, as above stated, to
be the supra-ecapnlar. This veeeol pulanted powerfully, and at
firdt gave nn nppeaniDce of puL^iition to the tumor, but, by
careful maniptilatjon, could be Bep^ralcd from it; the puUe ut
the wrist sttll remained a little leea etrorg titan in the corre^
aponding artery of the other eide.
Cv^E CCLV. — Lifjahirs of ih^ Femoral Art^rr/ pyr Poj>-
litcai Anetirij^n^ Uare, — In September, 1833, I was ro-
quceted by Dr. Joainh Dardctt, of Concord, to bcc a. ninn, a.
blat'kamith by trade, with an aneurism of the popliteal urtery.
Ki>ur or five months before* he hnd pcrrceive<l a email pulsat-
ing tumor in the upper ntid back purt of the left leg- This
increased elowly to the eizc of ft hen's cg^- The toice woa
bent, and he was obligeil to WLdk with a crutch. Tbe foot was
divoUen, excessivelv painful, and '\U motions partially IobI.
The patient beiii*r informed of the dangers of the opemiion by
ligalure of the artery, the poseibiJily of pnmlyeis or i^lou^^h-
ing of tbe limb, consequent upon it, and of tlie alternulivo
of tbe trentmem by compresBion, decided on the former, oa
he lived out of Boston, could not well leave his family, and
it was impoflsible to have the compre^eioo Batisfaeiorily eon-
ducted at home.
The femoral artery was tlierefore tied at the middle of the
thigh, and the pulsation of the tumor at once arretted. Tho
4S1
ARTERIES AJiD VElKS.
pntieot^ a very musculnr mnn, wiis directed to be Vept in befl,
artifi(?i.al wjirmth to be appliwl if necessary; ant], in vase of
great re^actiont blood to be taken from his s-rm- Fnr n week
or two after the operation, the onmbnejiis of the foot waa much
inoreaaed, iliougli the pain was relieved. The ligature scpa*
rated in sixteen ilays.
This patient was seen by me some montlis nfterwnrds^ when
he wa8 able to wnlk. A sma.11, hard tumur sEill i^xisted at the
place of tbe former aneurij^m, having an apparent pulsation,
whicb, however, after Tepeatod eTiiminations, proved to arise
and be commumcated from an cnlarirpd cnllateral ve9?('l. He
was diverted to keeji stilly avoid animal food, and to do ootliin*^
that might excite the aru-ml oetlon.
By subsequent reports, he was quite well.
Case CCLVT. — Largs Ajievrtum of t/ie Thorticit Anrtti^
v^ith PerfopiifioJi 'ff the iSlpnium. Denlh. — A^-ntleinan,
fi^j years old, was attacked in lS(i5 or IWfin^, with dyspntrn,
attended with t'onsidenthle conirestion ahoiit the face, {"oniitijT on
suddenly, after mental eoiGtion caused by the death of a friend'
Being examined \ty IiIj* physician, >itrong pulsations were per-
ceived in die aeigliljiirliiHHl of thi; t-ieruuni ; iwd ii pulsHiiog
tumor, with aneurismid thrill, was detected at about the middle
of that hone. At this tiinc, T saw hiiu in ron.mjitntion.
Tlie |>alient wms uf plethoric Iwdiit, haJ been generally
he^dthy, hut led a lahoi'iou8 IJIe, being connected wttb a prints
ing offif^, and up late at night. Some years before, he bad
hud a rhemualic attack in his shuulders^ lasting three months.
I advised qiiier, a vcgt^table diet, and ^re!it care as to esen'iw?
&nd excitement, until the course of the disease wan folly de-
vehiped. Tinder this treatment, the thoraeic i(vin|iloms were
relieved, bui the tumor grudually increased ; and lie finally came
under my care, with severe attacks of liemorrhage from the
nose, which required snr^icjd interference.
In November, iJSd^, afler having thus |iass»I t^v^o or three
yeara in comparative cnnifort hy inrams of great care, he was
suddenly taken, while absent from home, witii lainttiesH and
biJ^en^ihilily, and wufl CJirriod to hi8 fiouse. Oh seeinij him, I
amp:ukisu of aorta.
4.15
focind the right side of tlie body pnrnly/ed. His (ave \rn» not
re<i, t\3 in npoplt^xy, but it' a livid pnlpness. Ha gruAnnWy
recoven^d hi:^ een^es ; and, by tha following morning, his mind
wflft fidly restored. Tlie tittack ivnw siippfisod to b« cunseJ by
the escape of a con.pnlfl from the tumor, lodging in niid obstnict-
\ng the ve3f*e]a supplying one poninn of the hrain, nnd tempo-
rarily saspending its fiinctiuns, Tlie pnra.lysis of the leg and
a^n^, whidi liud bcpn complete, grniluully diJ^appenrc^l ; bo that,
iLt the end of five or »i\. week^^ nothing but a sUglkt stifTneAa
remained. At this time, the tumor on the sternum occupied
nearly its entire bfertdlii : it wjw thirteen inclie** in circnmfer-
enne, and had an elevation uf betAVeen three imd four Indies.
Tlie pB.netcd appeared bony for nbout linlf this diatancc ; tbuiigh,
on exiimination iifter dc^Eith, thin pnjved to havj; been decep-
tive; being above exceasiveiy tfiin, and apparently uom|)iiafd
simply of the skin and the aneuri.qmal flac, A aligbt ccchy-
mosis bad tuken place on the eurffiee, Pule&tions in it were
very active and ponerful.
Some diunge in the aneLiriiitiial tumor hud produced an tif-
fei'tion of llie air-pii^sagej^f tto oa, lit titnea, nimost to tbreatcti
HufTocalion, Tbe^'C symptoms, however, gradually Kubaided ;
BO (bai, at the end of a couple of luuiitliH, the pntient was in a
conipEirntively comfortable state, able to walk about hiB roam,
and to tnke a Jiioilerate amount of food.
On the 15Lh of Jatjuary, 18lj(j, airly lit the morning, at
abnut foLir u'clock, be cojuplnined of a juidden pain in bis ri^bt
eJbow, shoiilder, and «ide of heiul, and ahunat tmmttdiatul^
expired.
On eitHTui nation of the body the nej^t day, tbe folloniiig
were tbe appeiirancea [jrewnied ; —
The sternal tumor had shninken but lillle. Tn the left side
of tbe cbest, there was a tjuantity of bloody serum : in the ante-
rior mediastiuum wnB a large coagulum, enough to fill a cjuart
measure. The pericardiiun wns firmly arlhercnt to tbe heart
sud paLrieteA of the tumor. Tliroiigh it, by a amaU rent half an
ineh in length* tbe blood had e»enp4?d.
Neither tbe trachea, a'HOpbagus, nor bonea on the back purt
of tbe cheat, appeared to be interfered with by the Inmor; the
436
ARTERIES ANli TRdS,
im'fntiJin of thp liiTyngpnl nerve proba.ljly linving n pirt in
the liirynjreal syniploiiis whirli were oceflflionally iminiresteU.
The aneiinnmal sac was as large as the two £«l0, Jtivl closdy
fLnd exletifiiveiy lullierent tit flic- mitmor pnrieles. It iiruae from
the iift(*(!inlmg norta townrja the left aiJe ; taul the opening,
which waH of an oval furm anil remiirkaljly clefineil, commeaced
one and s half inches mIjove the aortic valves, itvirl ren*.'hed to
within the HJime dislHnce of the arlena innominalJi, It waa
evidpnrly a fnlsp anpinism, and the cavilj was nearly fillL-d with
soft lihrirt and gminuus t^oa^la.
There were alf*D two other sinnll (jntiiHfittnjiI sacs, qTilte dia-
titict from tlie nlpove. One wns un inch frmii die ttoriic vulvesi,
find formed s very defined, rounded tumor upon tlie riglit
Bide of the artery, of □ dark-red eolor, firm to tJie fi.*pl fivim its
being Sllei.] with coagula, and in size ahont ei^un.1 to a nntnieg' ;
the otijer, arieing from near the ori«:in of ihe aneria innominalA,
was in every res|>ect siniilnr, except that it was more than twice
as largp. Tin* orifiee of each of these little sacs was of an
ova[ fornif quite sniaU, and ho de£ncd aa almost to look ati if a
piece liad been piin<^eJ out.
The nortrt, as fiir an where it was cnt oft' towards die dia*
phmgnii wiifl (juite disf^aatU, with ci hi nidendile rrelaceoiiH dejHif^it,
The nflcending portion was very much dilated, and measured
transverfiely nhuut seven inches, withonr inrhiding the opening
of the large sac. From the nreh downwarda, it wiis nbont the
natural eiKS* Upon the right wide of the ascending portion, and
commencing two incben above the vfilvefl, wiu* a "true" aneu-
rism, the cavity of wM<"h wa» shallow, hut sotHeiently di?tinedT
snd measuret] one and a half inches in diameter. This, of
course, wtm not Included tii the above measurement. There
wna also a defineil dilatation of the arteria Innominata, at it4
origin and in Lt« wfiole circumferenoe, extending ujpwards about
three-fourths of an inch.
The heart was healthyi with the exception of the adhesiona
mentioned above. The upper vena cava was completely ohliter*
filed within an Inch of li» opening iato the anricTef and to tbe
extent of three-fourths of an inch ; nothing being seen of tlie vena
aEygofii
ANEUTtlSU OF AORTA.
437
The fltemnm woe entirely destroyed froin just below the ojirtj-
la^e of the second rib to oppoitjte that of the fifth ; and, the co-
flrrula hnving been removed, the ragged ooda of tlie cartilages
were distinctly felt withiti the sac.
Case CCLVII. — Enorfnovit Aneiiriim of the Abdomxnfti
Anria. Dstitfi. Atttopity 1 was first culled to the palieut,
A ^nllpmaa 43 yoars old, in 1840. He wns afflltilod with
severe iieurnl;jjic pam in the left hypoi-hondriau region, ck-
temling in diHerent directions to the bladder, kidneys, and olao
down^varde to the integuments of the hi\ thigh, where it ^vna
almost in support able. At thiit time, no tumor couid be dis-
covered in the abdomen- The sufferinf;, in spite of all reme-
dies, became so severe, that the pntient, iu order to got auy
relief, w^a oblicved to place himi^lf on hU hftnds and knees ; and,
tlius situated, wilh hiu head dovrnwards, he was able to ^et emne
rest in the course of the twentj'^tbur hours. Thift position was
mniritained, for the ^ri^Liter (portion of the lime, for six weeks.
At the end of that period, be was eei^ied wltli a violent hemor-
rhage from the nose, which wna only checked, at the end of
twenty-four hours^ by pluffpn^ the nostrils, Subset^uent to the
hemorrhage, the pains became somewhat relieved; and be was
able to resume the recumbent position, . An exnmitintion of the
atidomen being now possible, a pulsating tumor could be dis-
covered in the loft liypochondrinc region, having on its front
part what appeared to be tlio kidney.
From timt period till 18-12, the tumor gradually increased in
BLca, citonditiK in either direction, upwards towai'ds the thoraic,
and dowmA'Ards ttjwardf^ tlie thigh. The pulsatiotis were usually
so strong as to shake the whole body, and were "much in-
creased before an occurrence of hemorrhage ii-om the nose,
which, from ltt40 to 1642, occurred at pretty regulur in-
tervals of two or three months, and was nlwaj^s checked with
great difGculCy, but was attended with relief to the system. The
digestive functions were pretty regularly performed. He was
obliged to take hie food while in a recumbent position ; otber-
wiae the tumor seemed to press upon the stomach, and destroy
the Appetite. As the tumor encroached on the thigh, the limb
438
ARTERIES AND VEDiS,
grfliilanDy hpco-me nir^rc :liii1 luorc He^ed* iinlil it woe drawn up
ao iis ti> furm a right aji«:li; witli iIr' body.
July 11, lfi42, he was nQti'm eeieed with a return of hemor-
rhage from tlic iiuse, which, though checked from lime to time,
Q^iti returned ^o a.s gruAunWy tu exliaiit^t hhu. Tlie nostrilfl
were pliiggeil huth behind and befare: the bloods howerer.
was in such a fliiid st.ttc that it »tdl coDtiDued to find on exit
througii the [mncUk hidirjiuitlia.
The jm dent ii;t[uiiei.l hii^ faculties perfectly to llie last; mid,
tJjrough the wliule of this lung and trying period, bore hia
Huffennga with the mofit heroic fortitude.
The irtjilmeiit consisled principally m small bleedings, vrhen
the Ay^tcni from time to time hei?iuiie plethoric^ nad intimationa
were given of a recurrence of the heiuorrlia^e. By iheae
xnciuiB, tfic epiJ^tiULis was oc:eitdli>UEdly wurded off. The patkut
ticiself wiiH iilwuys well uvvare when thia became aeceaaarv-
The following appeariuicea were preaeiited at the poat-morlem
e^camiiLriijon : On turning back the ^bdumlnal panetie^* all the
organs of the left j^ide were found In be ruised np on the surfiice
of un enornioiis tumor. Tlie left kidney mwiipipd the epignfltrio
repont and was the moat proininent orgjin.
The tumor had pushed up the diaphragm, bo as to be, at ita
npex, on a level witli the fourth or fifth rib ; below. It had
passed down on the anrfnce of the psoas and ili;Lc mllat■le^,
underneath tlie cruml arch, and descended nearly to the middle
of the thigh. On removal from its situation, it was found to
commence in t1ie alKlominul aorta, oppo-tite Eo the onirin of the
coihae ftxitt. The superior parietea of the ariery nppeiLred in-
tact; below, ut the puitit of origin of the tumors ihey were
deficient for the space of two inches.
The parietes of the tumor were formeil beneath by the ribs, the
muscles, and the iiite^p.inieiLts of tlie posterior part of the aUlo-
men; above, the usual appearance presented by an anenriamal
sac. The bodies of the lower dorsal, and three superior hiiuliar
■verlchric, were nearly destroyed ; also a portion of the body and
crista of the ilitun of the left side. One large coagiittun ap-
pcareil in the sac. The blood was in a very fiukl stale, eo that
nearly all which remained in lite body aeeiued to escupewith the
UOATUHE or CAKOTID.
439
irat inciBiona- The tumor -vins nineteen inches in len^h, and
eighteen in circiimterence ; l>eing, 1 believe, one of the iargest
on record*
I
Case CCLVin. — Wound of the Carotid Arten/. Lifja-
hire itoice repeated^ Death /'rorn Heirtorrhafje //v/n the Jieevi^
r^eut Circulation. — Enrly ia tho flprinj; of 184iS, while a youn«f
TnttUi 18 yciire ithl, wae wnlkiii*; in the atrect, n pcr&on stubbed
him from behind in tbc neck. The wunnd bled freely at the
time, ftnd ugain on the two subsequent days; the bJccilir»g ench
tine bein;]: nrrcetetJ by expofiuru to the oir, and cumprcasion.
The cjirtiUp:e of tiic Itrt cnr was diviilod ; mid the weapoQ had
perpetrated the neck behind the anj^de of ll)e lower jaw, and
about hiilf an inch behind ami below the left ear, in a direction
du^v-nwarJy, inwardd, nnd forwards. When I saw him, a week
afkT, he wafl very pak-, and somi^wlmt emaciated ; hia pulee was
;^uick nnd jerking j there wns eligbt paralyaie of the loft side of
tiie Iheo. £ lictl the Icfl commoD carotid in the ueun.1 nizinncr.
ly'roni ifie seventh to tbe ninth ilriy, rcE>ented hcmorrhngea oc-
curred, each time being checked by compreseion. On the ninth
dnvi the wound waa opened, and cleaned out ; when it was found
that Ihc blood onmc from the carotid nrtcry, where the Ji^r-iturc
bad been applied* On cundidtiUion, the iirtery yvaa agii'in tied
below the former place. Two days after thia, the blood began
to How from the upper part of the wound, np|iarently coming
from the f^|>ol where the first ligature wns nppJicd, and from cbo
recurrent circulution. Presaurc arrested the flow of bloodi
which recurred, however, in the courM of the day* Coma
BUjjervencd in the course of tlirce days; rcjipimlion graduniJy
bccHme more feeble; nnd, on the thirteenth day after the first
operation, he expired.
At the nutnpijy, it wns found that the wound in the neck was
irregularly triangular, ailuatod fi& incniioncd above, and pene-
trated beyond the carotid. The lower jaw wae eawn through,
and the Jctt aide diaarticolated. The wound waa tlicn followed :
it divided the nmatoid pruceaa of the leuiporal bone, nearly
[uinLllel with the base of the skull ; a poi-tion about half an inch
thick being aepamtcd. It then piiaacd inward, upward, nnd for-
440
ARTERTKd AKD VEINS,
wanl, lit front of tlie styloid prttceas of the tempnriil bone
and Llie Intrruu.1 uiroud mtury lu lUa ileptli uf abutit Ewo JiniJ a
hair inc^hps, in the direction of ihe H-oterior pnrtjon of the boJte
of till? bniin ; and Bto|j^»ed verj ncjir, Jf not in euntact wilh, the
»kull, L'loffc to Uie innei- estrcniity of the ^ti'ons portion of the
temporal bone- About two iucbes from tbe commencement of
the wound, a cuvity nearly as large oa an ahiionil bud t)een
formed by tbe force of tbe bloud issuing from rm artery, ibo
o[>cn niouili of wliii'h was found just l>eyond. Tlie whole of
the left aide of tbe neek wa* much fiwullen- Tbcre were ni*
liL'ahby irniiiulatione in tlie wonnd miule for tbe purpo^^e of ty-
iu^ the caroud. The eiithi of lliat vesseb wbcre it liad been
<livided by tbe first Hgature, were separated about half an inch.
The eerond lifziiture alill surrounded tbe artery, wbkb was filled
below with eoiiguhi of bttle dcjii^Jty.
Tlie whole of tbe brain wad pale, bloodlcaa, and rery soft.
A layer of lympli covered its butie, extending from the middle
of the fissjrc of Sylviua on one side U> a eorreaponduig piiint
on tbe other, and from the middle of tbe anterior lobes, baek-
wanU and dowowardi^ nearly to the foramen magniiiu.
Tbe heart wafi contracted, nearly empty, und tto miiaeulai'
xubsiam^ loose and flabby.
Ttie lefl lung wa« adherent to the coi^tal pleura by ab-i]ng
adhe£^ioD». The organs generally pi-efteutc^l a bloodless appear-
ance.
Case CCLIX. — Wound of i%t}n^r-Jii:ial Palmar Arch,
Tjiffiituiyi iiviue nup^ditd. — -March 31, I8fjl. A woman* 18
years of age, received a> wouud in tlie palju of the band by
thrusting it through a pane of gloss VThile trying to present ft
vfcuidiirt friiin fjJling. Tbcre xvas a good deal of bleeding at
the time, but it wjib aiTcsted by compression. April Ut, there
was a I'cturn of tbe hemorrhage ; and she blcd» according to Lbe
account of her friends, "two quarts." ^he was then biouiibt to
the tloapitab On her entmnce. she waa very weak, and fditit.
There was a pulsating tumor in tbe palm of Uie hand, with a
omall wound over it. Comprcaj^ion of tbe radial artery Lid no
etibct upon it; but tbe pulaatioos were at once arrested by
VASCULAfi OR EREcrriLE TCMOR.
441
oompreeain^ the ulnnr artery. It wtis decided to secure the »r-
tery iu the wound. She waa elliemed ; and, the wound b^ing
etJar;fed, the superficial palmar arch was cxpi>a^, and thu
aource of the bleeding:? at once diecoverpd. The artery was tied,
and tlic wound iiloaed, SI»o was ordered heel'toa, and brandy
ami water. Ou the following Jay, the 2dt there was an (jozing
of blood from the wound; and comprcsaioa was applied,
On the 4th, quite a hemorrhage occurred; and. on Hponfring
the wound, the ligature applied before became loo^c, ami
e away. The wound was ofjened^ and the aflme veascl tied.
e waa disehar^;p?d on tJie 23d| well. The seouud bleeding in
this case, ilk all probability, waa oecasioned by the arch having
been raieed up, and the ligature applied to the loop; tbo force
of the circulation gradually presain;* the ligature ofT, At the
time, it seemed to have been lied with ordinary force. On a
second application in the i^amc way, the result, wtia successful.
In recent ca^ee of ihia kind, it is l>eil to search for the vesael,
and lia itt if possible, in the ground; otherwise, try pressure.
Xfthia faila, tie the brachial rtrtery, although this is not always
certatin ; as, in one instance 1 have seen, the hemorrhage re-
curred after this vcaeel was supposed to be tied^ en account of
its division higher up.
*
VAeCDLAK OR ERECTILB TUMOH.
Th!6 diae&ae has been admirably described and dcpicletl by
John BelJ> who named it aneurism by anaetomosU. The name,
erectile tumor, \s given to it on account of the striking auiJogy
which it prcaents in structure with the erectile liosue found in
certain pnrta of the body in man, and In most of the higher
aniuLiJa* Erectile tumora aro made up almoet wholly of great-
ly enlarged bloodvefiaeU; and are divided into urterial and
venoua, according as one or the other cktts of veaaelB ecema to
predominate. The arterial tuniors, winch are altogetlier the
mo«t formidable, nrc ollen of very rajtid growth, and are marked
by active pulsation. The teuoiia tumore are more indolent,
and often impart to the touch the feeling of a fatly growth :
they may, hovrcver, be partially emptied of blood by pressure,
442
AKTEItlES ANU VEINS.
BDil ibua temporarily retliiced m she. It ta a common clinrnc-*
teristio of erectile growths, that tliey liet^umts i?nliir<^ed and
turgif] during any net whii?h obstructs the free returo of tlie blood
to tlie heart, — such as coughiiiy, crj'itig, laughing, &c. ; can-
tracting iigain to iheir former size wiien the patient becomes
quiet.
The treatment cf siuall erecitile tumore — najvl mutemi, for
inatnree, — is very simple. Hud mjiy l>e eillier by excision or by
the ligature. In exeJ^Jng them, the absolute rule is thai luid
down liy John Bell, — " not to c^ut into them, but to cut iheni
out." In operating by the ligature, Jt Is esseiitijil thut iht whole
groi^th nhould be tlicrouglily sLraugLlateil, If, hi (lie attempt
to excise the tumor, it ia unfortunately cut, the whole growth
hIiguU he immediately included in a ligature, and allowed to
come uway by sloughing. I haie Miveritl times treiilwl ereo
tile tumors of the face by rG[)G:ited small e^uteri/iUioiis with
nitric acid, ;ind have thus ^ui^oeiided in destroytn^^ the whole
morbid tissue piet-emeal, without the loss of sutjstiiTice and ron-
sequeril ecnr wbi<;h follows eicisian or xhb ligature. Injection
of the growth with ^lerchloride of iron Jiaa also been etuployed^
m rtiHtiy oases witli i^uceess ; but death has occ&sionally resulted
froni the pnictiee.
The ojteration fur the cure of extensive disease of lldti kind is
one (if the most formidable ia surgery, owing to the liability to
dangerous or even faul hemorrliage. In two cases, where large
pulsating tKHiors oceujiied nearly tlie whole forehead and upper
part of the head, I bare succeeded in dej^troyjTig them by a
series of ojjeratious, in wluch the afferent veaseb were obliter-
' ated by atrong ligatures lied over jiins pissed beneatli thcTii, and
thus the whole circumference of the growth thoroughly Blningu*
lated. By tlie application of new ligatures as often as any
return of the pl;l!^fttion wiia deteeletl, and by tlie free uae of
etyptics and escharotics, the disease was finally extirpated. In
another case, I tied hoLh tlie carotid arteries for an immense
erectile growth* which occnpicd the lower lip and a hirge part of
the face and ne<^k- The I'esiilt of this operation, which was then
only the tlurd or fourth iu which botli the carotid arteries had
been Aucccsafully tied, wad perfectly r^tieructory. A part cf the
VA80UL4E OR ERBCTILE TTMOH.
14B
lower lip, which had been the aeot of an ulc3cratcd aixd a bleed-
ing l»mor» woa afterwnrda ctcised without trouhlcBome hcnaor-
rha^ ; and, on seeing the pntient two ycata 3ubacqiii?ntly, the
vnflcular tiflflue was found to have wLioIlr disappeared* In a
pulaatin^jj tumor of this charactcF, occupying the palm of the
hand« and hold, qjj it ^verc, liko a ball in its gmsp, the tumor
gradually increascdj and finally involved noarly the whole upper
extremity. The hmb wne nmpiitntcd noar the shoulder, in time
to eavc the lite of the pntient ; nlthough the erectile liasuc had
partially invaded the structure of the port, and many li^turca
were required to arrcnt the bleeding. The Bpccimen, which
shows a direct continuity of the lar^y dilated arteries with
the vcnou3 trunke. was beautifully injected aud prepnrcd by
Dr> K. JM. Hodges. 1 have also had under my care a girl,
ninotcon yeari* of age, with a lar^o venous erectile tumor* occu-
pying nearly half the cavity of the moutlj, and ban^fing down
&om the lower lip. It also included a large portion of Uie
tonguOf and at times serionely affected [leglutitlon nnd respiration.
This caee was operated on by the ligature, tying both the tumor
of the cheek and that of the tongue on the same clay. The
tjgaturea came away at the proper time, and the result was fully
Bucccsaful,
1 have ppokon thus at length of thb disease, on account of ita
rarity, and Irom the fact, that, ovring to the absence of piiof it
is too often nogleetcd until it has acquired enormous proportions.
In such cases, it is rarely to bo cured by a single operation \ bat
requires a patient and persevering use of needles, ligatures,
caustics, and sometimes, although very rarely, the knife, before
it can be completely extir[>ated.
Case CCLX. — J^ormidabls Case of ^^ An^iritrn bi/ Atvio-
tomottis '* of the Scalp, Operation by LiyatuTt. Crtre. —
A healthy young man, 19 years old, entered the Hospital on
the fifteenth day o^ April, 1801, for the treatment of a tumor
of tlic scalp, which hod begun to grow with great rapidity.
About five years before, it was noticed that the bloodvcwela
under the skin of the forehead were bceuming enlarged ; but it
was only for about a year that a decided tumor had existed.
444
AKTEKEEft ATTD VEINS.
The tHiEor wna rtitual^il in the nieiliati Ime, ami mea^nreil
ill \U loiicTfi^l (liiLiiietcr ubout three niclti?.i, ami in ita amallec^t
nfjLrly two ; its elcvatiuQ being about two inches alwve ilie
friHital heme. Its shape was IrregTilaj; its bulk, about OuiL of
hulf a large orange; ltd A|)pe&r»ince, that of a lurgc mass of
earthworms eiiclo^nl in a eack- It wa^ of a retlili^h color, 6oti
and coiiJ|ireri^ib]e, and had a pulhation HjnizhronouB with that
at the wrist. It nn^ supplied by a great number t>f large, tor-
tuous veBS<?la, which pulsated strongly. Tlie terapi>ral and
frontal wterieti in front, and tlie (xxripilal artery liehlnd, sf^uied
to afTcird the chief supply of blooJ lo the tumor. Tlie frontal
arteries were especially enhirged, lieiijg quite etjuaJ in size to the
ratlial artery. The patient had Iried compression for six weeks,
without dhninishing tlje elite of llie tumor or the puh*atioD iii
it. All the ^easeb in the neighborhood of the tumor were
greatly enlarged, and the whole surrounding tififiue bad that
aueurianial thrill which belonga to u,Hecdon9 of thiB descriptioD.
It fteemed to I* spreailioy gnulnully, and ii]vtj|ving the whole
thickneee of the ecjdp on the top of tlie head. The attack of it,
therefore, by ligature of tlie large vesseU, appeared to be at first
cjf somewhat uniiertJiin pnnnise.
Optiraiion. — On tlie 17th of April (the patient being ether*
ized), by meaiia uf curved needles a strong ligature was intro-
duced under eaeh large vessel supplyuig the tumor. au<l Jit hh
great a diatanee as poeeible fronj ihe erectile tiaaue composing it-
Tbe ligatures were tied as llgliUy as possible, including tlie
pkiu. The effect of this wiu to diminish the puhatiou ia
the tumor, but not entirely to check it. Inside this circlet
three needles were thertifore introduced under the skin, eacb
about three inches loag* so aa to include all the tissue around
the tumor. Ligatures were introduced Ijonenth thoie needles,
and firmly tied. This served to cut off the oironlftLion between
the tumor and the surrounding tissues. There sdll remained a
Heiisatiun of vascukr motion in tlie substaiiee of the tumor.
Two stroug ligatures were iJierofore passed through the base of
tills last cirele, and were brought over the summit of the tumor,
and firmly tieil. The operation occupied al*out an liour und a
quarter. In the evening, the patient waa quiet, and slept a good
VABOULAB OR EQEOTILE TUMOK.
445
part of die time ; hi? pulac was VO. On the 18th, he had aomc
hcadacho. ixtid was niudi ineliued to sleep ; ekin hot, piilae 82,
There wns DO piUentioo in the tumor, itnd ^miUl vesications wcro
appearing on its Burftkce. On the l^th, he vt^ comfortoblo ;
puJac, akin, and tongue iiAlural ; bowtjla had moved without
medicine ; api>ctitc I'jiir, ami no unplei&unt eymptoma. On the
23d, putient liaJ ruinaJned eomforUihle since last report ; was flit-
ting up in bed- There wtis a ehirht serous diachargo by the fiido
of the nceillcfl. On the Siith, there was a swelling of the right
parotid gland, and a gloesy appearance of the tiasucs het^t^cen it
and tlic tumor. Walcr-dreseinga were applied over the whole
Burfacci On the ^Tth, n ligature and a needle were removed*
2Dth. It was found that a part of the tuiuDr indiided between
the ligatiiree waa jjtil] nlivc ; but no pulsation could be detected
in iti On the ^d of Mavt I removed all the euturea and a por-
tion of the slough, which was parliidly dctaclied. On the 11th
of May, ttic }>atioDt wae again othcrhicd, and two largo needles
passed, nt right angles to cneh other, under the base of that
portion of the tumor which remaineti (dive. A large and strong
ligature was then passed under them, And tied with great
foree. On t.be 15th of May, the patient having gone on well,
and the tumor being quite loose* the ncedlee wore withdrawn * A
thiek bilk ligature wild pasttcd around the base of the tumor, and
liei) wltli a jerk, eutting off it^ remaining attaehmcntfl, and com-
pleiely separating all the dJseai^ed tiflsuc* TIujj wae followed by
<tuito free blceiUng, requiring the npplii.yttion of lignturea to one
or two large arteriea. The bleeding which occurred from the
flmall vceeelfl was checked by the Ui*c of a solution of perehloridc
of iron, Un the ^.^tli of iMay, the csHmr formed by Uic laat
application separated, leaving a healthy granulating aurfaoe.
Thifi healed kindly. Some weeka later, there being a suspicion
of a&liglit erectile tiat^ue remaining in a portiou of tlic j»kiu, I
exciecd it, which hnished the cure.
This ease is interesting, first, from the large size of the erec-
tile tumor ; scoondly, from the great calibre of the principal
vesseU which ^uppUe^l it ; and, thirdly, from the immiLnity from
unheaJthy action in the skin, notwithstanding the great amount
of that tiriBue implicated in the ligatures. The {wrotid gland, at
3fc I
I- >!<■>*- ^ -
":-'. £11. _:tr^ zr
446
abtehie!? aito VEirsft.
ore time, was certainly irrltateil, miJ the straining of the whole
Hcalp enused a certain amount of swelling and an sipprniLeh to
o^JemA; but there was never tiny lliin|^ liJie erythema. !in<I bui
little constitutiOEuil disturbance. There is but little Jotibti thnt,
if the tiiruor hiiil goue on much longer uncheckol, the viisciilnr
system of the scalp woulil have become »it implicated aa to make
any attempt to relieve the patient by o;>eratian imavEuling.
Case CCLXI, — Ligati/re of hoth Carotiri Arteries for
a remarkttblc Erectife Twaror of the Mvuik, Fnce, and
^ecJ^, — A young man, 23 years of ago, oonftulied me on
Oet, 1, 1845, for an enonnoiw tumnr of" the lower lip and
tongue, which hiid supervened ou u birth-murk oocupying* a
good part uf the face and neck, and presented the following
appcTinince^ : —
The hcEid of the patient was larger than common : the left
side of the face was almost wholly ocenpieJ bv a diBcoloratioa,
which xviis orii^nally less extensive and Lighter coloi*ed. but had
ttttaiuod the extent and appearance above mentioned. The
right aide presented a discoloration about half the extent of the
left. The lower lip was much enlarged, everted, and gave three
Ewpecta : esternally, the thick lumefiGd lip ; internally, a fungoid
tumor, covered by red granulationj* distended by bloo<?» ns if
ready to break thmugh i tlie whole Burmoxinted by an irregular
ulceration with thi''kpnefl edges and a hardened base. The red
granular appearance extended undemeatb the tongue to the infe-
rior surface, the left half of which was enlarged. to double its
natuml aize and partially protruded between the teeth ; its upper
portion being the sent of five or six *niaU ulceratioi:8. The dis-
coloration of the face also extended on the outHide of tlw lip
downwards over the ehin and neck, covering a apace of seven
or eight inches in diameter ; the wholcT eflpt^eially that on the
face, being rather more full and distended with blood than
natural, (See Plate lit.)
The history of the case was this : The mark, as above stilted,
waa congenital. About 1641 the Hp and tongue began gnulu-
ally to swell, and the former very shortly ulcerated- The
ulceration occaaionally heidetl, until the last year> when the
VASCULAQ OR BUECTJU: TUUOK.
447
enlargement Lecftine permanent. By compression, the blood
could be eAtirely expelled from the lip, and m the anmc manner
from ibe toii^c. Since the erectile tissue hoci been developed
in the lip» tlio dieeol oration of the face had become moro marked,
bad cxteniledt nnd evidently partook of the churactcr of the
erectile tumor in ita neighborhood.
Thin oaHG was a very critical one ; and tlic two moat prominent
dangcrd whiel] threatened him were ihej^e : Fir^l, a poaaiblo
defeneration of the ulcerated lip; and, secondly* alirrniug
hemorrhage, vrhich waa likely sooner or later to take place,
and which must^ in all probubilltyi prove rupidly fatal.
The following la the course I proposed to him ; First, to have
the left carotid artery lied; Second* after a considerable Jnlcr-
val of time to lie the right carotid; Third* to attack what-
ever p*»rtiDn of the tumor remained by nieana caltulntcd to pro-
duce eoutractlon of tiic vcsacU and obhteration of the erectile
tissue,
Tif ihia course, afVer weighing well all the dnptrers connectod
with it, the patient agreed; aud, on Oct. 5lh, 1 tied the left
carotid artery. He recovered from the oi>eration, and was out
in about ton days. At that time the lace had become more
pale, the erectile tittsne and the lar^c tumor of the lip much
dhuiniflhed Jn sizci and the painful ulceration which surmounted
it was mpidly healing. He seemed to be in perfect health. I
wlvised him to go home, remain three or four wecka, and then
return to hare the other carotid tied.
He returned Nov. Tth, when the tumor of the Up waa found
to have dimmii^hed onc-ludf. The fulncsB of the face and neck
waa less, and the discolored pjirtd wore much paler than when
he left. TliQ BiKo of the ton^e was Igbs, and the ulccratci] spots
on it had <^uite healed- His health remained good. It was
determined, tlieroJotc, to proceed at once to Ihc ligature of the
carotid of the right aide-
The patient being placed in a sitting posture, tlie carotid
artery was laid bare, and a ligature pasacf! under it. It waD
dilated about one-third moro than its natund sice- He was
then placed un hid bed, with the head sli^^ditly eleyated: the
pulfic woa found to be !$U in the minute. The ligature woe
448
ARTEUIES ANB TEtNS.
drawn fi^lit. At first lie exhibited no chaiiire ; but, shortly after,
the jiiiUt: n|l[le^.red lo luliur, and became sli^^Iitly Irr^^gulur : ilie
odI/ HjmpLom Dotlced m tbc patient wua tbat be became drowsy.
Alter waltin*,' about fifteen mluute^, the eecond knot vna tied*
nod tfie wound dreaaed-
No iiit:oDvenitQce waa exj^eriEQced from thia 0|»emtiun, fartlier
than n tdigbt ftautDesA ilurhig the oflemoon on attempbiig to
mlae bia he.'uJ- He wm directed to keep perfectly quiet, and to
maiiiliiiii atriclly thtr horizontal |>asitloD.
On ihc third daj, there waa & s\i^\il aorcDeas about the larynx,
which lasted three da,y&. Nov. lDlh» at the end of ten daya, be
waj> ill j;ood heallbi and able to go down stairs- TIjg face was
mu^ paler than before the \ast operation, and the morbiil
appeurriueez^ vn^n^ dlmmifiblDg.
Nov. 2Gth. TIjc Likt^ration of the lip woa quite healed ; but
the li[i itself tviia still tlilck, and aomewh^it everted by the erectile
tissue, which cntere<l iulo its whole substance.
It was riincluded, that, although the swelling was ^lulunlly
diuiiiiisliing, y^t !t wonld mil wholly disappear without a further
operation; and that, as the patient lived at a considerable dis-
laiice, tile dij^ease, if dir^posed to returu, might get heyotid
control befoi'c tlic proper menne could be npplictl to cheek its
increai»e. 1 therefore detennined to remove the di&CJised portion
of the lower Up, Pi-eviously to this, and in order to avoid hem-
orrhage, I j>erforined tlie following operations : — '
A cataract needle was pluuged into the vascular texture on llie
left «ide, and caniRil in different directions, so as lo break up
and dt'fttroy its orgjLnization. No hemorrhage followed tin*
aj>[iliration' Three days aflcrwards, a similar aperation wa«
repeaLed on the ri^ht aide.
Nov- 29ili. A final operation was performed- A strong
compression being exercised^ by means of two steel forceps pre-
piired for the purpodc^ on each side of the lip, sa ika completely
lo interrupt the coutae of blood into it, a portion not les^^ than
two Inches in length at its free e<lge wii* removed by a triangular
incision. At fir^t tlicre was not the slightest liemorrhngc, the
two lipa of the wound remaining perfectly dry : nn the com-
pression being removed* however, blood gradually oozed from
VASCULAE OR ERECTILE TUMOa.
449
the whole cut surlace. Thif? wan easily checked, and the edges
of the wound apjiroximnted by n launiher of pointe of tHe inter-
rupted suture, ami a powerful coiupresaing huinln<re applied,
For the first Iwenty-four hours, he waa carefiitly watched,
Towarls evening, n coogulutn was found projecting; from the
wound, whiclt wan removed- From this time, there waa no
farther hcmorrhn^e or bjid symptom \ aud the wound bealed by
tlie fir^t intezitLon.
The portion of JIp removed presented a spongy tiaaue, like the
body of a leech, and gave a senention in cutting like a piece of
diaenae<l hinp; ; parte of it were indurated from the previous Hub-
cuEnneoua iDciaions, The muscular tisaue btid almost completely
disfippeared.
Ou Dec, 12th, the pnticnt returned home quite well-
At thia time, the drawing, Plato FV-, wne made- As will Iw
seen, the discoloration of the ftice had become much paler^ and
that of the neck and cheat had almost wholly diaiippeared. The
ear bad lost its awollcii nod doop-reddish color, and had become
of a natural size and of a pnle as|iect.
No pulantion eooid be discovered in cither of the temporal
arteries, or, in faut, in any of the arteries of the head. In the
neck, just above the clavicle, two large aneriee, nearly the aiae
of the Parotids, were acen pulsating poworfidly under the akin ;
being, iti aU probability, ,the eupra-acapular arteries greatly
enlarged-
Meriifirka. — It ie now mther more than sixty years since Sir
Astley Cooper first applied a ligature to the carotid artery for
ftneuri^^io ; nod the operation at thnt time wns looked upon with
great dtatruet, from the fear of a fatal disturljanoe to Ihe funcuons
of the hrain. It has since been frequently repeated, and with
as good siiocces as perhapa any of the greater operations in
surgery. The object appears to he, tbat aufficient time aboiild
elapse between the ligature of the carotids to allow the (Collateral
veaaela whirh supply the brain to he dilated, so as to carry the
quantity of blood required for the performance of its functions-
It seemed probable (hat hemorrhage would seal the patient's
fate, or the morbid degenerution of Vissue would haaten his
.death, unless some sure and active means were adopted to arrest
57
450
AKTKRieS AVD VSmS.
the di9«^*^. If c}i? di««:u« htA been etmated mt a gretit distanett
frora th^ ves^ls to be lifted, on the sciiJp l«r nistuio>e, th«ra
wuu]d ha%"e been n question, wheilier xht* supply of blom] mi'giil
noi be kept op bv a coUnt^ml supply t}iFO[ig1i the vertebnd
aiteriee, by tneaua of the opbtbalmic. In [he present caae» no
danger of tbia kind was Utely to ^ve eaose for imiuediiite
apprehenfiion, and the aedre put of the di»caac mi^ht euilv be
estirpnie^i before the annetomosing vessels Iram other qmrteri
had bepTjn to supply the lunior, — iin opinion Bupported by the
eTent. The attempt to remoi'e the lip without the ll^ture of the
carotids would pivbably liave been attended %rilh fntnl heraor-
Thage ; and^ even if the patient had eswiped Ms aceidpnt, tJ>e
diseased tissue in the nei^borhood would have been an obji^ction.
ThU patiefit I bad an opportunity of seeing three yeiu^ After-
wards, and of making some observfltions on the slate of the
cirpidation in tho^ purts about the faee and nerk supplied by
the carotids^ The situation of the temporal arteries bein^ ea^
ploped, no appeiUTinee of puliation in them (Nwild be dii^covered.
The ftAUie was found to be tnip in regard to t!ie labinl fine-
ries. The angular arteries, where they ino»Ptdate with the Dusnl
branrh of the ophdialmic, pave die faintest pulsatorv motion.
In the reg-ion of tlie neck were a number of large ves'ieU^ having
their origin from the ^bclaviiui ; among which the supra-scnpular
was chiefly to be distinguished. The lip was mlhpr more fiill
in appeanince than when tlie report of the <yiBe -wtm niadi?, but
^e Irom uhTeradon. The funrtions of the bniin hail noi in nny
wav been disturbed.
I have^ however, twice attempted this operation in anetiriem
by anaslomuHid of the upper lip, where the ditseane hns been
partial. One of tlieT*e wifes i^ deembed In Dr. J, C. Warren's
work on Tumors. The individual had n lirge red mark occu-
pying nearly ^jne-hnlf of the left side of the fiice. During- liis
childhood, the upper lip on that side had enlar^Z until it formed
a permanent t.Lunc^r, hanging down and oliwuriiig the under lip :
the ^ms had partjikeit j>f the dir^cu^e ; had liucoiue s}Kin|fy, ami,
widi the rest of the diseased maaa^ were bleeding on the leji^t
injuiy. Rather mcire than half of tin? iipfier lip waf^ alVecteil-
T removed the whole of this by tnemiB of two incisions made Jn
VASCDLAR OR ERECTILE TUMOB.
451
tbe adjoininn; soimd textures, A triangular pioee beiu;; thus
incIuJw], a number of dikteJ vefieelu, which supplied tbe erectile
tissue, were tied ; and the oaly hemorrhap;e which waa Irouhle-
Eome arose from the augle of the wound, whtn-e the diaeaae had
extended up into the uo^Crile. The int1»mm cation superveoing
on this opcrntion wti^ c^utHeicnt to obliterate the mi>rbjd tji^ue,
wliieb per^'uded the mouth and Jt^ neighborhood. Three moiitha
afterwards, 1 saw nluioat oxactly n similar case of disease (t>n the
right aide of the fiice)] which was t^uccei^si'aiJy treated tii the
eame manner.
Case CCLXH, — Anomuiitn by AnasfomosU HiwceBsfully
tnfdted h/ Various Operational — The eiihje<?t of.tliis case waa
an inhabitant of Nova Srotin, a hoalthy man, 33 years old. He
bnd on hi^ forehead, prinoipally below the roota of the hnirf a
little to the rij^hl of the raedia:i lire, a soft, pulsating, irre^^ular
tumor, ubout thi-ee iuohes in diameter, and from a half To three-
fourths of au [ueb iu Ehickticsa, which gdve him a very formid*
able iiJ^pect,
Tbia tumor was of a reddish color, becoming redder and
larger when the patient wai excited, either by bodily exercise
or meatal disturbance. It a}>peared to consist of coils of veasela.
It wflfl easily eompre8ae<I, and, on removal of the pressure, im-
mediately enlarged again. A number of pulsating bloodvessela
were seen to enter it from different directions, principally on the
rijfht side. Of these might bt» di6tinguishe<l, first, tlie tempond
arterji wliicb was in n very enlarged and tortuous state aa ^
dowa aa the lower part of the external ear; second, a branch
of the frontal artery; third, the facial or angular nrtery, from
the interna] commissure of the eyelids. On the letl side were
seen tlie left temporal artery, whieh viis nearly aa large as
the right, and the left facial artery, which, with its fellow, the
artery of the right side, and its aceompanying veins, formed a
vascular tumor at tbe mot of tie noac. Tlie vciua tbemselves
were of an ent»rmoua size, pnaaing down from the lunior on
either eide oY the nose, coverin^f aud ptirtUJIy obsL'Ui'Jng the
intemul commissure of the eyelids. Beside* tliese vessels, the
whole Bcalp in ihe neighborhood of the tumor aeenied alive with
«»
ASD
bc^B BXMCtt 5«ui b<fart^ wilkoat h^ known
CM»e, bf « ivtn reUkb ipaC «a tke n^ nde of tlv fiMvltfad.^
TliBe tTM AA oce«aoBd thiohbipg of ihe orocid mrtcnes,
tkuUrlr that oT the right At^. Tbe p«daU wu «iso wbject to
dktTttttng hcftdacfaev, moBampuMaed wjA incRucd MtioD of die
Moodfawtli of die tamar and of die heftd genefsllT- This
ribnUoTj ftcdoo of die mrtcnal ^ratem of tb« head, iwck. «ad
i]p[>er oxETCnutics, wu quite remaricftble- He tu iaespMlBlcd
br it fri.>m idl active exerttoa, and wa£ readv to undergo an^
operafion ihni proiFU«ed Xa relieve him.
The coune of thU tumur, if not nrrMied hy ffnT^ical tntft^j
merit, could be reaJily foreeeen- The morbid at^tion wrmld^
l^iuliially Involve otb<?r ve&^el£« imtrl die Hhi>]e »c^p becamoj
filled with enlarged arteries. The vessels of the eyi^lids, of tktn\
fju^ [^ncr&Jly^ and even of the inteHor of the moaih, u'ere likely
to Uc involved. The pfitieat^e condition would, in this war,
beooiiie almoHt imupportAblc ; and \m life would perhnpe be
bftzarded by the rupture of the tumor, which eeemed atmoatj
reodv fo tnkc place.
What rnesn^ shonld be adopted to arreal it* progrpas? ThosaJ
wliieli naturally presented themselves in the 6rat place were ofj
two descriptions : First, ligature of the carotid artery- But^ in
thirt case, tlie ligature of a single carotid might not sufEc'e to
Arreat tho How of blood into the tumor; gioce the vessels which,
aup|i[ictl il, althouirh principally from the right, were partly
friJin iIh' li.?ft ewriJtiii. The ligitttire of both carotids wculd there-
fore b« necPBHury : hut the result was lesa Ifkely to he successful
lliiin in the |irti;eding ca^e, on neeounl of the greater dielaECe of
the tumor frum the Jirterles lied, and from the probability uf its
having other means of supply through the vertebral arteries,
wbii'h iniK^CLiliitu freely witli the branches of the inCeiTial enrotid ;
tlje ophUmhnit; in thiu ciu^e being unusually dilated. The Hecond
VASCDLAa OR ehectilb tumor.
453
mode of operating which euggested itself was to expose the ditler-
ent vesaele Bupplying the tmnor, anJ pusa a lignturc under
them. The objection to thia course Wixs the length of time
an opemtioD upon so man^ vee^s would require. Were
there any meana that cyulJ be Ucviaed other thnii these two?
Tlie tumor wiLd mucli too large to admit the sulc juid ctloc^tual
applieiUion of caustic. It eould not be cut out witliout daiiger-
O110 liemorrhagCp It waa too large, and loo much conneutcd with
the bune* to admit the application of ligature en mctsac.
Oct. 31, l^'ld. Having compresecd, on the right nide. the
frontal and the two tempore -parietal artcnea, and on the left
aide the continuation of the temporal artei'y through the froiitnl
region, and the tempo ro-parietal, the pulfiatiune of the tiiiUL^r
appeared to be arrested i and its conlcnta were readily expelled
through the large veins, running Into the tac.ial vein. It waa
detonuiaei-I) therefore, to intcrn[|jt the cii^cuktion throu^^^h the
five vejdcob £r«t luentloDod; three on the right side, and two on
the left. Instead of exposing and taking up these vcaaela in the
uatial woy, they were compressed by a ii-^'ature, thrown over
the nocdlcfl pasaed under them, in the form of a figure of S.
Afler this, tlic pulsation of the tumor waa taucli diinininfied.
Voncaection wa^ then performed, and Uie patient placed in bed
with hie head elevated*
Nov. tilh. The needles were removed. Very alight eorences
bad been experienced from them. The tumor woa dimlmshing
in eize; the vceeeitt constituting it ap|x;artd moru Hoceid and
compreaeible. The aoreneae and all the uucomforiable aenflationa
connected with it were leesencd.
I^th> The pulsationd in the right and left temporal arteries
atill continuing, a needle wiu^ paaecd under each of theeci directly
above the ear; ufier which fhL> pulmition BubeidciU and also tlie
general ecnee of beating about the bead. The patient was much
more eomfortablci
2Iat. In eonacqucnee of q slight bleeding from the wound of
a pin iuaertcd on the Hith, it was tliought best to nbetruct tlie
ve^r^cla on the anterior and on the interna] part oi' the tumor;
and pine were parsed in each of these eituntiunfl. There wa£
then no puluatiou iu tlko tumor; the tendorneae oxiating ou the
tfae
phce- A li^Mnic ««« earned unafid
tfcackgj- It wu to be feared, bpwcf, (Jhil, at ilic pn nlcv-
ii«d o^ 1^ Lmimiha|;ft widd item, Xfcoc bcia^ & wxnt ef
■tWMimmndifiiMi in kii lad^^. aad b ovilv tbst be miotic bi
nan GanfiiU J vatdwd is cvcof afcoaod n^lNK of the tonorr
Le wM adraed to go to the Hotpital, wkoe be caaic exckuiv^
■nder Uhs au« of Dr. 4<Am. C. Wafrea, to irlM» I am laAAt^
for iht remaioiiig hLetofr of tbc case.
25tli. " The puUe waji novr natura], 7i» ; the intern^ setiA-
tioii* were Enitch improrcid; there wbp do nbratory motion uf
tbe artcfie* oi' the head, and Dooe were diacofcnble tn the tumor,
thuugh a pubation gtiU ezut«d-' A fi&ght tcdema extewled from
the tutaor Ui Uie ao^ and erelids. Oixk^loq^t a drop of
blood atartcd iVom the needle wounds. FroiD time lo tiuie,
leechcv have been applied with great relief-
dOl}i- "Oil thle daj, a vewel wae diflcofered nmning from
tlie left fronbil artery acroj^a the leFl ejebrow, oommuntCfttiE]^
with a bnwcb in the angle of the eye on the right «ide,
dience ninntng up nlong the left edge of the tumor, till it
ruuulied it^ AU]^teni^r pi^iatcrior border. It did not produce a pui«
Butiuii in ihifl jjurt uf the ttiLuor ; but ekirtuig aioug ite edge for
■oine difltoncct &« it did, there was a ^rang proLnbilitT of ita
*l^n"[lll^^ vc^eeli* into the mosB, thus tending to keep up the
ijLOtbjiI m'tidii. The necdke which were inserted on the 22d
InMt. cwjned an Influmtnation and iudurjition of the tissue in
tlniir iiii;^'hh<jr]nio<[i and were removed without hemorrhage.
"Ah cmuprcpMon of the artery riein^ on the forcliead checked
the fi|reciHe<] piilfiuti'jn, it wntj determined to lie this veaseK A
liMdle wan ju^i^oiijjngly paeF^i^d under it oxi Dec* IsL Defure
plAeing the li^iiture, tho veAdcl waa couiproflW on the ncodlc:.
VA80CT.AR OR EBBCTILE TDSIOB.
i55
without interrupting tlic pulsation along the edg:c of the tumor.
Anotfier ncctHc wna theretVirc pn^scd under thai purt oF tJic
artery where it penetrntcJ nt the superior internal nn^le \.tf tho
tumor, embracing, over the needle, a votfcuUir aub<taiicc nt IcujjI
half nn inch wide, A li^aturo, pushed in the fi^rc of S over
this needle, suspended idl puirialion. The patient hiui some
pain, which lasted a cyupie uf hours; nttep which he he<;niue
easy.
Doc, 3d. "Two needles hod flcparttte<L from the aubetance of
the tumor without hemorrhage. Beaidea the needle paafied on
Ucc. 1st) thei'e still remained one needle nt the lower part of
the tumor, which was passed under an artery from the right
ircntul. The tumor, which h^ul been hard from inHammalion, waa
eoftcred ; it« heat, except near the needle pnseed the last time,
had suhHided. There was no throbbing in any of the arteries
about the head : the earotid bent naturally. The patient was
tranqiiLl, felt well, and eat np, which ho had not been able to do
for flome time on aceount of the throbbing in the head pro-
duced by any motion- U.e had a goo<l appetite. Hia Ibod
was rcfftrioted, however, to half a pound of eolid farinaccouft
matter per day, and about a pint and a half of l]f|uid'
6th. '' Although all pulaatiima were at an end, die tiiukor still
cjcifited, hut in a diminished state. It was thought^ that, If left
to ttaelf, it would in all probability disap|>ear without further
applicatione ; but, as tho palient lived at n great disLnnee, it
aeemcd to t^e n duty to see that the tumor waa certainly ond
perfcdly enidieated before he went houjc to Novo Scotia. The
best mode ef accomplishing this was by the application of
cauiiitic, which was rttorted to without much danpcr of hemor-
Htage, the peat vopboIs being cut oH', The use of caustic waa
therefore eommenoed by the application of caustic potaAfi, in a
solid form, to tho wound lett by tho eeparation of one of the
needles. This wound was about one inch long and two lines
wide. A little blood followed the oj^plication , whicit might
have nriaen frr^m the pressure of the enualie; and therctbre n
portion of the saTne aubatancc, in amount eight gnuns, was ap-
plied in powder.
16th. ^The caustic hod been applied throe or four timo».
15S
ABTERIES AND VBlIfS.
Twice A flJiglit hemorrlinge had occuired, requiring an mttnni»-
sioa in iu lU'ie. A ;)ul«atQry movement liaviit^ re-appeitrt-J in
the relics of the tumor, the application of ice two or tbreo tini^^
a day waa directed, to be conttoiLcd as long aa tlie patient roftld
bear it. To-day the caustic was re-applied to the ulcerated
Durfooe, which waa about an inch long and balf Em inch wH^e-
The tumor had scnsiblj dlmjoished in i^'izc,'*
It will be uuiiecesaary to proceed witb all tlic subsei^ucnt
details of this ca^-<e. It ia suBicieut to state* that the JilTerent
portiona of the diacaacd inasa which rctuaiued were siicccsstvelj
attacked with caustic ]>otasli, and with the occasional a^ipliciLtion
of croton oil. Anj' emiJI arteriea which were discoveretl nju-
ning into the turaor were treated, as in ihe commencement of
the ca^, by the nccdlefl*
On i>th April an operation waa performed to exciae a portiaa
of the erectile tiesue, which c:cifltcd at the njiper part of the
woiindt when u large veaecl wns opened and tied.
May 20th. After the wound from the inciaion and cauatic
was nearly healed, a fulneae waa perceived at ita lower angle,
immediately above the supra-orhitir forameUp A triangular
piece uf tlic suapicioua part was Lherefore cut out, and the fuprii-
orbitar artery ticdp The whole wound, after thia last operation,
waa nearly the aize of a flilvcr dollar. Strips of adhcaive plotter
were applied to apprijximatc its ed^ea. The wound came to-
gether witli great r^ipidity. In a fortnight after tlic last incision,
it was healed with a iunated cicatrix, and the parts appeared
perfectly soundn The patient was in excellent heoltli ; and,
May 20th, waa diachargcd to return home.
liftnarkf*^ — In conaidcring this case, the firat circumstance
which preecnia itself is ita protracted ami com])licatcd treat-
ment. The neceaait^' of this arose from the obstinate character
of the afibctiun^ Tho fir@t operation wa^ inaoHicient, and ad-
ditional intertercnco waa required under the various appearances
which occurred. Four different racasurca were aaccesBivalj
adopted.
1. The large veeselswcre interrupted by needles pasaed under
the artorica, and compression made on them by a thread in the
form of a figure of ^.
VAfiCULAR OR EEEOTILG TUMOR.
457
2. The lj;^&turee being iDsuflScicnt to repress tbo action of
the sinjbUor voBflela, caustic applicationa were resorted to for the
purpose of destroying the morbid texture, tmd In part obiiter-
ating it by the in Summation produced by the action of lUe caus-
tic. To thia end, ii very t'rco iip}ilicntion waa niado of caustic
potAdh, and re[icatcd between twenty and thirty times,
3. Excitiion of the rciuaiua of the vaacutar texture was per-
furmcdi after the arteries su|)plying it hud been so far obliterated
ad to remove tbo apprcheaaioa of bemorrhogo.
4. Coniprcfiaion by odUeBive plotter and a bandage had a
sensible induence in finiehin;^ the cure.
Tho general treatment gave important aid to the local applica^
tiona. The patient was kept very etJli, and for the greater part
of the time in bed, with the head much elevated. Hie food wae
realrieted to the emalleat quantity, &d that he waa reduced tor
a tioie to a state of total proAtration of the muscular pi>wer.
During moHi of the trcatpjcnt, if a stuall addition was nuide to
hjti food, its effect was genomlly aocu in tlie production of
arterial vibrations and the recurrence of headache. Abstrac-
tion of blood and the use of purgotives were reeorted to when
necessary.
It is worthy of remark, that, while eryaipfllne prevailed all
around this patient, he was never aifccted by it In the elighteat
de^^ree during exposure of at least three months.
In concliifliont it may be ftaid that this atFectioa could only
have been deatroyed by a resolule and active perseverance in
tike various remedies, continued through all the turnings of the
dieea^.
Case CCLXIII. — Reviarkath Case of Aneurism by
Anaatomosh, Operation. Cure- — A boy, 16 years old,
partially froze tlie lolje of hie left ear in 1818. This remained
larger than the lobe of the right ear ; and, in fact, alowJy in-
creaeed in pixo, finally forming a distinct tumor, red on its Bur-
face, anil having a powerful puUatJon. In 18^12 it w^as found
neeesBary to undertake some means to arrest Lte growth- For
this purpose, compressiou between two plates of metal ^xaM
odvUed and proctifed by his eurgeoQ. Although this was done
458
A}£TfiKl£S AND V£1NS.
in the moat carf?fiil end scientific' way, yet ilie eufferinj^ became
so eevero, that, after having persevered with it for a fortnifrht, it
WHS found neceasary to abandon its furtUer application.
When tlie patient applied to me, it was with the full deter-
mimitfon of having any c>perfttion done that might be though:
expedient- The tunjor had arrived at that condition whc^rein
it was evideal, lliat, if an ojMjration ehould not he succefieful in
removing it complettlj, it muat soon pass beyond the reaoh of
surgery, spreading over the eai' and takin;^ iiossession of the
face, as in the cjwe cited by Dtipuytren In hia "Lemons Orales,"
which resisted numerous nnd formickble operations, performed
by some of the most distinnfuished surgeons in Paris.
The nppcaraiiee of the tumor at this time was as follows:
The lobe of the left ear was occupied by ii globular tunior the
size of a hens egg. The aurfiice waa re<l^ and ci:»vere<l by large
veins running over iC in all dirertions : the redness and swelting
belonging ta the lufnor extended above, into rh<! ecnchn of the
ear, and ran up for a short distance on its back pnrt- In front*
it slightly encroached on tlie cheek. On taking h in the hand,
it had a powerful pulsating motion : not that alooe presented by
the common ereciile tumor, but^ added to this, what niigbt be
expected in an aneurism of a lar^ artery, the carotid or sub-
clavian for instance. By manipulation , vessels of considerable
size eould be perceived tunning into it from the oar and face.
At firet, I was at g. loss bow to attack the disease, the danger
of hemorrhage appearing to be great Irom any cutting operation ;
and, if ligatures were iisedj the same danger wa^ to be appre-
hended on the separation oi' the ihreafls. A combination of the
two was finally resorted to-
The patient being etherized with chloric ether, the tumor was
dragged upon, so aa to stretch tlie integuments as mUL-ii ns pos-
gible. A pair of screw forceps, similar to an enterotome, was
now made to embrace the whole base of the tumor, about tliree
inches in lenglli, that is to say, the whole enlarged lobe of the
ear, with a portion of the cartilage. This was tightly screwed
up, so as completely to interrupt the course of the blocMJ into
it, A needle^ threaded with a strong double ligature, was next
passed behind the forceps, and the nee^lle cut off, leaviug the two
VABOULAR on ERECTILE TCMOH.
459
thrcocfs. The tiimor, now itpparcotly effbctunllj- coatroUe*!. wjw
cut flway close to the forceps. It was, howover, iit oiitic found,
thai, on the tension of the piuls bein^ reliovod, that portion of it
towards tbo check liad escaped from tlio gmap oi the fotcepa, and
ttn arterj was e:cpoeed nearly as large oa the cjitcmal carotid-
Thie waa seized by un n^sie^tant with tooChed forccpa* and a
lignture applied to it, The grasp of tho forceps being now
slowly rolajtud, it was observed that the whole cut surface was dia-
powxl to bleed* Some large vessels bled violently, and were lied.
To Btop the bleedbg frora the other parta, it was iin&Jly found
necessary tu apply the Jigatiire en ma6SG, wliich wa* done by
means of two double ligiiturc^, In the subsequent mana;^;^-
raent of the case, all means were used to prevent too high a
degree of intlanimntory action about the ligatures. The pnticnt
was very enrcftilly watched, kept quiet, a low diet enjoined, and
a compress, constantly wet with cold water, applJedi Once or
twice, blood started by tho side of the ligatures, but was re-
strained by refrigerant npplicatious. At the end of fourteen
dayS| the ligatures eepiu^tcd, le^vin^ an exuberant granulating
surface, upon which the nitrate of fiilver was freely used* On
the twenty-third day, the wound was almost entirely healed,
and the neighboring parta vrera in a perfectly heulthy state j the
effect of the inHanunntory action having destroyed ihe cnhu-ged
capillary veaaels which had CTiteadcd into the concim of the ear,
nnd invaded the integument on its posterior pnrt,
In order to have extirpated all apjKuranoe of erectile tissue
at the iirst operation, by the knife, it would have been necessary
to atieritice nearly half of the car, and to leave the patient with
a great deformity, lu order to avoid this, I removed the tumor,
trusting to the effect of inflammation to destroy the erectile
tissue which remained.
The ftppcnrauce of the tumor after removal was quite inter-
esting. The main portion of it was composed of a spongy
tisaue, which enclosed an aneurismal cavity, apparently the ex^
pansiou of the largest of the \essels deacribed above, which
were tied when the tumor was removed. From this cavity,
branches extended in all directions, which finally could be traced
into the cclluhkr tisane covering the periphery of the mass.
r
460
ARTERIES AND VEINS.
Cabe CCTjXIV. — JV^ci'u^ over thf Knee-joint, — A young
man entered the HospitAJ in JimeT 1S52, with n ulcvub on the
kneo. The depvus wae of a blnck color, PituntCid over the in-
ner part of the knee-joint, below the pntolla. Until within two
yeara, the tumor bad been about tbe eize of n {loU^r ; but, since
then, a supplementary tumor had appeared uudemeath the ori^-
nal one, not eof%, as k usually seen in these cnses, but qiiit«
bird- and extcndinsj fcr Rome diataace into the adjacent e^Uular
mcmbrnne, and apparently attaching itpelf to the aynovial osp-
etile. The whole tumor had become extremely ^enaltiveT eo that
even the contact of the clolhea caused much sufferirg ; and pre-
vented him from attending to bnfiineas. It was impo^Eible to
make any fatisfactory examination^ the padent dremie<l so much
the eli^hteet manipulations. He wa^ dieted, and kept in the
horizontal position for a few daj'e ; an evaporating wash being
externally applied- Thin liad the effect of relieving the tender-
neaa in a eliglit degree. The whole tumor was now congealed
by means of a iTeezin;;^ mixture of pounded iee and salt, aeeord-
inn; to Mr, Amolt'fl process, which I had juet oommenoed to
experiment with. The hard baeal tumor was then very freeiy
cut up by a eubcutaneoiw section^ The operation was cntii-ely
painlefis, and no unpleasant symptoma ensued. The vicinity
of the knee-joint of courae precluded any operation for tlie ex-
cifcior of the tumor. The above subcutaneous section was,
therefore, once or twico repeated ; and re^ulteil In the absorption
of a large part of the tumor, and diminished the eensibillty, bo
that it could be handled without sufFering, He left the HoflpitnJ
aC his own request; otherwise, bv a repetition of the above
meana, the ctimplete destruction of the tumor would have been
effected.
In another case, I removed a similar nicvusT in an uleerated
state, situated on the upjier [>art of the calf of the leg. The
patient wae twenty-six years of age. Two years before, tha
tumor had been injured, after which there was much hemorrhage.
In spite of treatment, it had remained in an ulcerated state. The
skin around it was much infiamed^ and at timeii very painful- It
^as removed by two elliptical incisiona, without much hemor-
rhage.
»
VASOCLAR OH EHEmLE TUMOR.
4S1
Case CCLXV. — l/nustial Uojig of Varico^ Ancni'tJtm of
palm of Hand and Arm. Amp^tffition. Jtecovcrif. — A
^1, 1^ yoara of tige^ of a dclicAtc constitution, received nn in*
ji]r3^, when two years old, in the pnlm of her hand, from &
stone i and, very shortly nftcrward, n email piilantin^ tumor np-
pearcd there. Twelve years nfterwnrd» ^he entered the HoBpit&l.
At that time, a large tumor occupied tho whole hand, held oa it
were, in the palm. It waa tirui at some |x»mte» soft and pul^
eating ot cithere ; and eecmcd to have mflde ila way backward,
fio OS to give the idea of all the bones of the hand having been
flattened, and formirg a shell to it. On eompresfiin^ the tumor,
it hod a powerful ancuriHmol thrill ; and, In some ]\nrts of it,
the blood seemed to be contained in Inrge ancunsmtd eaca ; at
others, arteries of the size of the carotid could be detected. Am-
putation woe advised as the only rceource, but dceJiiicd. A cast
was made of the arm and band at tbo time.
In addition to the tumor of the palm of the hand* there was
also a tfiipplemontary tumor, quite firm to ihc touch, reaching Up
the whole fore-arm under the muaclee, without pulsation.
In the epring of 1857, she came under my care again, the
tumor bavjn;: more than doubled in size, and the Bwolling on
the fore-itrm increased in a corresponding; manner. At thia
time, a distinet aneurismal thrill attended the pulsalion of the
brachial artery; and the surrounding veins were in a highly
varieose atatc. On au@cullatJon, tbe tumor of the hand gave a
pouud like the noise of the machinery of a factory. The arm
was quite unwieldy, and at times very painful \ and the
dieensc was rapidly increa^ingn The surf?;eons of the Hospital,
in consul til ti on, decided thut amputation was the only means of
relieving the patient, but considered that there was a possibility
of mectinj^ with erectile tis*5ue in the arm. She was ^juite timid,
and unwilling to encounter nay more tlian the ordinary danger
^m an amputation. She therotbrc returned home ; but,
subsequently, the |>ain being so severe, and tlie tumor making
advauece, by the advice of her phyeician, Dr. Jones, she came
to town, and submitted to the operation. In making the com-
preesioD, it was deemed necessary Eo place a tourniquet quite
high upon the arm, and ictew it up so as to forcibly eonipreee
4&2
ARTEBIBS AMD VElKfi,
»I1 the tisBUPs- Npnrl_v tvrcnty vesflpl^* Itoili artftriefl and veinn,
reqiiirei] ligature, a^ iL was soon Itiund flml tJie veins carHeil
BxterlH,! bloixl, and were (Itsjiai^eil ti> IhleeiJ. The cjiiflntity of
blooil lost Iji tlje uperjitlcvn wue emdl, mi nccuuiit uf tlie very
etfectuuj way m wiiicli die rmiijjra^Rion wn^ a]i^>LjeiL
Od the duv ufter the uperatioD, there wb>« a great re-4ctioD ^
and t\ua was sa violcot on the fbliuwtng flav. that it was fnund
Jiecefiftary la take Mood from ber, whith waa done wilh re-lief.
Tlie wliole htiinip, however, whortly I»eeanie nf ii fiery red color;
and a Jiffuse jiajufijl swelling appeared in the n«:k, abi>ve the
ciavicli;. In a week or ten diiya, thia sulwiiletK but one innmiug
it WHS ohserveil that ihe breast had sujclenly become [lufled up ;
and, a day tir two afler, a great quaatity uf pus was discharged
through an im'Jsion at (liii^ point.
After ii very long convaleaeenee, flhe went home nearly welJ-
During the whole of the afler-lreutment, tliere was do hemoi^
rhagc from the stump, and no evidence of any erectile tissue
reukainliigH
The arm was very beautifully injected by Dr. II, J- Higelow,
litid n wu-eful disset^tion niiide hy Dr, R, M, Hodge«. The whk
inje(^tii»n waw thiTiwn into the vein.*, and rpturnpil by tlie bracbii
artery. Tlie veins of the arm and hand wem greatly dilated^
and formed a beautiful baaket-work around the bone: in the
piilin of tht' hand, they couimimirak'd frody with the ai
which were dilated bo a^ to form what ojight be caljei] h
iinusea- The solid part of the roural tumor in the hand audi
fore-arm was fornietl of conden^^ed and infiltrateil cellular tiasue.
The specimen, Togclber with the east, wna prBsetiteil by me.
in the Warren Museum.
I savf her a year aHerwjird^, quite well, and wearing an nrti-
ficifl] nrm.
Cash CCLXVT. ^ V^}iotts Ereceih Tumtir of Mouth,
JAp^ and Tovi^ne. -^ A yonnir womaHj 19 year* ohl» entered
the Hospital, on the fL.»urth day of April, 1864, for a con-
genital Tenonfl tumtir, occupying the left side of the under lip,
which hung down lite a hag out 4if the mouth. Thp whole of
the interior of the left cheek wa.^ pervaded hy the tumor, an alao
VABCULAK OH EKECTILE TUMOH*
463
half of die left ^ide of the tongue. Tberc were Iraces «f it on
the velum pnlati. On the outaide of the fsuyj, a. huiidle of vein*
could be »ieeii niTining Troni the imgle of the mcutlif and a rouiid
mBRs [inssing up towjinls the ear» nn if from the liiTimr within.
The left imder-jaw waa excjivated hr the pressure of the tumor.
She hud been Buffering with choking tiims m the night, iippar*
ently from the obstruction caused by the enlnrged tongue.
I deeided to attack the disense by the ligiLliire ; and, if found
neeessary^ tc expose it by an incifiiou uuide through llie intpgu-
ment of the eheek, from the ungle ot'tlie moutli.
On the 0th of Aprils the patient being etherized, the mafls of
the tumor of tJie cheek and lip was seized with hooke<l foreepa,
and drawn outwards irom the moutli. Two needlei^, Hrnied
with atout jjgntures, were then piiased through the hase of the
tumor, at right angles; ruwt the ligatures, being out near (he
eye of the needles, were tied together, so nn to embrace and
strangulate (he whole maw- The tongiie was then seized wilb
forceps, and drnwn out of the mouth : a curved needle, armed
with u HtQUt ligiLture, was passed from above downwards through.
In the median line, just behind the tumor, and relumed from
below upwiinlj'. half an inch nearer the tip. The ligature wa5
divided, and the ends tied ao as to include nnd strangulate
the posterior portion of the tumor. The nnterior portion was
thcu strangulated iu a flituUnr mminer. The bleeding was very
slight,
'The tongue swelled eo na to fill the entire moutli ; and the
Buffering was great, both from pain and the obstruction to
breathing aud deglutition. On the tenth day, the slough from
lh(* cheek and lip separated without hemorrhage, leaving an
idcerated surface; and, on the eleventh dny^ the slough from
ihe tongue eaine away, with the exception of a portion included
in the posterior lig:Lture, which hung by a small pedicle.
Thie pedicle was surronnded by n ligature, and the day after
separated. She did well, nnd was discharged on the 6th of
May.
On the 17th of September, ahe returned to the Hospital for
the removal of the remaining jiortion of the niDvua. During
the Bummer, her health had greatly improved.
464 ABTERlEfi AND VEINS.
She waB etberized, and the tumor seized from the inside
of the mouth, with hooked forceps, drawn forward aa far as
poesibJe, and a double ligature passed through its base. The
euds were tied both wa^, strangulating a lai^ portion. She
did well, the slough separating on the tweliUi day; and, on
the 7th of October, she was discharged, apparently entirely
cured.
CHAPTER X.
INJURIES AND DISEASES OF NERVES,
IxJLiUES of the nerves belorg more ospeciaUy to militnry aur-
gery, ami have llierefore, uniil very laiely, been Ijtit little
atudletl anioD^ us, Tlic Lnformatioti given in the common
lianti-booke is ul?^o quite raea^, ami eminent authorities differ
widely upon impurtnuD poirite bmli of prognoj^Ia and tfeatment.
The iminediate effects of the diviaion or injury of n large
myvvs are the loss of *en«ation and of riioiion, and a dimitiished
pijwer uf rcaUiiiig changes of temperature, which would ordina-
rily cjiuae no inoonventence- Severe pain ia tiUo a very com-
mon symptom, bnt is not always observed until the lapse of a
certain time after tlie receipt of the injury. The Iobs of sen-
BUtion and of motion iimy be either temporary or permDuent^
M9 might natLrnllv be QX}>cctcd ; but the conneetion between the
precipe nature of the injuiy and the £ubsc?quent phenomeim has
not ot\eu htjen marked out with bo much exnctneau an could be
deaired.
The proposal of the plan of trenting nervous afTcctione hy
neurotomy involves the whole question of tlie repair of injured
and dit'ided ncrvea ; a fliibjoct not very fully discuescd in n'orka
on surgery, and therefore not very funkilinr to praclicaJ eur-
geone-
Aa regards the question of rc-union of the two endo of a
divided nerve^ there ia no doubt that such a result often occurs.
A fiiiffitiont proof of this fuct id seen in the rcetomtion of ner-
vous ncijon in the trifnciid nerve, even after the removal of a
portion of one of its larger branches lor facial ncura]i:Jn ; ftlfio
in the occftj^ional rcproduL-tiun of the nerves in the fuot of the
horse, when divided or partiiUly cxeuul, to cunctal or relieve
6U
4G6
DiJUBIES AND DTSEAflES OF NESVKB.
certain forniB of Inmene&s, TIjc snine fact is aIbo pruvpc? pLysji>-
logiciJlj by ibe exjieiimeiita of Onuksbank anJ Haigliton tipoii
tLe vague of doga; and anatoiuiciLlly by Meyeri Svroir, TJed1^-
mnnn, and tiHiera* wlio lave acluslly traced tbe new Dcrvaus
fiJuiuciita iiL the cicatricial titj.fiueT uniting tlje rut euds* anil frllin^
tbe vtiid cuuseil by tbe excifiion uf a portion of several lines (luid
in one^caric nearly an incb) in lengtb. Clinical obfiervu lions
bearing upon tbe aaiiic piuiit are recurded by various nutliorj^.
Mr, Synte, in lu« " Treatise on tlie EidNion of Diseaw^d Juinu "
(Caae VITI,, p^^ge S8), givea n renmrkable caee, in wbirh llie
ulnar nerve wu-h wbnlly divided at tbe elbow, in (be oj^rmtiun
of excision of that joint, luitl in vvliirb die funotiuns of llie iirrve
were jierfectly restored in tbe course of a few weeks. A sul>
sequent disseelii^n of llie arm. less ibna a y(*!ir afVcr ibe O2>ora-
tion, rnvealed tbe fact thnt perfect iniion of die cut emls of the
nerve bad [aken place, and dial the nervous filaments oouhl be
traced from Ijotli enih into tbe intermeilinte new tissue, nnd
anpnrently also from one end to tbe otber. Ir a simihir raae,
reported by M. Rons, a pialion of the ulnar nerve was actually
cut pway : but, in the courae of a year, sensation had entirely
reuimeii ; and when the pHfiput was e?camined, fourteen years
aftet' the openition, ibe sensiitioa wns na perfect ns iu the other
arm- Mr. Paget alao, in bis Tabiable "Lecturea on Surgical
Pathology/ given cases of tbe return of the function* of tJie
nerves after ibcir division.
Tn view of these facts, it is important to in(|uire into the pro-
priety of dividing tbe nerve as a remedy for triimuiitic neuralgia.
In answer to this question, it may he stated, that, if tbe nerve is
simply divided, sensation will probably return before the tissues
implicated in the original injury have hn<l time to recover their
normal condition ; and thni therefore the operation will afford
only very transient relief, and may liave to be repeated several
times. If, on the other hand, a portion of the nerve is eicisod,
the restoration of the nen'ous function will be very much longer
in taking place ; but there will also be great danger that tbe
repair will be incomplete, or even that it mny fiul nltogether,
and thus entail permanent loss both of sensation nnd of moiion.
The deliberate removal of a long section of the nerve, with a
nrjURiEs xyn diseasrs of nerves.
467
Tiew to tho permanent nboliiion of ir& runciionr^, can he but very
rarely tnUtcot^, and then only its a kfit resort, as ihe ^oa-
BJble alternative of nrnputntion.
The rrLtionnl treatmenc of diese neurnl^"^ iiflVcrions seems to
Tnc to be based on tbe Tiict} tbat tbcir natuml teDtleucy ia to
recovery^ if only we gqd keep the pruient coniforciible, and thur^
itHluce him to wait for this tardy relief. Tbid can only be
effected by division of the nerve, or by the use, either local or
genial, of uarcoticj^. The protrftcted use of opium Internally,
in sutficieut quantity to relieve the pair, will almost inevjtnbly
exert a most pernicious infliiGnce on the health, while mere local
applications to tlie skin seem to have very little effect. The
great benefit which has been deriveil from the uae of hypodermic
injections of morphia for ordinary neuralgia naturally eugge«te<l
the propriety of trying them in thia affection ; and ti»e succesa
which has attended the experiment bos beep moat gratifying.
The following cofiea of severe traumatic neuralgia, which have
occurred in my practice^ serve to throw light upon eertuin
points in the pHthoJogy and treatment of tht9 painful attection.
In all th&9e eases^ the injury eeenta to have been to the tissues
Burrntinding a nervous trunk, rather than to the nerve itaelf;
and the immediate ceiusg of the painful affection wliich followeil
would seem to depend upon the effusion of infl[unm*tory pro-
duets within the dense fibrous nourilemma, thus enlanglin;* the
nerve in a mass of cicatricial tissue, perhaps also compressing
its Rbres. The highly favorable result, in die firet ciiae, may be
readily explained by the well-known law of development of new
reparative material, by which it becomes gradually assimilated
to the |iro|>er ti&sue of the part in whioh it is deposited. The
disflcction made in the course of the operation showed that the
nerve ivoa then firmly glued to the Hirrounding tissuee ; and it«
release from theae conneetions was followed by pertect relief of
the pain, which, however, returned in a diminiahed degree, an
soon iLs the process of cicatrization had again commenced. The
pain was then controlled during eix mantha by the daily use of
hypodermic injections of morphia ; and, at the end of this some-
what protracted treatment, the neuralgii^ atlection was found to
have disappeared, and the nerve hod «o far recovered its normal
468 WJTTKrEfl AND DlftZASES OF SEKVES-
(iiann'-rH The rtec<i[iil aiul ifiinl ca»en iii-e e^uall^v ini|)(jrintit, oa
ehomng tlie powerful eflect uf iIib narcotic [ojection ^ In the owe
Cube ill relieving llie pnm, ailiI in iLc other acCually curing it.
CAftlc CCJjXVU. — Severe Neuralgic AJecf*07). Xoltmri»rf
n OutiK/ifit Itfjiiiy ofthit Median Nertit. SiihciiCatieotiJt Tnjrc
tion o/ Morphia. Operaltfni. Injection <:ofltiinied Jhr nine
tnoiiihg. Ret-ovtry, — In the bccoih) Imttle of Hull Riiiir Lieu-
lenant A. was struck liy u ball, on llie ouMule of llie niiJ^lle i>f the
nnn> Tlic: IruH pusaed obliijiicly ihrough, traveri^ing the bic^iiji
mu^rle, B.ntl *nm\\iv^ out on lIji: in^^ide of Llit.' zirio. Fur twu i>r
ihrc? cinye, he wils exposed to ttie weather, lying under Uie |iifizza
cif » huune. having; Irut iitile fuofl, nod ^^I[b M^ hnml constaintly
wet with the rain wlu:',[i was falling- Tlie Wid wna benumlieJ ;
but he floflf^red stime^vhat w\i\\ a sen^iition of bent in iC, whicli
was |>artially relieved by kecpng it espo^ed to the wet* Tliere
wiw no jMiiii in the woinid ilJ^tlf. Shortly after, be was reniwvc-d
to Washingttin. where be first ex|)enencH[ very rte\ere pain in
the whole hrmd, Imt more piirtit-uWIy in the jiart of it au|>[j]ieJ
by the medimi nerve. I wiw him ubnut a fai-tnight aAer the
reeeifit of ibe injury. lie was then in (^instaot and severe piun
in the bund ; mi niueb eo, as to require to be kept more or lese
under the Jiirtuent* of morphia, which be waa tJ^klu^r to the
nnioiint of a grain a day. On exainhiing the pomi at which the
wound waJH received, a pockereil ej*diar wa8 ^^een, with an indu-
rntiun extending deeply into the lielly of the bieep8 mnatdeT ti>
wbi[^b the skin waa ndiierent. The situntiou occupied by the
vesaelH and nerven, on the inside of llie bicvp^, was also tnvel-
oped In a lua^ of indurated ti^triuc. The ftr^t idea suggeet^ hj
this slate of things was to cut down upon the nerve, and divide
it. It seemed, however, possible, by the gradual ehunge g^^tng
on in the tiBsues* that a healthy action might uUtmately be set
up ; and, at tlie snnie time, the indurated tissue auiTtmuding and
compreH^ing the nerve might }>t abacjrbed, finally relieviug tbc
nerve fnun preeaure. The jpiestlon wilh, wbefher ihe suffering*
\j{ the patient could tx! fiuffit'ienlly niitispilefl, by artifieijd means,
Co allow of the adoiiliiiiL of a tenipori/ini^ couree. lie Avaa ad*
)
n?AUMATlC NEURALGIA.
469
vised to plitcc the limh perfectly at rest, wear it in^iUc hU clothoe,
next tliu Wlv^ iiud ii> havo ti sleeve mado of eljcet Jndiu-rubber
to cnvdop the luwor jin-rt of the arm, whk-li coverin"; was to he
removeJ from time to lime, the nrm exposed to the air, anJ
washed with &onp and water : he was directed to Jiscontinuc tlie
use ut' tiio rubber elccve if much irritation waa set up in llie ekin,
and to envelop the arm in Dannd inatend, which he hnd pre^
vioii^Iy ftmnd ncce88ary, owin^ to the gr^'M reduction oftemponi-
tiire» He went home, and tidlowed tiiis plan for throe ar four
wcekfl- At the end of tfiat j>criod, he come to me t^nin, with
the deBJre of liavln^ the nerve divided; as hic^ BuEfcrings hjtd
become so intolernblef in spite of tlic u«e of opiates, ne entirety
to deprive him of rest, liefore ro&ortin^ to an o|>cnitioii cm the
nerve, I determined to tr^' the etfeet of eubcutanetma injcctione
of morphia. Platf a fjfrain cf sulphate of morphia, in bolutii^tii
wa* injceicd deep under the skin of the tbre-nrm twice a day.
He wae at once placed in n etnte of oompnrnlive case; and the
evening- injection ^five him a good ni^ht'e rest, duch as he hail
not eajoyed for many wecka. Thi-s phin wne followed up for u
month, with equally ^od effects ! hia digeelioii was not in the
least aflreete<l by the iit^e of the morphia, and he gained consid-
erably in tlc^h. If, however, the doj?e was omitted, the fHim
became as severe as ever> It was therefore decided to perform an
operation. An incision of throe inches in length was made over
the inner cdj;e of the biceps, and the integument dissected on
both fidea separating: the oicalricee, eaueod by the entnince and
exit of the ball from tlie eubjuccnt tiaaues* The indurated ma^fl
which surroimded the vessels and nervoa was now cut into : an<]
the mLHjian nerve hdii*; diwcovcred, where it entered, wna gradn-
njly laid bare and dirteeeted out, bo that it lay perfectly ]o<^ee in
the wound fiir an incli and a half or two inchea of its length.
It was thought be^t not to divide the nerve, but to await tfic
result of i\\a healing of tlie woimd. Tlie edgea of the wound
voro loosely approximated, and water-drci^sin^'* applied* For
some days the pnin wa^ entirely relieved, allhoui^'h, from the
effect of the habiliLal iLr^c of morphia, a qmall dose wi]^ rccjuireii
to promote aleep. As the wound be^r^tn to heal, however, the
pain recurred, but with much less severity than before* DcHiring
470
INJURIEa A>'ri DISEASES OF NXItVCS.
aovi tn return licjine, OEC of h\s fnmilj' waa iii^trui'led in the u^
of ilie pul>culjiufc.ma ijijection of moqiliia, Abutit two raontlu
Bfterw&rds hi; called on mc, nnJ agnin (March 20, lJf03) four
lDD[il}i» after the operation. He wns tbcn in a state of |>erfect
bc^lUi, nnil htiil r;jiiu(?d uiiicli Qeeh, but eoinplainra:! 9<lil] uf
reuralgic jiaiD in the hunilt requiring tlte emfjluyiucDt nf the nar-
cntic inj(!L-tio]t ; wtjether Tr^m habit or not ^^itnied lt> be u ijtiea-
tiuu. Tbe ami, lianU, unci fingcra haU heguu lo iLcquire :?K>me
motioii. In regard Li> tlic Iticnl ufTtit uf lLc injecliunB, It iitnv he
Ba'iilt tliat. altlmu^^h Uiey Lad Ijcen uped twice a day for 6ve
muntlifi, hv hiid never euffi^red from any irrEuilou at tlie |ioiDt
of ^unoUire, except in one inshinrc ; in ibc en*e of a IVeshlv pre-
pared Aolulion of sulpbate of mor|]hia, tlic uac of which yva» ful-
Idwed by tiie production of n lari^e red blotch, wlienever it was
injected. On eLiballtLiting a Boliitiun of Eicetute of morpliiut no
farther trouble uf thia nature wru experienced. This atx-'idenC
IB probably to be explained by the common practice of ndding
frpR nulpfmric acid lo promote the fiolubililT of certain specitncn^
of sulphate of morphia- The acetnle le» very soluble iii water.
Tbe [latif lit had lind nearly three hundred injections of morphia ;
and, with the above exeeplion, no traced rciuiiiQed of itn pro-
tracted n^ei
Oct. 2f>, ld6<S. — I J4nvr this patient, and found that he had
recovered hia licaltli* and enjoyed complete immunity from prtin.
The hypodermic injectjons were continued until the nionlh of
July, or about nine months from tbe receipt of the injury. He
then, by a gi'eat elTort, enddenly dltHJoutiuucd tbeiu, anil hml
not used iheni sincc^ The neurul'iic uflcclion. except during
extreme changes of tbe weather, had left him* The fore-arm
liad recovered its natural fieneibiiity : he bad tJje power of coiu-
jilcte flrsion of the elbow, acid of partial rutation of tbe fore-anu ;
while the fingers, which were formerly held in a state of exten-
sion, could be approximated to tlje thumb, so aa to make the
hand useful for moat of ibc ordinary puqtoeea of life. Tiiia
motion waa continually improving.
Case CCLXVllL — Qunskot Woaml (yf thnThirfh^impH-
caliny tks Sciatic jVcryc. — In April, IS^J-l, I had uiider my
A
TKAU5IATIC NE0IULGIA.
471
cure, in the Hospital, a soldier, wbo, two m'tntlis before, wii9
shot in tlie tlii^'h, anil t:tkon prisoDer, The hall traversed the
thigh from side to «ide, anJ prubably injured tJie eciatlc nerve, in
the immethftte neighborhood of which it must have jjassed. He
suffered no inconvenience in the site of the wound ; but, shortly
r»fter;vard, tt severe neumltfic [rain ooratncnced in the sole of tlie
footf flcconiiia.nied by a sensation of heat and grent toniiernefl« of
the part^antl entirely inoapuoitnTing hini for li>cohiotion. 0]>i!itos,
in tie usual form, gave hiiu but little relief; and the only iiJleviii-
tion of bis stilferip^s^ while in prison at Hichmond, was obt'iined
by keeping the ]cg constantly plunged in u pail of told water,
I ordered the aubcuiant^oUA iiijectiou of a quarter of a grain
of morphia daily into the leg, and g^-jidually intreaaed the dose
to a ;^raiu a day. By thii treatment, the poin was completely
held in (ihcok, renderin;^ his davs and nibble ccimfortable. Tlie
full etfccc of each do&e waH obtajued in from five to ten nnnute^
ftfter injecting it. The patient left the Hospital very much
relieved; and I lost siglit of him afterward.
In tho cifur^o of this case, I exf^eriniented as to the eflect of
the injection, when made at a distant part of the body, as com-
pared with its effeci when applied in the inimediafe vicinity of
the affcctod nerve. I found that, when the injci^lion was inaile
in the opposite limh to thnt affected, the relief was ae prompt
and as complete oh when made directly over the courae of the
nerve ; and this occurred repeatedly, in every inslanee in which
it wae tried. This ia a point of very considerable importance,
imwmuch as it ia otYen very ineottvenient to lunke the lujection
in the exact situation of the alleeted nerve, n» has beeti utrongly
inaisied on by aeveral writers ujwpn tbid suhjecC.
Case CCLXIX. — Ltjurif gJ the Uhiftr and Mttucnh-
Spirai A'erpes, from a BitlleC. — Captain C, who liod already
been twice wouaded in the thigh and leg, in the battles of AV^in-
cheater and Frodcricksburg, was struck at the battle of Getlys-
burp; by a ball, juaI over the median nerve of the arm. Ic
pasecd in a spiral direction around the bone, and came out half-
Wity down the limb below on the other aide. The hand and
fore-arm were at once partially paralyzed ; and, in a day oi' two,
47«
ISJUJUES ANB DISEASES OP NERVES.
very severe neuralgic puina comnienceJ, prinoipailj in that part
of tliG hand fiupplk'd by the ulnar nerve. When I first saw
hifii, ahout a weok nher tho injury, iho nrm was much swollen ;
and the wounds, whioh hud »tiJI on theni the colit water-i]iY!«»-
ing, were lu an irritable etate, and there was no appearanco of
HUppiiratioD. The Wiiter-dreasinga were replaced by r }eag9
warm poiiltioe : Jind, on a free suppuration beinp eat^Lblit^hrd,
ihe extreme [yaUx in ihe ann and Ixand wua much relievtil. The
pam, however, atUl t^ontinued to ret-itr at mterrals, fttid the par-
oxysms oomiuLT on at night were very severe, Finallv, the hv-
podennio injocilon of murphi» wm tried, and a einjjle doee uf
one-half grain afforded entire relief fur ihe time lein^ ; und,
iti faet, destroyed the habit so that the paroxyaiu* did not recur.
The hand and artu, however, for a long time aftcrwjtrds, wore
very unt^omfortable, on ncoounc of tho excessive boat uf tlio
pnrtd, which was only relieved by the oonstant use of cold water;
ftiid it was not iinfil nher several months thiit the normal scnei-
bility began to return, and this symptom to disappeiir. Seen
Again at the end of live muntlis, he was (Vec from neuralgic pain,
hud some use of his band, and tlie elbow had become flexible
after eniphiyjng foreible ejtenajon to overe^jme the etitlbess pro-
duced partly by inaotion, and partly by tlie contraotioii of the
injureJ muscles. The movement of rotation of the forc-ann
had not hL-ou tf^eovered, although it could he easilv luudo hy
a second pcr^ou, Uie nervous power being titiU dtficieut.
Tlie three cases which follow are instancea of excessive neu-
ralgia affecting tbe inferior dental nerve, in whbih all known
medical means had been resorted to without avail, and where
life had become insupportable. An entire reli<?f w:i* the result
in two of the caiies, and a partial relief in tlie other, by trephin-
ing the inferior m3-\illary boue near its angle, exposing and
exeiaing a portion of the nerve as it lay with its veaseU in the
bony canal.
Cabe CCLXX. — Facial Xeuraigia, TvephminfftkeLow-
et'JatPjfinJ I^emoV'if of u portion oft/ieIiifei-wrD&r>lul^f>rvf,
Partial litlief. — In October, 185&, a young man, 23 yoore
FACIAL NEDltALOlA.
473
^
of age, entered llie Hospital on account of facial neural^ria, of
two or three years' Juration, in the rij»]it side of his fac^. When
the pain £r&t appeared, it waa attributed to carious teeth, which
were removed, but without relief. The pain was very severe
iind jiaraxyemEil, occurriug after ajiciikirig or eating. Brisk
friction gnve lempnrafy relief. He wna trauted hy tonics and
narcotjca iuternaUyt and hy hypodermic Injections of morpliia.
The eitract of conium, in dotsee of five grains, seemed to give
motft relief. On Nov. 12lh he was diflclmrged, relieved.
The relief, however, was only temporary. He entered tlie
Hospital a^n, Aug. ^0, 1801, Meansvlillc he had been oper-^
atcd upon, and two ner^'cs divided In the U[)per jaw.
His jaw was now trephined hy one of the surgenna of the
Hofipital, who removed a portion of the bone half an mc}i m
diameter, with tlie contained portion of the inferior dental oerve.
He had entire relief for tliree or four moulliH, at the end of
which time he expeneneed occasionally attacka of pain s their
severity and frwjuency inere^n^d ; and on the 22d of April,
l^Co, he agiun entered tJie Hoepitul, and came under my care«
Quinine and Fowlers Solution intci^ally, and aubcLitaneous in-
jections of morphia, were tried without effect; the pam rather
Inereasmg. He insisted on another operation, wliioh was done
on the 2-id of May ; being, of course, under ether. An incision
ODU and a half inches long was made [larallel to the body of tlie
jaw iiejir ita lower border, and anotlier one joiiii[ig this niatle
along the edge of tlie ramiL'*. The flap wa:* dij*flerte[] up, e^ipos-
Ing the hune. A portion of the ramus near its junelion with
the body of the jaw was denuded of its [jeriosteuni. A piece of
bone half an inch In diameter waa now removed by a trephine
juet below ibe inferior dental foramen. Great care wa* necea-
Bftry while trephining, in order not to fracture the jaw. 9f> much
of Its 0ub«tance having been excised at the previous operation-
Aller removing tlie bone and cxjitjsing tlic nerve, half an inch
of it was taken away. Temporary relief followed tbcojieralion.
Tlie diflca>e, ho^^eve^, afterwards recurred, but in a millgated
forni ; und his subsequent liistory is not knuwn.
It is important, where the bone Is excised oo the ramus of
the jaw, not to go above the interna] aperture, where the dental
60
474
DnJURIES and diseases of >'ERyES.
lb.
ntii
tlic whole eub^f-nm
nerve penetrates (tie jnw. utJienvise
ihe UfiKi will be removed ; aiiJ tht* guoCiitory nerve, a* it pa*«e
elnng the Inner side of tlie nonius of the jaw* may be miAt&keii
for the Jnfcrior dental nerve.
Case CtXXXl. — Neuralgia. liclief btj Trephining the
l^oiocr Jaw-bone Jttr the Jicjnovtil of u^ portion of (he Tiifcriar
J)cntat JVe^^'f. — lu July, 18-17, Dr, J. C. Worren removed
a i>iHtion of llip inferii)r dentsil nerve by tre|ihining the hotly
t>f tbc j»w in iL ]in\y ^("tj-nine years old, and thus afPanled her
relief frtim on exrni minting neumlgia of iJiree vents' standing.
She Liid D(j recurreQcc o£ tlie pain until a year after ; and then
the suffering returned, and became so eevere as to confine her
to the Ik?i1. She waw unable to eut ur ppeak witlwut eiiuamg a
puroiysm of pain. The pain CLJtumenced lit the louver jaw^
always iit the same e^Kit, and thence exteuded over tlie wbolc
side of the fai^G.
A year und a half after the opf-nilion, hi^r son, a laedicn] n»ui,
applied to me, saying ihiit sometliin^^ must be altcm^jted for h^r
relief. T suggesteil an opemiion Jiir tn-pbining tlie jaw raitluT
hnek than hml been done befoT-e, and rennjvin^^ a portion of ihc
nerve neur where it enters the inferior denlnl i'oramen. This
waa rendily aji;re£^ to-
An mdj^imi being made from the sigmoid notch down to the
edge of the jaw, the parotid gland wna raified and tuniod back-
The lower portion of the ma&aeter muscle was now dis{*ected upa
and a ^eetiun of bone removed by ineimh of (hf trephine iuid
chisel. Half iin itieh of the i^aw fidly expitfipd nerve was ei-
ciaed. The inferior dentij aviery wa» nnavuidably rui and tied.
For Gve or hix days snbsequenlly, there was a slight diachnrge
of Baliva from the wound, owing to the interrerence with the
parotid ; but it healed favorably, and llic operaiiun wa* aliended
with die most t^omplcte relief. I heard from the patient a yenr
nfterwiirda, and there bad then been no recurrence of tlie neu-
nd'Tia.
I
Case CCLXXrr — Facial Neuralgm. Trephining the
Jjototr JJiw, and lif/novti! of a jmHwii of the InftTior DenU
NEURAiaiA,
475
_^pri*e- — 1858- A Indy, nged 40, hnd auffbrc(l for eight ycnra
fr*jin ncuml^if nttaoktj in the ciglit aide of tlie l^wcr }txw. At
timoa, the poin was oxoruciutiiifr. During this poi-iud» every kind
of trcatmcDt tlmt tho bcst-dit^cctcU ekill and jiiJgnient couEil
dictfllo was employed, but svilhout nv:iil. All the teeth in both
jaws hud been extracted, but with only temporary roiief, J was
called in consaltation in 1954, and then advised nn operation;
but she declined to undergo it. The pain extended IVoiji tlio
jaw to the upper pnrt of the face ; and her suftcringa becnnic so
great as to contioc her to her room, and reduce her Atrcngth,
Por the greater pm't of tlie eix months before the oj>eration,
fihe WLie kept under tlic iufluenee of inorphi.i. The eljghtest
motion ncuT her, i>r an unexpected draught of air, were tfuffi'
cicnt to exeitc an atlack. Under these eireuinJ^ljLiiccs, liuding
thill all the means tried hnd fuiletl to relieve lier, she eoueented
to ail operntion.
Under ether, the jaw was exposed at the edge of the modseter
muscle ; nnd, tlic Utter bemg raised* the trephine wns applied,
and a cirele of bone about half an inch in diameter removed.
This opened the inferior denial eanaJ. The nerve was now lifted
on a probe, and as large a portion of it us tlic aperture would
adroit of excised. It wtia ngain divided where it idaucs from
the mentid foi^nien. The cnhirged And irregular olreoEar pro-
ccoacs were next cut away witli the bone forcepa.
She recovered rapidly from the operation; and, for a year ^
enjoyed entire immunity from the neuralgic attacks- From
that time to 1867, a period of more tlian eight yenrfl, there were
ueeasional paroxy^^me of fuciul neuralgia, widj coni^tdemble gen-
eral nervous dij^turb^incc ; but she luul not been eoniined to her
room except during theao attacks. During the intervals, aho had
been in fair hedth,
Case CCLXX1II-— iVeMm/jicc, Exciiiion of the Digital
Xftrvfi of thu Forefinger^ — A lady, 35 yeai-s of age, in 1843,
woe seized, v^hile pregnant* with a severe pain in the tip uf the
forefinger of the right hiiud* The only Ciiuac to which she could
attribute it was the too free use of the needle. The pain Itad
gradually Incrcaaed, affecting the arm and shoulder, and finally
476
IKJUBICe AND DISEASES OF KKBTfEfi,
Other parte of the body on the enme &i<ie. Every remedy
which the experience of dietioguisheU Burgeons in the vicmity
coidii euggcat Imd been iaeffcetuolly tried. Aside from the
above diaense, bcr health vftm ^'ood, aud she was in ^0€>d eoc-
dition. The Qppcnrauce of die finger was B^jmewhiLt red, nnd the
motioD« impaired. The elifrhtest examiDfltion caused exceeeive
aufierin^. Although iiirorriKHl tliat the tu^eees of an operation
was doubtful, she consented to As peribrmance, and it waa
done in the fallowing manner : —
After she wns ethemedT an inciaion was made a little iti
front of the Inner aapect of the firtit phalanx of the finger, tJie
digital nerve exposed, iLnd about half an inch of it cxci^tHl.
The same operation was repeated on the other side. The end
of the 6nj2;er became at once benumbed, and the pain <;c4i3ed.
She returned lioroe five days after, free from paiu ; aaj, iwo
mootha later, I heard that she was perfectly well.
The operation, so far as T have since learned, was succe**Ful ;
but it must be confessed, that, in operations of this kind, the
relief is very apt to be but temporary. Howerer., a initigiition
of suffering, even for a time, renders it worth while to portbrm
it; and 1 am not aware that any permanent ill effeote ari^e
from it.
Case CCLXXTV. — IuJut*!/ of a Nerve from Puncture \cith
C N^ecdie. Tretttment leithoiii tjtt Operation. Cure, — A ladv,
35 years of age, of delicate organization, was sent to mo, for a
stiflbcea and loss of use of the thumb of the left hand, owing to
an injury from the priek of a needle, received about a roontb
before. The injury was not attended with much pain at the
time, but an irritation shortly commenced in it, which extended
up the arm to the shoulder; and, ^vithout much apparent in^
flammation of the lymphatics, a Ewellin^ took place near the
axilla^ wliich suppurated. The whole hand bocnuie more or lesa
etiiT and useless.
When I Hrst saw her, the thumb itself was entirely im-
movable : any effort made to approximate it to the forefiDg^r
enucied ^eat pain, and th? whole appearance led me to BUppoae
any attempt at restoring its motions would be likely to result
TRjiUUATIO NETJRALGU. 477
in failurCi I recommended to her a toric course, nnd free cx-
^rciE^e out of doors; to balhc ihc whole arm witli vrarm bull nod
wnter twice a day, and the liand anJ t}miul> with nn niLodyno
embrocation, allemnCcd witl» frictions of sweet oil* The thumb
itseJf was kept coiiataotly wiirni nnd tiioidt by the use of & looae
cot of oiied silk.
Under this treatment, more or less varied from time to time,
the pjitient very gradually recovered n little moCioEi in the thumb.
The imjn"ovement, however, was very alow, and ecnrcely per-
ceptible from week to week ; and it wae many months before she
could allow the paeaive motion even of the pftrte. By pcrscvc-
rnncc in tbif^ course for nearly a year, she uitirnately reeo^-crcj ;
and I saw her eonie yeara afterwards, when she consulted me on
the case of one of her children, without any return of it
This treatment of wnrmtb and moisture, with entire rest of
the liiiib, combine*! witb an invigorating course for the general
health, I have found effectual in n number of cases.
Case CCLXXV. — Ncurtdgla of thf^ Forefintjtr front rm
Injury. Op^raiion^ — In December, 1861, a y^ung raan, 19
jearaold, applied to me to amputate the forefinger of his right
hand, on account of jta cxcc^dively sensitive condition, produced
by an injury which he had received nine yeors before, Tlie fin*
gerbad been caught in a fulling mill, the soil part? lacerated,
and the bone^ enished, Under the skilful care of his pliyt^jciun.
the finger was eaveil, with but a partial stiUneas of the pbalangeji]
artioulationa. The skin, however, was lefl in a state of exalted
flcnflibilityj eo that he could not bear the slightefit contact of it
with another body ; making it almost imposf^ible for him to dre^s
himself, or to pursue his ordinary avocntiona. When he con-
sulted nie> he had undergone almost every conceivable kind of
treatment, and was desirous of relief from further suiferin'r.
even at the expense of amputation. 1 proposed to him, before
subfuitting to its removal, to make trial of a course of treat-
ment which I had found succcaflful in a number of similnr cases
arising from traumatic causes. This was to keep the vvhole
Limb in a state of perfect rest, confined by a sling beneath the
otothee, eo that the act of drcesisg should involve no muscular
478 DTJUSEES AND DiSEAflES OF NEBYES.
exertion ; aecoDdl)', to keep the whole capillary circulation of
the arm atimulated by wearing a sleeve of oiled ailk, extending
^m the shoulder over the hand, and closed at the end bo u
entirely to exclude the atmospheric air ; thirdlj^, to be puC
under a full course of the iodide of potassium. He agreed to
adopt this plan, and report to me in a fortnight; but did not
make hia appearance again until the Mh of March, afk«r an
interval of two months and a half, when he would not admit
that he had experienced much benefit. I now proposed to him
to have the finger girdled by subcutaneous ineisiona, bo aa to
destroy the whole nervous supply to the finger, sparing, of
course, the extensor and flexor tendons.
The operadon was performed, and resulted in the entire re-
Uef of the piun. Two years after, I heard from the patient : the
finger was then of good color, and free from pain ; but there
was entire loss of power over it, and it remained constantly
cold.
CHAPTER XT.
TUMORS.
tliB prcHuit chnpter. it U propoBctl to give in^trmopN of innocent
milignuit ramDra, witfi tlie a^>erationj^ for didr removal.
The subjei^t of tlielr i^athology will not be entered upon. SiDCie
the wiirk of Dr- John C. Wjiiren ud Tumor^^ piiblwhed tliirty
yejirrn mnce, the siihjecl has Lecn \i\j\y eliiboriited both in ibia
country iinJ Europe.
Tlie diagnosis itnd treatment of tuniora, and the ojierations
performed for their removal, eonstitufe ore of the mosl irnjwr*
tant de|»uitnieot9 of Aortrerj*. In miiny openilions, &uch oa tlie
ligature of artenefl^ amputations of tmiLG^ opemtioaB on the
bladder, Scr.j certain Rsaet rules L-an be laid down for tlie guid-
ance of the hur^rt'on ; but with tunmrs tlie vn>tv in dillt^reiit-
They are situaieil at times merely in the integument ; again they
are found di?e|>lv imberlded in tbe tissues, and not infrequently
involve importJint artcriciit, vein*» and nerves. For their siife
removal, ;i thorough anatomii^l knowleilge iind presence of mind
on the jMirt of the aur-geon are absolutely requisite. Thr |intir?nt
to be n[ierate(I nn should be well etherized, and in a re<'nrubpnt
potfiEion as a |renerid rule: ihe indHionf^ in ilie skin should bo
free, as tliey fiicditaie the Bub^equetit Hiages of tiie di^'^^eitiim.
The onvo|o|ies of the tumor are to be cut down upon Iwldlv,
wLlhout loo mui'b [>reliniin:iry disseenon. To the remrival of
tumors iVom deep and ibuigerous situaliona, it eb well to secure
the vessels as they are divided.
Qreiit cure h n^c^^Aary In the operaliiin for recurretit tinoors
Hituatet^ deeply in the neek, iVoin the ndheHon^ and at times in-
eorjioradon widi ihem, of iiiiportnni vessels and nerves. The
question of tlie propriety of openiting upon leucocythieinLC <r\iin-
480
TUMORS.
►
I
dular tumora occurring in the neck haa recently arisen. The
true n.-tlurc oi' these growtUe wiia firet described in 18'15, by
BeiiDctt and Virchow. They arc characterized by an inrrcase i>r
the number of white corpuscles in tlic blood, end are frcijiiendj
cu-cxisDcnt witi] an enlargement ^i the aplccn and lynjpliatic
glande. They arc ueually seen by the surgcun aa a mass of aoft,
muvable ttimor« in the neck, and are a Bourcc of inconvenience
in respiration ; but do not, as a rule, give much pain. In tboec
that I hare seen operated upon, eonie have rccovere<l, others
have died ; the di»eat<c in the latter being found to hnve csicn
aively invaded the glands of tlic cbcatp According to the prcACitt
alate of our knowledge, when other treatment fnila, the tumors
may be removed in the hope of relief or palliation, juat as wft'
operntc upon Bcrofuloua glands or malignant growths- Thft
subject, however, reniains undecided.
The question of the removal of niidignant tumora by surgicai
operation haa been a eubjcct of Ji^cus^ion from the time of the
Father of mtdicinc. It wnfl the opinion of Hijjpocratcs that tbft
diecaac had much better be Icfl to ittielf ; and that the patient
died sooner when tlic attempt was made to remove it, tbaii wb
it was allowed to pursue ita natural courac* The anme view%
flul^''tanlirt]Jy. have been held, untd within a few year;*, \a En,
land and the United StiUee.
in a report made to the American Medical Aflsociation in
1852, aupporled by cases which had occurred in my own pnie*
tice, I felt judliticd in drawing the following conclusioDs : flrM,
That, in a certain number of cases, ninlignnnt tumoi's, once nv
moved, do not return ; aecondly. That, in certain uther C3isf*s, h
the patient, nfter an immunity for a longer or shorter ^leriod, fl
hw a return of the dise^ae, requiring a second operation, whir^
eonictimca provea eucceaaful ; thinlJy, That, although in a ^ireat
proportion of casea of extirpntiou, the diacaac returns, either in
the neighborhood of the wound or in aomc internal org&n^ yet
even under these cireumt^tnnceH, it generally re-^ppeara in a le<8
loathsome form, and i;^ attended with much lea^ eulFering, tlinn
if the original local didcase had been allowed to proceed io a'
fatal termination; fourthly, In conecqnence of the imuiiinily
from pain afforded by the use of nniESthetic agents, one of the
Tl'MORS.
491
mo^t eerioue of tbe old objcctiona to extJrpnttOD no longer
After aa expci'ieoce of fourteen years since thiM re}Kkrt was
made, 1 feeJ even rnort fully ci>nviiiPoi.T of Uif pTopriety L»f re-
moving muIi^Tianl tumors, — pnrliouliiHy of the bi-eaat, — except
in casea hi^ :iiarked impoirnient of the health from the disease,
or wlien there U evidence of d^id^ conatitutioniil infection ;
nud i\i\a opinion would be justiliQ<]« even if we uUmit thiit the
dieeiidc IB nc^er really df^iriij-ed by «ury;ira] removal, I qtd
fully continent, bowevcr, that, in a certmn number of instincea,
tljo discji^e is mdleally extiqinted by the i^peratioti- There are
etill ]ivin;r, j^nd lii jj^oiwl lie;tllh. tteveral [lUticnCa upon whom 1
o[>eratcd for uiiduul'tctl mali^^naiit diiicn'^e ten or fifteen yent^
eiiicc. I have also a jiuljent, now in n t^tatc of perfect lieulth,
in whom the cli&eiiHe oenurred five Bepnmfe thnea within two
yeurij, and wiit aa 'lilon removed: the hut liiuo, more than nix
years ago. In another cane, opentted on in 1859, in which a
Inr^ deirihous tumor of ihe hi-uMt wod nipiJIv approaching the
Burfaoe, the whole di^eat^e v.-iis removed, mid the patii^nt recov-
ered her health. At the end of eigliteeu nkonthi^, a tumor ap-
peared in the uxillu, wbidi, after nttniniD*; the ftize of an npple,
waa cnudeutod tVum muon^' the ^TCftt vesseld and nerves. At
liie end of n ycnr, a hard tuiiior, inipftrlintr almost a bony eoneu-
tionf nppeured nenr the tipiiioiia proe<?d« of one of the ilori^al
verteLriu : thig wur- uls^o removed ; nod the pntient finally dicili
with cerehml cytnptinnjii, four yem'^ ttftor the fii-tit operation.
X)urin<; rdi thid period, slie wiu dieerful ; und moet of the time
waa iiUc lo take km^ journeyB, and to enjoy the aoeicty of her
friends: the quettiun of canoL-r wuh never mentioned between
herEcdf and licr eur^^eon. Thin is an extreme eaflo; and perhnpt^
eome mi;jhl qucHUon the ohoii^e between a large ulcerated,
eloui^hinj; oaticer, and the alleviution, both nientjJ and physical,
atibrded by re[>cateil operiitions.
In regard to the propriety of o|>erfttin^ for the removal of
epithelial disease, oi' course there etm be no question: ca^c^
of cancer of the lip and of the fuco being of constant oci^ur-
rence, in which there hiu been no return of the disease after
its i^;ritovul.
482
TUUORB.
The cuncer* tjf the breast, which. According to niT experience,
licivc been ihe moflt paintUl, nipid, and ItjLst amenable 1o *urgicd
treatment, are tho^e derelopeU Juring laclftlion ; and they often
uccasiim great em barra lament in diagnosii?. Tlic breoat swcUe,
becoinea iiiUuraiLiI, nud [ire^enle the appearance nt an obstrur-
tioa in the laeiireroua ducts : !n epite oT remedies, however, ihc
hnrdncM increft^es ; tlie ekin becomes rough ami brawny, and
the whale organ solidly fixed to the ribs; canccroud tiiberrlr*
flppeiir in tlie vicinity: and the patient often diee with either
cerebral or spinal syrnptoms. The wound iimdc l>y tlie remoTAl
of u tmnor of this kind irt rviry large, uaiially involving ihf
loaa of the whi>le internment over it. 1 biive onte or twice
ijpcralod tor tbi* diseaae, — ni the eamoet ^olit^icfitton of the
jtHliciit, on acc^jiint of intense pnin, — dressing the wouml uncr-
wards with dour, which avoidt^ the necea^*ity of s-ubeequent ea-
poaure to the air during the dressings.
It ie not unworthy oi' notice, that in removing large tiiniorv
iin the left ^ide iff the chcet, over tlie region of ihc heart, grtrHt
ilcpreiision of the vascular AT^tein, attended with eymptonie of
collapee, ia often Been to occur trom the CipOflUre of the large
tijifare to the nir ; the [*yinpEmns diaappeniriTig aa soon as l\ws
wnniid ift c^jveredn I h^ive therefore made iiarule, whil<^ [lie
vessels are being aecured, lu espoae Qn\y ftfl eranll a portion ot\
the wiiiind Jia Is. abs^fliitely necessary.
The ijueatiun of the destruction of niali^ant disease hy meana
of cauatics i^ one of much intercut, the practtec havioj^ IouihI
holh advocates and opponents among men nio?t ilir-tiiigiiisheJ in
the aurgicnl art, CJrciit mischief la done in tbia nay by char-
latans, who liiake u&e of cmistics for the deatnietion of all kinds
of tuniore, innocent aa well as niidignant, whoao removal they
would never daic to nttemjit vvitfi the knife. The chief objec-
tion to the uae of causUca, in all hut a few cxcrptir>nal cn,fies, ia
the extensive destruction of integument, which often renders the
cure verj- alow and hn[)erfo"t> In ea^e.^ of ajmdl or aiiporfirial
malignrtnt lumora, capccially of the epithelial variety, canatics
Bometiinca anawer a good piirpoac ; but If the tumor ia large, or
deeply eealedt the proresa ia h^jth ttdiuaa and dif'^ating. If
inefficiently eni[iluye<l, they jippcar to do great harm by atlmulot-
inir the "mwth to increased action.
I
ruNGrm) tlsior of forehead.
4da
Tbe most eflit-ient eniiatit*, perhi»|is, U the cltlorulfi nf zint-,
marie into a pasti? wkli tiour, a\n\ jiknttd wt'll down into ]n<!i>iii>nff
made with the knife. Aoutlier, lulvociled hy Vel|»paii, and
I hc'lipvi? nUu hy Mr. Synio, consists of stronir >*iil[iliijric nv'ul^
lulxed ivifli Hmri-'iml or some veijetabic |iowder. Tin? tri'iitint-nt
nt' cjiiicpr wJtli tlie liy|ic»derraic mjectioii of dilntp nceiii." ncitl,
i lit null K'i«l by Dr. liroatlbeni* liiw Itiu^ly been nttrncting iniK-li
uttention in Kn^bind ; find, fnun the? evidence given in ilH
fiivor, certiuoly deservt^s a Inir trihl, SmiUI cancL^roue tulwr-
de« prolmUy olfer the beet aubjects for il. I hcive seen the
effect of it i>idy in one eiLse ; n l>Lrge» solid, fi\t'd [.mnur of il
hi»[>e]ei^A [.^Kiiraeier, fiitunted just behind tbu ear. in ii male palrenl
of about 40 yenrtt of a^. In this ciLse, the «uHzLce of tJie
tinnor wua first laid bire by a free iticiaion, nml tho acid injpcted
into its snb^timcG, Now, at the end of two woekn, there is a
di^diurge of thiuk, creamy pua from^ tbe eipiiaed part of tbe
tumor; and tlje Lulk of il — which yvus of a Acirrhoua lm.rdne!^
— has now a sort of spon^ i*oHnef*a- Tbe case was operated
upon, nnd is under tbe eare of one of my collen^ei^ at the
1 II ispitid '
III eimneulion with tbe ptiob>gy of cancer, l wonld sav, that I
have had wevenil wcll-msirked (;nHcs, in wljicb the dinihcaii* wbj*
evidently awakened by a blow ; the patient subsequently dying
of nialiirnant confititntiona] diseoae-
Tbe following unnmiaJ CBse of fungoid tuciiur, uppnrcnily ori-
ginaiin^r in the dura mater, operated on by Dr. J. C, Warren,
16 introdoL-^d here, with the eolored delineation of ir: wlni^b tbrina
^K frontispiece, on accomit of the remarkable featnreri i.'iinnccfed
with it. Tbe patient applied to me for advice imee or twiee,
tiunie years nffer rhe operation, and I have been able to folhiw
tlie bir^lory of tlie cone ^inee-
Case CCLXXVL — FHHffoid Tumor of the Fo^t^hwd.
(t>ee Frontispiece.) —"In tbe vfar I84li. a yniuig Indv ap|iHtKl
to me on iic<?oiinl of u Inumr oTi the forebejid» near the ri^ht
temple, having the aspect of a periosteal tnmor.
"■ I advised an incision across it, to ascertJun itn character, imd,
if found to be ftuaceptible of an operation, thai it >*hould be
484
TVMOItfi-
removcfl. Tliir- was Dotdono; nnt\ in October, 1M7, elwa^i;
preecntcJ hcr-eclf. The tumor waa tlii^ii of two ycnra* "T'^wlij
It woe of Inrgc ai^c, nppr^ii'hin^ thnt ut' n JcmoQ ; its eurh^
WAA ukornted, fiirpild, anU bl(»e*iiii^r, Tliere wa.s no pain iq ii,
nor any ccrcbnU urtcction. Under thcee L'lrcuin.^tniK-ct^, I nilriiit^
that tlifl tumor ehoulti bo cut out, if pi>&ct]ble, tiotl the hlc^hfr;
ptirtUt'c caiiicrized.
""Ui-'L 27lh, A projcctinj* fun;;ue, of two or thrci? iiichrt'
hci^lit nniJ widtb, wue iirst rrmovt'd, and eutticJcnt evidem
obtained of its bcin-c <>f a tiingcjid dmmcter, if any wt-rc waxit-
in^;?. The eiirroiuiding skin, tcrnpoml fnecia, ami musolc. wetv-
dividcd on cikIl Bide vi x\iC tuimrrt u^bJeh, while it CTclcniM
a apace three inches in diameter under tb« ekin, writi found to
hnve a cimtmctcJ cervix of not more than an inch nnd a half ia
diiimclci". Around thia ecrvis wtis fuimd the <^]^ of a fttrio-
ruted bone. An instrument, parsed alon^ thia eilj-e« enteral fbc
onvity of the cranium. The tLimor being cut drhWn clncic ti> lb*
bone, tbc aelual cnuterv wis nppliod by a Buceeesioa of JicatcJ
irons. There was a copious hemorrhage; but one or twro Vr^
turcfl only were applied. The patient, bein^ under the Influence
of ether, autfercil nothing:-
'^Nov. lith. The patient hnd no bad s_v nip tome after tlictop«nt-
tion. At thia time ebc wna fitting up, quite cx>infortablo, ainl
experienced no pnin in the hcwt. The wound, liuvvcver, had ah
uutiivorablL- lu^pecl i its edyes were ncurly an inch thick, Aud
Iiiid a putiy or swollen ii|JiH-'ftrnneD. The fun^Ti!* bad a^^ti ^hoC
up half an inch, nnd rcipiired the diiily use of cnuetic [Hitiv^h,
Krum thia thuc to the \Mi of December, the cnuetic wjia frr-
quenlly ripplJed, but wna fliihscrjucntly omitted \ and» on ihc I7ih
of Jfluuary, there was n ^mall thell of exposed bone to Iw ttiiitid
at llie bnttom nf the cavity* whioh wa^ about two linea in <Ilaiu^
ctcr, wilJi henlthy ^^mnulationf. On tJic 3lst of Au^'ust, it is
rcconled thut tiie wound closed soon after l^ann;^ th^ HciepitnJ ;
tbc nhell <>r bone prcviou.^ly described etill remaining in eitu,
none ever having come awny. Henlth good."
I waa conaulted by tliis patient some five years a^r, with a
slight nppenrnnCG of n return of the tunior* It, however, iliij
rot accm Jidpoacd to incrcaee rapidly ; anil us she had no auH'cr-
TUMDR or HK.Vn.
485
ini; fiMm it, ami her henhli wn^ not nffbctei], I did nctt fppi
diatJ^j^oil tr* interftre liy aixitlier gritve optnitioti. I kepi lu*r
imder nbservntii>n for n time, but finnlly loet Btgfit of her.
About Ten vnir?) nfter thin. I WH* cimwullwl Ji^'nin \>y the
fnthcr of the ^iirl, In iTgiml to tlip pnipn<^ty of nnolfier operHtinn-
He infonnetJ me tlint sho IukI since betn innrried, »ml ^^one to
Cnlitornin ; thni she ivitri quite well ; timt the tumor bnd pnr^
tially retiirni-tl, iinil tlint siie wrtft iWiroiw of knowing wiiPllior
another opprniion r*iuM ho [>erfbrme(K 1 ndvised hor n&i tiefure-
Tn July, l^lfifi, I learned the ff)l]owing pHilii'ulars from her
f'jiihpr. [She wjis ■Jtifl living in {'alifi»riiiB» ilihI Hidfert'il no in-
(.ijnv<"nieni"e frimi the tmoor. It h;ul wlowly (■nliirge'l, until
three yeara ng^i ^Itiee \^]ien it hud -undergone nti material
L;h:iTiga.
Ca^e CCLXXYIL — NxtrfioTduirrr^ Tumor on Me Ifrail
if n Yuiiiii/ C/tif'I rfinor4ul ftjf Operation* — Tlie following- awe
is thus deyrrifw^] h\ IV, J, C.
Wnrrrn : — " Tn the munlh
of Api'il, I84a. Mr. , nf
nf>vrr» NMI., wrcite to me (o
ciiriit* to ihiit |ilii(;v, to pxion-
ine o tunnoT on the head of
his e\n]i].
"The cliild wiis a our^hiir
boy* fight months uhl, i|vnte
henltliy t a wet^k nfter his
birth, a tnini>r of th*? size of \ \^ ^^ \
R |ieri WHS (Ii«;ovored on ihe
back part of hi* head> Thi« m^Tease*] prettjr rapidiv, ami the
father at ont-c fonsnhcil ihe ine^licjil ifcntlemon in his viciuily.
Some thiiugltt it e(ii[jiK oiherji thooglit It t^niil ; vome nJvi»4H]
bim to huvc it desfnived by i^auHlic, and otherA to apply r Hgn^
ture about it- The latter atlvin^ buini; eoiipidprod tho mosi
safe, was adopted; n ligature wna licil nruund the ba^L* of ihe
tumor where it spriuig from die head, not tight onon^^b,
however, to strangulate it, but merely to irritnie the^ ^kin on
which tl was iipplied, whloh i)f course prothirod no iiopres«ioii
4ti6
TUHOBfi.
on the dbeoac; yet thia application waa rontiuucd fbr tluiv
months.
"Not being able to viait ihc pnlient, I ^vi«ie<1 that the rfiild
ehoulJ be brju<:ht to BoetoQi On the 3d of May, he wan aoccinl-
ui£\y bmnght.
'' Od examination by Dr. J. M. Warren and ciiyself, w« ruiioil
on ihc buck of tlii9 ctiild'a hc;uj u tumor alin^iat na lur^e ns the
heiul it^cUV of a globular tbrin. It wild clastic to the tuut^h, not
inidiiUiirig, itor ^enaitive ti> pressure* It retained the nMnnl
color of the «kin. except whci'e tbe arCiTtes and veins rutiiiJied
over it; these vesBeU were enlarge*], ainl tlicir hrjiitcJieA and
inosuulaiioiifl prL^sented a bcivutit'iil apiicanniL-c ; thei-e whs uu
pulsation, On moving the body of the tumor, it diti not ap^iear
to ailliei'ij cloaely to the bone or pci'ioeltuiu,
^ Fi'uni this cxEiiiiinjLtion, my opinion wn« that the liiiiiur war-
of tioljd <^rowCh, supplied by the vee^ls of the flkin and thitec of
the occi pi to-frontal niusde ; tlkut it wua not mali^mnt in char-
acter; tiiiit it lai^bt and imghl to be removed. Tin; fjneralion
was performed tlie day following. May 4, 18-13, by Dr« .T. M.
Wan en.
" An inciflioD waa made into each hide of the tumor, tYimun^
hcnding ekin onough to cover the wound, and tbe tuim^r rv-adilr
didaected olf from ihe bone ; six nrterles were tied, aud the ^kin
bi"oii;^'ht together by strifes of adhesive plaster.
"On examination of the tumor, I found It to be covi;i-^ nnd
insulated by a complete coat of cellular texture. Being tlividt^d,
it presented a very white, uniform, granulated texture, inipr-
rupted only by some irregular partitions of cellular tif^aue. TUe
microscope dij^covered uodiing beyond wbnt h<is been fituted
above. The most remm'knble circumi^tnnce about this tuinur
was its firmness, which was very nearly efjuni to tlmt of Gbrir-
cartihiginuua texture. On scraping tbc cut r^urface of the tuinor
with a knife, an opaque fluid waa obtained in conr^Idcrabk quan-
tity, similar in appearance to turnip juice and to the fluid
obtained by scraping a scirrhous tumor of the bre^wt,
"The wonnd, wbtch waa about Sve inches long, waa foimi]
united almost wholly in two daya after the operation. The cliilJ
hjtd no fever, nor any sign of indiapoeition ; but, on the contrary*
ti;mou of iirah.
487
Axprceaed lir its movomcnis a feoKn); of relief fi-om the cnc^um-
bmnce it hnU so ]f>ng borne. Tho diild being so well, ib<? pa-
renU, on the rliLrJ Uiiyt took it home to Dover, much gr'Liiitii.iI
with the result of un ojienition whi<?h they h:ul iiuagined tri be
luore foniiukble In its execution, nnd more protrn^f^ti?)! iu iU
conaequencei-
Hemarkn. — "The mother nttribu»ed the growth to her hav-
ings, when prefTtinnt, iioi-iiienrully stuml>led ovl'V n hsisket of
oranges ; ttie tumor rescmbliny this iVuit iii itji form.
"The diflsunilarily nf tbi^ turaor to the teilure from which it
ftpning would lead to the opinion of its helnr; n (*nnc?ProUf> for-
niiitkm. Its consistenee, color, mid the fluid obtained from it
by expresaioD, were tuoat similar to rhe apjx^JiniQcee in ^ seirrhus
of the brenat. On the other hauj, its perfect iiisulntion by a sue
from the surruundiniT lexturei*, the nsitnre of the eonnection of
this fliic with those textures, nnd their perfectly nalurs;! f^ondition,
eniihled me to assure the parents of this child that there would
not he a recurrence of the disease/'
This ease is interesting fi-om its resefuhlance to another turaor
which we oeeasion^lly aee ati?ijng in (he same t^itustion, imd
which Bpvingfl froru the interior nf the craninm, Mr. Costello,
in his " Cyelopiedin of Surp:ery,** under the lieiid of Kneephn^^-
cele, frive« a deaeripiion of the disease, with drawings, one of
which, with n broad hjiao, resembles the present tumor. About
the time ihut lhi# c^a?*? cnme under our cure, n clultl wnn bronjrKt
lo our Bnrp^cal infrrmary, with a con^nitnil tumor appi^rently of
& siinihir ehamoter. It was examined by many surgeons, and
ftuppoweil tn be n tumor, sprinjrjng frtmi the cranium, of an en-
cy?ued character. It wa* therefore decided to remove It-
The operrtlion was nearly coiiiplete<I» the diiiseciinn being very
euy, when it wn* fonnd thnt n small pedicle of the tmnor pene-
trateti the crmiium, or, in fiu.t, came out frL>m ir, hh the tumor
proved to be bu extension of the membranes of the brain. The
pedicle was diiMdc{l with jjrcnt care, and means were tnkcn to
prevc^nt any air from eominjr in contact with tlie interior of the
sac, tlio ftkin being brought together over it at r.ince. The pii-
tient, however, died in a few days, with cerebral symplonis.
Ir the ciute first related, it was thought possible that the diju
46n
TL^MOBfl-
siK!tiun miglit in ^>nie wny interfere whh the crnnuii okvhy ; ii«
rim of l)oim cinilt) Ltr felt i|iliti? ruuiid tlie circiiEnferctice of tUl
tumivr, j^iiiih nfi is mtt iii]frt*i|iiC'nrly seen where the Tumor bui
1ikI|^i'iI I'ur a liii>g tliiit !» cuiiUiut i^ith the cnutiuin, noil m]aA\
idwnyfl renderA tlie dJAvm^AtA a littJc diliii^iih.
TCMOUB in THE l-AROTID IEB010N.
'rijp lumore u^imlly riiiiiicl in iIila rc-ritm, eitljer oni^nutB bi
Htuiil] ^Uuid plucreil iivtr tlio fmrutiil* ur uri: eiii]>ei|4KHl in tu f*^
f4tJinoe, or iin- pliu'eil undtT its lnwor eilge, which ih expiinJrtl
U> fonii ji coaling over llie tuiiiur, msiklni,^ it iiec^e«snrv ta ditfft
thruuglk llmt jK>rtiijn of tin* {.'x^mndKil gland bf^furc the tnmiit U
rc;iL-]i4.-d. Thvy lire, for llie most ]>nrt, innocuaua, niid are re-
moved ^I'ithuut great risk, uliliotigli diimewhat vnscul&r. Tlv
tiiinorn of the [nirotid il«Of me [>f a serifnia uhnracter, often iif
a niiilignant nature, and tlien Lnually sdrrhoiiSi
A« to the practical questioB wliieh le atlea raiE^ed, whether [In*
gland cnn lie removed witlnmt the ligature nf the parotic], tW
resnic of mv experience \n ih'm : Tlie paniLtd ^lund tins Ix^n
removed liy me in many institneea, stime uf whit;h nro givva
beliiH^ : in none of them wnm tUe CArotld Hrtety tieJ. Ii^ »cil
rliims affL^rlionif, tvh€ire the gland nndergoes a grHiTiial indiirativrii
iIji* vpuseln are frefpiently pushed buekward, iW llitiy were in
or Lwo ol' The oa^e^ here given.
In iL CHbe mcntroitPil Uy Dr. J» C- Wfirrrn, the rnrotid
cut lit dii^ end of llie operuliiin. Tlie ve^^el wn« fieoured, ftfid
the patient did welh Tit \\ ^eeond cane for the removal of a
nL'irrhcajs prtroiid, in whicli 1 a.*fii,steil Dr. Warrpn* the carutidi
AviLH divideil and ilhI. TlirfU i\i\yn after. »& tlie jialient ivn«'
Bimining nl Ktoiil, tlie vpnsel gave way, and the IjIoimI strurk tli#
■spiling. He almost at onre fainted; and die tnende wer6 tor*]
tunafely eiti>] enoiigli Tu jihiee a sponge in lite woniiiK and to
eliei_'k the fliAv pjiriiidly. Being tiilleil, I at onoe tut dovm
upon tlie vessel in tlie neck, tied it, and eto[i[ked the furtberi
effiifiini of bhjinL Bi^rMrd, !n hi>i nnmc»grri[ili on tlii'4 iiiulyeet,
mentioii.t manv initliineeft of removid of thlr^ ghtnd uitlioijt hgatun^
of the cnn)lid, and (jiiulBa a caae of extiqiHtinn (if the parotid
PAROTirj TOMOlt.
48d
iy mv gnrndfatlier, Dr. Jiihn \V;irrcn. in 1804- remi>veil willi-
out tyin^ thw vessel, — the IVmhI iiecvt Ufing iliviilef], mid tlie
fe(?e paralysed . Tfie [mtient iJvtfl fifteen venM aftenvariU, and
died iii\ n diwose foreign to the glandular iiHeclion,
The folluwing cnscfl are iJliLHlralEve uf the abovt: fad?', and
also of Home pei^uliuritie^ in die nature of the tumora ihemaelves :
Case CChXXyiU- ~ P'trotid Tumor. E^.tnova/. — A
jounff miuTie<l wtunan entered the Honjjiliil in April, ltf-07. witli
ft EUTiKir [>r ihe parociii gland uf one yeur'H dumtiuik. Ei^ht
years before, ehv liad it turiiiir belnw und Iteliiml the. ri^lit enr,
whiL'fi wiw vt-rj' fiurd Jiticl nc;ra.*iim:dly jJididul : die integunieiit
wiu net dise^dored. Al die end of foiii' jrearji, having atltiiDed
the Bize of n roliin** egy;, it waj- rciiimed. The wound, she
tljink.H, never ciriitrized ; and, in timr months, the tumor, having
re-appearetl in tlie miilst of the scar, was again removed, hi
cEiurarter was ^itnllar tu die preceilLng. whh ihc exeepliun that
the t^urf:ic!e wftts niMluliiEed. The witiiiid liealeJ im iir>na1, but
the eiiiitrbt rettiuiiicd very red. In IH.O;"* tlie tutnur begun to
furm about in the name phtee^ and in 18rif] was as large aa n
hen*tf egg. pnijecling ivti iiuh. whh a nndiilated and red siirfaee.
lli?gioniiig L*'biw Llie ear, it priireednl upwiinl and forwnnl to
about half nn ineh in trant of the mcntus-
On the first dny tit' Mny- 1857, the patient being etherizpfl.
tlie diseased mai«s wna i^nrnKinded by an elliptical inriiHion. From
the mmatjon of tlie disease, the di^^eetion was mode very vliitvly,
requiring nearly nu hour lor the operation. At the lower part
waa a firm adhesion tu the fibres of the slcnm-mnstiiid mii^etc, a
piirtion of whioli wn^ reiikoved- At the ij[iper part, It was neees-
eary tu carry tlie dissection down to the artietilaiion of tlie jaw,
below and behind the angle uf tvhi4;b the dis&as<r dewend^^ dee]>*
ly^ rendenng neresnary the exposure of the leTubin of the digas-
trii'iis. Oil rair^ing the tumor tu cuniiniie the deep dissecdon,
\ioleiil effort* at vomiting, diffienlty of breatbing. and convul-
fiive retellings from die traction extrcit^ed on the deep nerves^
came on , ho that it wa^ neiTeiisary to desist, and destroy the small
poriiun of the base of the tumor with the hot inm. A few lig-
uturt^s were apfibed ; and tbe wound, rneasnriog three inches and
490
TlMORm
n UM vertlciJIy hy two irnnHventely, wn^ forerMJl br ■
cltttb. The growili ni<'n^ure<] vprtic»t]y three inches. Tlnfa
WHH mon^ or lc-^» luirnlvzeil itftrr tlic o|K*r»lion.
She \inH ili^char^L'il Irum llie lluts^^ilJiJ akn iIk^ I^iK nf Jae;
all llie diBcnao betng u]i]irkrei]tly removtrd, and rh« «v}i<>le n^
redHcefl h* ii Ji!imer(»r oi' vuc'iWnxl of an ini-li. In the nA
of Scjilt'Hibev fiillmvinj^, a k^ilcr wjia rtsH^ived, eavin^ tl«i !^
jmljt-nl rcniuined wl-11» and iIlc wuuihI wn« henlctl.
Case COIjXXIX. — SiitrhoaB Tumor f^f I'aroliri. /^
inov'ii, — The potient wue ti fHrincr, 52 years oJJ- T^vniT-fci
ywir* lM?ri>rc, u tiiiiior iiiatle its appearance in front of the at
This imi'rcn'ciil'ibly iricrcneed, giA Jti^ hinj no nam oc inom*'
iiioncc uiilil twi> iiiuiklliri iHrrorc the i}|H'raliLiu , wJi^^n it wta Injunf
Uy n hltiw, imH since then ni[iiill.v increased in nize. The W)|*i
'iflor llii" blow, he pcrceivetl that there was j»um<^ itison^thililT »
the Mi\ in I'i'ont t;t~ the tumor. For euiiic time, he iiml brra
iiDnhJi^ to clo£e llie right eye. "Ntjw tJiere is nn ov^, frfon^
ntijt, even, welWefir it'll tumor in front of the ri^bt ear, oW^
lyiii;^ the rnniLw of tlie lower jnw, and occupying ihe posilionf'
llie piirolid i^hmU. lla long axis ia parallel wjih n lin« dn«l'
from the nn^le of tlic Jaw to the externiJ nngle ni' cbe ctbil-
Ila }^rcuk'Pt [eii^'lik Ja [hree ineliee, width twu U^cUes. Upper
niMf;;iii ia uu n li^xid ^ idi ihe uu;;le of die eye ; lower mnr^io
Midi ihe an-^le of ihejnw; posterior la overlapped hv ^»xlffrftal
I'ur. Inle^iimtnt is m<n'rthle : not JiseolorecJ. Ttitnor is
firm eontfidleiit'o ; iii.fl tender on preeauic ; not altneli^d to in.
yet but filightly movoLiIe ; doea not move «ith lower jnw ;
not be felt in moutl^ Tlierc m uuich ntimbnc«8 of i-lieck jc
fi'unt, aod n dull, hut not ecverc piiin in the tuumr itself.
JJojfpitnl lifcoid*
When the piilleiit entered llie Iloc^pital, one or tivi> (rlnnds i
llie neighborhood of llie luinur "ere enlar;::eil. nppnreiiTlv fro
tlie effect of bOine iml^itiug application which hail beon made
it. Under Ercatment* tl^ese, with one exception, di5;i|ipc'art<l,
He was estreiiiely deslrinia of having the tiiinoi" reiiiuvetl ; ami,
iiri a e{Fn^iiltalii.ai uE' the eurgeoiis, it wua dix'lded that this sjitfu
iteuipied.
MELA-VOTIC TLfMOR OF PAROTID-
4»1
Tlie pntlcn! bein^ etberiKeii u'llh clilori? etlier, nn incision wn*
mndc from just above ihi; eitpcnor border of tbc lumor lo a Jitll^
1^ below it^ iDferior port. Tbis vas croieed by another incUion,
^ ooraraencinjij nf the tnasioid [irficess, and terminntixl on ihe L^heek.
Tlio fibrLUie i^apaiile of tlifs fjfltind wn** now put into, tind the tunioi"
groduallv InoeoneJ bv di^soctint; cnrcfuUv around its circtimfer-
[vnce. It^ ndbf^BioiiFi w^re eo close and the texliire ao lirmi th^t
tic WM found impriSBiHle to jirocoed oxccpt wJih preat oaufion ;
|tbe veadel^ tbnt were ilivided under tite ed^s of tbo tiiiunr bein^
mred with nitjch dIfiioLilty. Tho tumor wne first loos^n^
[from its atlaebment to tlm z\"p;omntio proce&fl, tlipn di^eooted
■from tlie mai^seler niuaelo ; the transverse facial ai'tery and the
[parotid dnet bcin^ divided at tbU eta^^ of the dissection. It
'was neNt dctiipbed from its firm adfieslona to the alenio-mastoid
musele and mastoid pm^ess^ and its ndbesione to the ear cut off.
Finally, by mesinA of llio blndc and handle of the knife, it was
Hepnrnted from the grent artery and vein which ]ay embedded
in its posterior wall, the latter bein^ cut and lied. Four or
five arteriea required lipalurcs. An enlarged *jijind In Uie neigh-
borhood was removed separately from the tumor*
Tho mouth was found pnrnlyaed after the operation. The eye,
which tlic patient wiis unablo to eloae before, i^itlior in sleep or
when awake, wiu found, a few days mbsequent to the removal
of tho tumor, to drop down^ bo ^ piirtiaily to cover the eyeball
when he was asleep.
An examination of the ttitnor, nf^cr its removal, ahowod it to
be the parotid in a scirrhous fltalc ; tho mieroficopc dieeloeing an
Rbundanee of eanoorous eell* : with it was hicluded a Ivinphatio
gland embeilded in it« lowor and under portion^
The presence of the parotid duct and the facial norve in the
tumor, together with its annlomicul rclntione, left no doubt as to
tho or^'Ab diseased.
Case CCLXXX. — MclftnoUc Dieease of the Pnr^lid
Ghind. Operntioji b'j L\fr'ieuir, cuUitt^* a\id Jretx^tti^^ — A
Bcnman from Maine, unmamcd, 25 ycara of o^, catered the
HoEpital in 1852 with a melanotic tumor. For three years
before, he had had a Bmall black fungus upon the rijht check,
498
TUMOItS.
in Frctiit of tlie ear, nrd the glanda of the nec\s bcTfttne &<»i
what irrilated.
At the time of liis ndiniBHian, there was an irre^lar, lobl
tumor, the upper part of whirh was eurTnimnioJ by a IjJaok ft
gua ns lar^ iie iX walnut, occupying the ri^hl pnrotici rc^ii
where it was eli^jhtly movable, descendin;; below and behind the
uigle of the jaw, where it wa^ immrivable. ^|
The patient bein^ fully etherized, the tumor was eurroun^T
by AH elliptieal incision* nnd the dis^ction coinnionc>ed. 3ti
however, followed every stroke of the knife, and poured
the whole eurfftce of the tumor, po as only to be checked,
the further prueccution of the operation allowed, hv applving
tfw freezing tnbiture, and constant compreision of the carotid.
After the rcraovnl of aomo cneily detaehei] portiona, by the ad-
vice of the Burgeooa pitieenl, the ojwration wna finallv terminate
by trs-nsiixin^ it at the base with a very strontj double ligature,
and tying it in two segmentfl* Before thw, many li^turco we?^
placed on bleeilinr; vesaele, and the henaorrhafje was vorj- "renl.
Wherever the tumor waa cut or broken, a great amoi
thick . gnmuhir fluid, of a jet-black color, floAved out.
Upon partial recovery from the effoet of the oilier, hi
rha^ from the tumor continued to such au extent ns to rcndcf^
necessary to again encircle the base by a strong lignlui'o- The
tumor ultimately returncdn
I
Cask CCI.XXXI. — Parotid Tumor. Jiemoval
married man from Nova Scotia, 58 years of age, eTitercit the
Hospital in April, 185-1, with a parotid tumor of twcntv-sii
yoard' Ptandinj^- It was aituate^l on the le(^ side, and exten
downward, lifting up the lobe of the car, partially ctosin'^
mentufl, and causing some deafness. The iniegiimcni over
was injected, but not adherent. The pain, for a ehort tii
had been severe, preventing sleep. It waa considered uf
formidable a character, th^it the flurireona to whom he had applieJ
declined interferiag with :l.
The patient Iveing cthetiicd, the tumor was removed
crucial ineision through the skin, followed by a careful di^j^sccd
terminated without the ligature of tlie carotid artery, 'Xhe
PAROTID TUMOR.
493
orrhn,^ wna vpry Trpe ; and tlie (li«^ECtl(>Tl coiiU imly !ie |>ros:^
Ciiti^ l>y i?Jup|Hii;^ iViJui litiic to tiEiif;, aiuI H}>[j1vmg n freezing
mixture uf salt nud ice, &o ae to allow an inspection of tUc parts
to be divided* It wta found to consist of hypertrophied glnud-
uUi' tissue.
In a slicrt tlmef he was dli^ultur^zud nell ; and, wlicii hirard
frouj, on Nov. G, 185G, woa in good Leoltii.
Case CCLXXXIT- — Cancer of the Ptirottd. — A woman,
3? years uf age, applied to me In ttie month of NuvcniLer, 1853*
nitli a tucnor o^eupylng tlifr seat of the parotid gland. It hnd
appeared Jirat, two years before, in front of liie etir ; and, in its
increase, had extended downward and under the ear. lifting np
the lower pirt of that oi'^rnn, II WEia a little movable, iind did
not project mneh beyond the snrroiindin;! pnrta. It appeared
firmly nttiiched below, wju somewhat Jubukted, and imparled a
aense of elasticity to the touch. Her father dieil of nmcer.
The tmnor was eipnsed by n careful di^sei-'lioii j but, on its
investments being cut into, a gninular matter, like {:ancer, exudct)
from iti and the hemorrhage was very violent, welling up, as M
from the canjtld nr siime very large vesseK It was tlierpfnre
fouud net'es^ary to tenninate ilie operalion hy tlie ligature ^a
^luissr, as in the case of the melanotic a^ecliitn-
The disease, examined under ihe micrascnpe, exhibited well-
marked cancer-cells.
1 learned that she died sLibsci[ue[itly i.if a tunior of the ab^
domen.
Case CCLXXXIIL— Tumor of Pttroitd. UcmovaL —
A lady ap|}]ied to me on June 18, 1850, on nceoiiut of a tumor
of the [litruliil gland. She wns 43 year* of age, and enjnyed
fair healtbr aklumgli dyj^peptic : none of her laniily, th^it she
was aware of, had ever been artected witli tumors. Ahunt two
years befoTe, f*he perceived a small swelling over the ramus of
the upper jaw, juet in fmnt of the external mentiLs cf the ear.
ffie BiEpposed itt And so did others, to be a tnnior proceeding
from ihe bone. During 1858, it increased much more nipidly
than in the year before; and she was Ji^iutly induced, by the
494
TUMORS,
ndvicr> of lirr |>Iiysit'!iiii, alrhiiKgli eKtremelj nervrnis in regnrd
to it, Xti u|)jilj- lo me for irdvicp.
The tiiinor then wns ntiout ihp size of a lien's Cpg, plof^
Hourly over ilic npriciilntiim of ilie J!nv, nnJ extendinp tti ih#
mnlHr lione. It did not exipnd down l)4?liind the jjiw, elovnriHff
tbc l<d)e (»r th(? cmr, a diLi?i;lion must cif the^e tumors are ili^pot^l
to take. It wsifl perfectly solid and immovjthle, ami, in mv
orlier Bitiiation^ might havp been tnken fnr n. disoase pirn***!
b^tneeii tlip pi^Hoj^tnirn »m1 thi? boiie, sf] Urmlv was il liK«<!-
Tt did not [wtrtJikt* of the uiotiims of the jaw, which moved
iT!de|)endeiitly of it. There whs no pjiiii attending it, Thr
putienr WHS denf on flint Aide, which she ntirilniterl lo prestur*
of the tumor on the audiiorv pHHsng-e. As it wns increasing,
with the pnilwihlllty of lakii^ n deep dirtttinn, and ae it ^oeiued
liiiklLtil li> tJiut [jortiun uf the piirotid more ^iipiTficinllv eitunied.
I ndvised .in upunilion^ at the »;une time lit running her frieiidj-
tliat there w^n a jiiissihiliTy ui' its recurrenee. 1 anxd po^eibiJiT^,
rather than pnihahility. because I have once or trt ioe fieen lu-
raor-* of this deseription whieh were eomplef.ely liihiitod to tht
parotid ejipHuie, imd of an almost osseons firmness^ removed
witliont rernrrence. The jwilient and friends Iwviiig agreed Ic
an upemtion, it wiw perfuniied on Jitne 24tli ; one or two g«nt]^
tnen who aasisted at the opemdon thinking, from the firmness of
the Tnmori tlint il inn.^t be an pnrboiidroma.
An incision being mnde over the wliolc length of it, and
crnnsed at right nn<!;les by nnotber, the entire Inmor wjis exposed
bv dissect ion. The pj<rolid enpsule bein^ (ipxl cut into, allowed
a ^rannlar matter lo p>enpe, havinij the appearance of colloid.
The dissection was now commenced iD front itnd rnitj^jde uf the
capF^ule, which was gradually dissected and jieeli^] up with tliC
hrife and fingers, no us to remove it clcaidy from the bone,
and x]\us rdlitw the delioUc capsule of the upper jiuv to escnrc
tjntnjured. The facial nerve was seen emerging from the i^landi
and it wa?( at firat snpposed that it would be necesearv to di-
vide it;: \l was uftenvards'4 found possible, Ijowever, to split lh«
tumor trfiUfiNerflcly, dia&ecL out the rerve, and leave it unin-
jiired» with the exception of one or two of the bnmches prot^ecd-
ing to the upper part of tlie face. The deep part of the g-lnnd
P-^liOTlD TtfltOR,
495
rhii:h insinimtes itwdf Imc-k cif tlie lower jhw ^jeeined to liuve
jcaped Ji»easn ; a t'urL u|]i[:l» I Imw oin'i- or twWe (il>M:iveil,
Ami vvltidi liaa bfcn frei]tK'n[Ly ubserveil \ty other Biir<^Gonj4, Tlie
iHJiie, on vkliiL'li iIlc tLimor lay, li^id iiliiitj^it LIil* atLfi4.'(^t t^f be!n<r
liollowtil out l»y it, Tlie wuuml w«m brmi^lit t»;rt'lla'r by siitiirts,
and eoM wftrt;r-<lt'esair)gfl H]i]>lie(l tn it, with n little cixiiprpr^Mion.
The jiHtii-nt icogvereil rii|ii<Hy, tlip skin ailhenn^j chiscly to the
jbooe^ M) ti& to Ipfive rjiiite nn csrawileil h»iik ti> thuc psirt cif the
!. There H'N^ iiu fiinul |i;ti';tlysis ; hiil the imist'iil^Lr jLCCiun
nbuve the urbit, nn thn right ^iilf?, AceiitMl lodt from tho nectiun
ofihi' ntrve^ diwinhut^l lo thut imrt, utnl wns in whcmjj (.MntrEist
whli ihe muM'ulnr uriivity ilispliiyi-il in\ lli*- iij>|msiiti teiiijile.
Tlus |iiiijeTLt flietl nlniut ei^liteeiL iiLunllis after, fnmi (.-iinferoua
dipenfte Jirtni'kinif tht iniegiEtiicrjtri i)t' tfie i)we, in frntit of ihe
former ullei'JJiin, whli ultcLtJaiit cunAlituLiunul (Ji^eiue.
Cabb CC:i.\X\\y.~Pninfid Ttnuur. n^vitjvnl. ~ K
hi?a]ihy Inokinj^ olfl womam. (14 yeiirs of n^e, einne iitider my
..^
■j;:>
SI
cnre ut llie r(i*!*pitn], Jiint! 3, 1*^51. Thirty-Cv%'0 years before,
she Eind the inuinpa on the right side of lier fAce. unJ, ivheu
496
TUMORS.
llic ewelllng eub&ided. a pcrmnnent tumor was left, wliirh gradu'
a][y enliir^^ed. In ten yc^Li'd* it fiHil uKnincil L}ie oiza* of a snuiU
orange ; jid(1 a fem^ile cuncor doctor waa «]ipHed to, wlio *'clrew
it out," leaving an open evfrt. AVlitii this healt-nl, llic lumur
a*nln ejikrgeti, and ftftcr ISVJ prew rapidly.
When I saw [ier« a tumor, euch aa is represented in the wtMid-
cut, ot'ciipied tlie right side of tlie face and neck. Tlir clinmHfr
of its hate waa five indiea in one directiun, und fciur In the* olW,
Itfl circumference about iIlc base wad n little mure t.linii n ftxil.
It waa nomewKat lohulnt^l^ and vi^iy elastic ; the sWm of it vm
railicr strongly marked ity veins, and scarred by iliu Hp|dicA(uin*
of caustic. It waa freely movable on llie &»bjac<?iit pHrts, ruiJ
caused a. sense i>f unenMtJc^a, railicr ibau ]Hiia.
The patient bein;;: etlieii^ed ^Ith chloric ether, two vertii*d
inciBioiis, ecmilunar in .*liape, were made over the tumor, incJud'
ing the cireiimacribed akin, which waa adherent. Then, cnm-
nicncin^ iit ita lowcal part, il was partly Jidaected* antl pardv
peeled out. lu adheeiona to neighboring' parto were not vctt
firm; but it was exceedingly vft&cular, and the operation ww
frequently intemiptal to tie vesaelo. The jugulai- vem wb§
wounded, and the sound of air entering waa diatiDcrtlv beflfil.
The vein waa severed, to prevent further ingresa of air. At this
time, ahe became quite faint from loss of blocid.
Afier the reinitval of the tumor, the cai'otld artery wnp found
cip*i^ at the bottom of the cavity. The reniaimnnr fi^in wnft
not 8ui£cient to cover thewound* which waa therefore (illeil with
lint.
During the operation, paits of the tumor were so soft 4u tn
be pressed out between the fingcra. This matter wha nearfv
flcah-culored, and of the eonsiateiicy of n aoft apple.
On cutting into it, ihc acetion wn^ found compoecj of aimilur
matter in pari, but in some places waa quite fibrous, Undtr
the microacopCt no true cancer-celia could be found : it a[>-
peareJ to be coinpoaetl of £brea, with granular matter intcf-
flpcrsed,
The wound grnnulatcd rapidly, and healed without adv tin-
toward ay mp torn.
nEOUEHEKT PAROTID TUMOR.
497
Cape CCLXXXV. — liecurrcnl Tumor of the ParoitH
Hand. — A lur^e, powerful. liiU-bit>i»iled tnnw, 34 vcaw of
^ conaiilted mc, in Maroh, 1847, for a ttimdr m tlic rl|;r]]t
prii"i*ti<l ^'l;;nd, A tumor luivl hcen rcmovol from the e/inic spot
twcDtv j'envfl beJ'ure, wliith ahorHy ^ifccrwrvrda re-nppe-irecl in tlie
form of n smtxW hard tubercle uiidur the ear. For fifteen yenra
it rcinjiLTicil dtaljon.'Lrj', and then ]>cg^n (o iiicrcnsc.
It wna uhoiit tho eiac of u Lcn's-cg^. of n bhuah coIi>r, lobu-
klcU, anJ having a Imrd bitae Biirroundcil bj smaU cvjta. The
lobe of the car Wiia pushed upwnrd by the ttiiuori, wliich ex-
tencleil mwnril, and fippareTUly involved ihc lower hnlf uf the
pnrotid glamh The p:Uie(it was very dcrfiroua of an operation,
and I dctcnuincd to atlcmpl its removal wilhoiil iirdt applying a
ligature to ihe (;ari.>tld, wliich r*etmi;d to bo involved in it. l^rs.
J. C. VV'ftrrcn, George Parktimn, Samuel Farkman, Dr. Brlgg^,
tad Dr- D, D, Slnde, were prcBent at tho operation]- This vra*
one of the early rases of tho iiao of ctficr, which wns adminis-
tered by Dr. ilorton with his ftppamtua- TJic tumor re-
quired a very alow and carefal dieficction. The base of it was
Ossified, and preascd upon the foeial nerve ; and this had caused
A partial [laiidysis of ihat 6idc of the face. The removal of It
waa aeconipUshed without tying the carotid artery ; and the
patient wad aufficieully recovered in n week to return home, a
distance of some hundred miletJ,
Some twelve or fifteen year:* after, thia patient again applied
to toG witli a tumor in tho same situation; ihc faec parti^dlv
paralvKed on that aide, the paralysis increasing as the ttinior
became liardcr.
The tumor was again removed, the wound healed, and the
patient remained well for a time. A few yeara afterwards, ho
appfiei^l to me a third time^ and came into the Hospital, with a
large ulcerated cancer* whieii had retunieil in the s^me Dituatiou.
On conaultation, it was decided that no ojieration was advis-
able. The patient, liuwevcr, was ^o eolicitmis that 1 ehould do
BDmetliing, that I diaaccted bjick the llaps of »kin at tiic base of
the tumor, and then passed two double ligatured, the size of a
whJ[iLN>rd, by means of long needlea willi handler, at right
angles^ aa fur beneath the tumor a^ pjsaible. The ligaturea were
4y8
TUMORS.
tlien tied, and the whole masa etran^ulaled. AfU*r it a^paxalM,
powcriul citu^rLC upplicfitioiie were madci and iho niAn, vihcu I
]net saw biro, had 0 email hcaltlij wound, in pltice of the offtn-
Bive tumor which he wns autftring JTom before the oi>erfllr(ici-
Thia tuinot* therefore, fVoin Ita <^omniencemciit to tlie last i)|>cra-
tion^ Tlb^ a course of between thirty nnd forty yeare, Doriiig
the whoJo of this period, hia gencmJ health was ^od.
Ca6£ CCLXXXVI, — lietnarkalle Disappearance c/ m
Appiireiit ScirrhoH» Tumor of (he ^ecJc* — December, 1*^6S.
A gentleman, nbout 5U years of age, of epare hitbit nnd io deJ>
cate health, applied to me, about two ycnta eiocc, wiiii n bard
tumor of the eize of a. large lien*B eg^, situnted pardj under tU
ear. It w.ifi nlmo3t entirely eaveloped iu the eubstaiice of tJ»
8icmo-nm£told nmtele, whore it is atliidied to iIl^ mastoid W9-
cess of the temporal bone-
The tumor was ovoid, well defined, Jind njjparcntlj finniT
fixed to the hone : the skin above it was a httlc U]^'olt>red<
There was no tenderness in it, and no timrke of an active influD'
matory character. The patient ^aid tlint it Lc^^n, ahout ^
months betbi^e, in tlie ^Libstance of the muscle^ nnd had grA^u-
ftUy grown to the above-mentioned eize-
I had no question, from the appearance of tlic patient VtA
from the examinntien of the tumor* hut that it wad M" a mtSiT'
nunt ehamcter- I did not encourage its removal, ae it invohcJ
a loBs of ekio and a large portion of tlie muscle, and it di&aevticJ
from the bone, with every probability of recurrence^ The p*-
tient waa much averse to an operation, unless 1 could Lironu<<
him a perfect certainty of cure fntm it, 1 advised ium »on»
constitutional reniediee to invigorato hia health, nnd esriei^iolJT
to avoid having the tumor hiuidleil or disturbed, ns 1 Imie ofkn
seen the growth of tumors accelerated hy repeated mauipuU-
tions.
Widiin a few days of writing this, agcntleman stopptxl me 10
the street to iliunk mo for the advice I liad given hijii^ ami rr-
called hia case to mc. Ho said that, ehortly after consulting mti
the tumor began gradually to disappear, and finally v.ns entirclF
abaorbedp On examining the spot occupied by it, 1 found dx
TUMOK OF CHEiflK-
499
upper pnrt of tlie sromo-mfl^ioid mustlc eligliilv bulbous, as if
^1 mflated with nir. The par:, however, was perlecily soft^ *^*^
not iho filighlest trace of the tumor remiunod*
»
i:
I
Case CCLXXXVIL — Ttiitior of the Ftire m^ OrbU.
HecovGi-'f. — The pntient wna 40 ycnra olJ, Fifteen years be-
fore, n siiinll pimple, followed by n, ac^nl6f appeared on hi!4 face,
below the eyeliih This u'Jis kept aore and irntittofl hy beiny
constanily pickinl. It slowly incrcaiw], invaJiug tlie ii;ie<[u-
ments of the face, cellular membrftue, muscles, and nppiu'ently
the malar bone, and takiiij,^ partird possession of (he orbit, *o aa
to force the eye backward and upwoni, flnd in a great ineaaure
conceal it. The tumor af)penrcd perfectly ibted, as if involving
the mu-lar jltuI other bonee of tJie orbit • and the operation wjia
one alter stating (o the pati:>nt the uncertiuuty of the reanlt, of
which he seemeil fully inviu'ef und with the expec^tntion of the
neceasity of reinuving the niivtar bone nod ihe obitAr proceM of
the superior maxillary.
The tmnor on the fiuro being circumscribed by an incision, and
liie diiiBeclion comrueucwl, it was found pogslble, while using tJie
chisel to examine the stale of the bone, to peel up the Tumor
with it irom the bitae wichuut removing Any of the bone itaelf.
The discnec evidently had token hold of the covering of the
bone, but had not penetmted its structure. AVith much diffi-
culty and patient dissection^ (be whole periosieum of the malar
bonej with the tumor attiichedf whs removed, nnd the dissection
carried deeply into the orbit, removing the disen^e there in the
siime way ; the whole mass coming out perfectly clean and
smooth. The edge of tlie eyelid and (he mucoua membrane
were left ; and the si^t was not injured, although the eyebil]
had been much compressed and forced from its natural position.
A microscopical examination of the disease, afterward, by
Dr. Ellis, revealed a structure composed of much Eibroua tissue ;
but no cancer-eolls could be detected. The patient recovered
well after the ojjcmtion,
Case CCLXXXWIL — H^ctirrcni Tumor m Cheek, wlh
Enxtite Tissue. li^jtiovat- liecouety. — A young gentle-
500
TUiions.
man from Halifax. N.S., 16 ycrre olil, came under my care in
Jiiiiujiry, 1847, lur & tumi>r siiuntMl in tlic eubsljincc of the
right cheek. One of a aimilar milure hnd been rcmpvcd from
die ^nijic siiuatjoti two jeafs bclur^}, but hiKl epucdily re-
tur:ic(l.
^Vhcn I eaw hira, the wliolc of tlic right eidc of bis itict
loohcd larger Ihnn the left. The veins were much distended;
and, at lii'et flight^ a midi^aat disease of the unti-uin would
ha\c been euepccted- A lobiilntcd tumor vas found deeply
Bented in the eubstancc of the check, juat below the zygomatic
arch, And nppnrently CTctcndcd up under it. It was movnble ftod
hard* A large voseulnr polypuid growth occupied the right
noetrll, und entirely obstructed the breathing on that eide.
In coiiEuhalion, it was determined to reo^ove iJic tumor,
which was dune on Jan. 2Hth. Thia wna one of the early
cases of the uae of ether, whicli waa exhibited by Dr. Morton
with \m inhaler; nod, in four minutes, the palieut wiis quice in-
Bcusiblc. The polypoid growth in the no6Q was first removed.
A li'nnsverse ipcieion was then niride aloug the lower €^gc of
the zygoma ; the &kn\ and musculnr fiubBtiLiico cut through,
vrhleh txprjscd iin erectile tissue entirely cavclo[nn^ the tumor,
and intimaiely connected svitli the aurrounding pnrt«- In divid-
ing this, in order to arrive at the body of the tumor, a hemor-
rhage hegnu, which y;rcatly obdcurcd the diesoction ; and it wns
only by compressing the carotid that the oj^crntion could be
continued. The tumor was now diaeovcred cstendin^ up under
the zyg<^uui.tiu nreli, but only alt.iclied there by n looec ccllulnr
tissue; behind, it dipped down in the ihrcctiun uf the epheno-
mttsillary tisfiuro. It was detaehcd from these different con-
nections nfier it lun*^ diescction. The operation wiis ^uepeuded
irom lime tu time, in order to idlow the repetition of the ether,
whjth waa three times repeated, at the request ol' the patient.
He said subecqucntly, that he hud cxpencnecd no pain, and that
his impreasioua were njjrcciihlc. Hia call for ether, he £DJd, i>na
jwrtly from the pleaHUrc of taking it, and not entirely on ac-
count of tho relief it atforded him from sulfering.
Ill consequence of the great hemorrhago fpoo^ the whole sur-
face ot^ the wouud, it W&6 found ncceuBary to U6c compression
LEUtXJUYTH^HIO TUMOR6>
£01
I
with *(pong;e3. No su!iflequent Llt-edir*"^ took plfice^ find tlie pa-
tient recovered without any had symptom. One or two vvccks
elftpfiwi, however, before the Bpongea could be extricated from
the Jeep wound, bo firmly were they embrar-ed by the grnnu-
ktbna ; and ut length removal svaa only accomplii^hcd by tear-
ing them away jnecemeal. The disense nppefired to be of an
en(*e|jhiLloid character, and eDtirely surrouDdeU by erectile tia-
Bue, thedhittion of which gnve rise to the hemorrhage. With
the exeeption of the aetaal cautery, the u&e of sponges seemed
to me the only menna of stopping the flow of blood ; and
from the great difficulty in removing these from the wound,
I think, thnt, in a fiiniilar case, I should give the preference to
the forinern
Notwithstanding the malignant appearance of the tumor, the
puticnt entirely recovered ; und T aitw him Bome year* afterward,
grown to robust manhood, with a marked evidence on liin face
of the severity of tlic operaiiona he had iindergoue.
This disease was dimbrle^s a polypoid growth, inrestcd by
erectile tissue. The question of its maJigmmcy was seiiled by its
not recurring. I have seen one Instance of a eiiiiilnr growth
■which had made its wny out from the posterior nnrea into the
zygomatic foasn, probably by abdurptiou of the auiicriov m:ucil-
Jary bone ; a part of it appearing in the QOHtril of the needed
■kle.
LEUCOCYTII.EMIA.
Thia subject has been alrendy alluded to In the Introdciction to
this chapter. Ttri histury ban been well ilJitFitriLlcil hv Dr. II. F.
Damon of ihi^ eity, in hia "Prize Kj^eay" puhlii^hed in l^li4>
An excellent pnpL'r on the " PoHey or rm|iohcy of removing
Lem'orvtIijtmi[', (.rlnndidar Tumors," bv Hr. I). W. Chccver,
WHS published in the Boston " Tiled ical and Surgical Journal*'
for Ang. 2, \Ht\t^,
I huve iiad two or three CJiscd of leueocytha*nne grovvihs, where
the tumors were aa extensive — occupying one or both aidcjt of
the ncck-^lbnt an operation seeme<] tnimlvi^ablc. riiesc cnaea,
uf which the following is iin example, Imvc been much benefited
502
TUMOfia.
by the u?e of iron, aea-ti^tUin^, l^ iii^hly noiirU1iin<^ diei,
the <fElicr incEirti usually cniploycd in patients cnUed ficrofaliniH
or of oibcr diafinacB of lt>w vitiJity,
Case CCLXXXIX. — Tumotofl^eek.—X young w^
IS je^n af ngc, with scAnty menetruiitlon, and aiwftye of
tieliuftte conetirution, four yeupfl before I saw Iier lind a »i
tumor ;i|>iM;ar in the neck, iindci' the left eir, This* for about
two yeatB, accmed to iDcroase tatd climiniah nt intervals. At iW
end of tlim time, tlie tumor befj^nn to p'ow Isn-gor ; nnd oitica?
were added to it, until tJie wKuJe Mg of ilie tieck, from the wt
to the clavicle, wne filled with Jar^, sofl, ajid oneUr moTod
tuiZLOFB. The@e, upon any exdtement, became enlarged, and
li^^htly di St ended wjtl; bloini. The patient was modcmcdr
fleshy, hut lind n Uvid. uulieallhy louk ; imis tP(>nblc<l with piJ-
pitation of the heart, nni] dvbilitv ; also diorlnega of ]>rcMk
on Blifj;ht exertion. She aiiffered no poin in the tuomi-, which
seemed to dip deeply into the neck, nnd overhung the cbivirle:
but ehe had neurul;:i;ia in the leH &mi, whieh was eumewlul
ewullen. Her jijcneml hedth was improved hv a tonic eourx
of trentmt^Eit, but the tuniur did not diminitih in aizc.
Case CCXC- — Tutratr iff JVeck. Operation. Jnicmai
Jugular Vein cut and tieiL lUcover^j.^ A. grontlemati, 3*
ycara of nge, applied to rac in May, 1801^ for nn uicerdted
tumor on the left eidc of the neck, oucujjying the grcuter por-
tion uf the Tc^oii lietwccn the outer part of thi' stcrno-mustoiJ
lUUdcle and the ti-nchcn. A tumor of three years' gro\%th W
been removeJ from this fipot in May, 185!>. The sheath of \\%t
great vcsecla had been cipoaod, and the inft!?e separated nt that
point, the pcdiel^/ oppoiently cxletiding in between them nesirU
to the ccrvieal vcrtebrre : a lipnturo was tied nronnd this pctliclv
before the maaB wna cot off. The tumor waa of an encysted
character, and contained a thick fluid. The wound hcaloil well,
but shortly nftcrward the tumor began to rc-aftpcnr.
When he coneultcd me, it not onlj' occupied a good part of tliBl
loft side of the neck, but pressed back into the ihront ami on [he
trachea, impeding deglutition and respiration. Although I w
TTJMOll OF NECK.
503
extremely imvillin^ to operate, vet, at the urgent eolidtalion
of the pnlient to make nn eHViri to save liia Ijfe, I t'OTisenleil.
The tumor waa encirclwl by nn incision pxteiKling niong the
lower edge of the jaw ; another ir front of the Iiiimir, between
it nnd the trachea ; one below, iti a line with the clavicle ; und a
'ourth in a line with the sterno-mnstoid. The opemtion required
R long Tind laborious dii«ection of nearly two hours. In di*-
aeetiug tlie mnmr from thp grpat ve-^sel/*, iht intemil jtigolnr —
which w:i»4 pwriiidly incorporated with it — hail a pjef^ necessar-
»ily cut out from its side. The aperture in the vessel beinp i*eize<?
with two forceps, n ligature eloseil the npprtnre. The lunior,
which was of a dainb-hell shape, cxpaniW behia:! the great
veeeela ; nnd that portion which pressed up the mucous mem-
brane of the pharynXj and could be seen in the mnmh, was
removed williuut any great difticnlty, no inHammaiory adhetiions
binding it.
The patient auppoiled the operation well, being Heated in a
rfiair, nnd under the influeoee of ether for over two hour». The
symptoms that followed were not sny more violent than could
have been expected from sueh nn o[ieration. He was kept ex-
tremely f|uiei lor a numl>er of dnye, for fear of [lemorrhage from
the ju^mlnT. There wua much sorcne^Ji^ of the thrfiat., nnd eome
nffeciion of liie voice. But he recovered riipldly, mill woe well
enough to return home to aniitW State on the 2Sth of May,
nbout three weeks at\cr the ojx'ration,
Dr, Calvin^ti^ Ellis kindly giive me the following microscopic
appearances of a portion of the tumor sent him : —
■'The gro^vlh vrti9 flhout thri!^ inches in dianieler^ and compn^^iil of
umall hibiile^, clusti-'rii" of vhifh appeared to be rniitainetl in cyslSj
which tlicy (piite llllcJ, The color of tliwe loliulcs vtiried wilh the
uuinbvj- of bloodvcfificlfl corittiincd williia tlicio ^ fionic lii^in^ nvArly
while, while oiliere worts of a tlotp-red color. These vcHaeUj after
re&chiD^ the |)eriphery of ihe lobule, relumed in the form of loops.
The lobulca were uompoaeil uf deliculc RbrouH liaaue, with small nu-
clei, with^ for the uiaat part, cuiLipariuivoly siaEdL uud^i. la >ome
parti, these nuclei w«re quite irregular lo form-'*
One OT two year* aftorwariU, thja patient coneultod me for
u recurrence of thie disea^Cf fur which no operation wns avail-
504
TUMOB8-
able. Ilia ^ocraL hcfllch, aielcc the operation, hnd been i^^
good.
Case CCXCI.^i-fi^^e Tumor of Face and A'tfci". Rf-
niovaL Rocoverrf. J^f^currcjioe afitr three ^crrv. OfKm-
Hon. Dtath. — Feb. liT, 184H. A aiiiii^ aged 47, ftpplied to
mc with a tiJinor of t^vo years' standing, occupymfr a good part
of the left fide of the neck. It bcfrnn as a niovnblc luiiiLir near
tbe anj^le of tlic jaw, and incren^jcil iiniil it extoiidcd froni the
cnndyic of Iho jaw tu within un inch of ilic clavjcJc uiideme>lJi
tlio sterno-maetoiil mneclc, and bcyunU the nkedian line of tJic
neck^ farcing the trachea before it, and encrunchcd apou tlif
mouth, puttbin^' the tongue over to the rig:ht side. The cBn>I]ii
artery waa lost in the tumor. At a consultation, Jt Wft« de-
cided that an effort to remove the tumor eliouJd be ninde* al-
thon^'h the entire eKtir|iati'>n of it waa eonsid(*red as doubifuL
The patient bcinj^ |daced under tlie inftucnce of ether, the re-
raovfll was etlceted, after a lon^ and careful diSEcetioii ; that
portion of the tumor which projected into the mouth being enu-
cleated wilhotit any difficulty. The carotid aricry nod jugular
vein were huncd in a doep fissure on the lower part of tlie tumor.
ARet ita removal, the anatomy of the wbok neck wne bc.iuti^
fully dieplayed, jjartifnilarlv the Bniall muflclcs under the juw,
and the ueriea of that pai-t. The patient recovered nipidJv,
and, after a few weeks, left the Hospital well. The tumor had
a sfilid bopo, witli an innumerable quantity of cvets, ivbich per-
vaded its pubslaneo and covered ite eut'liiee. 1 »uw nothing of
this man, until twQ yeare afcerwarda. He then had, in the
middle of his neck, under tbe skin, a aaiull m^tvable tuaior, about
the size of a nut, which could he lakea up between tlie finc^ersj
and might Imve been easily removed by a tew etroke* of the
knife: he, however, declined to have it done^ 1 lost eight of
him nntil the s|irLu^ of 1851, when I was called to see him, and
found him in the following condition : The entire left ■'ide of tho
neck, together tvith the front part, ofi far as tbe clavicle and
etornum, waa oocupied by an enofmoua tnmor, c^»vered with
largo veins, and CKiendinp up into hie mouth. Oaij part of the
aurtace had ulcerated^ and, from ihia place, there had been
TUMOft OF FACE AXD NEOK,
505
I
TCpeated nnti Hcvcrc hemorrhn^jes. ITg tKoujjIit he Imd lost,
ont'c or twice, nearly a <|tuirC uf blt>od j Imt tliU was jn-obiiWy
Under trontmont, llic bleeding was nioricnlarily etnvod; but,
tecurriiig a<rnin. nnd threatf^nin;; liis life, lie woa finnlly inducted
to be removed to iho Hospitivl, where he could ho carefully
^vatohed, nnd means inetantly used on the return of the hemor-
rhage. After a few dnya' treatment, lio i-evival a Utile ; nad^
en a full consultation of the BU'^gcons of the hLij<^>ilid, it wtiB
decided to inform the patient, chat, if he chose to have tin openi^
tion donv., it was barely (>o*siblc Chat hU life might be saved,
To t\m he at once ctmjsentcdp The following day, his stren^rth
having; icvived a litUe, eiifficieut Co allow of an nttompt to
remove the tumor, it nna done as fulJowa, under otlior* The
Account 19 condentfod from the llosjiitul reeortb : An iuei^ioQ,
more than a foot long, was made over the tuinor, ihroufjih the
skin, from the mastoid proeeee to the opposito side of the nceh.
Tlic Cumor waa now |iact!y dwaecled, nnd partly onuclenlcd
with the fingci'fl where it pasdcd under the tongue. The
principal adhesions were in the vicinity of the great vc^^eld \
from the ehearh of which the tumor liad in the first o[icraTion
been dia^cctedi nnd which had since become completely in-
corporated with it. There was no difficulty in diHsnccia^ out
the enrotid; hut thia was not so with regard to the jn^^'ular,
wbicli was involved in a nia^s of inHaunnatory material, nnd
its outlines with difficulty di^lin^'uished. This vein wiii^ \v't\ii}d-
cd» nnd the opening into it followed by a great gia^h of blood.
It wnfl at once scizi^l, and tied on the side. The heinorrhjigc
elsewhere waa pnncipnlly venoua, coming from the lar^'c vcine
which everywhere covered the aurfaee of the tumor. The whole
time occupied in sweeping out — if it can be ho cidleil -— this
great mtifts, waa hut a few minutes; aa. after the firat incialons^
every moment of lime that could be »ivcd wad preeloua : the
surface being &o e:itensivc, it w&ij uacIcbs io atop to tic vessels,
Ou the completion of the operation, the ]>atlent fainted ; but
eoon rcvited, on taking a few drops of the epiritfl of ammonia.
The wound being closed nnd di-csscd, he was carried to Wi« bed,
and seemed pi'Ctty comfortable. Towards evening, lie had a
&4
isofi
TUMOHB,
reinni of r-ollnps^. ami tViefi sudilonl}'- He had, in ibe moR
dtteruiinpil nmnnpr, rcfiiBeil — nWer the operation , nnd ninit h^
for^ it — the use of ditfuftble MimulaQl!^. froTn batvinff tak^nilu
pli?()g<^ ftn^;iiTi^t inloximliiiu; i.ln»k8. Substitutes iverc used. W
InetfectLLAlly ; and It is diiubttul wltetber nay dung NrouU ln"
nlti^reil llie ret* u It,
Case CCXCTT, — Larf/e Euci/Rtud Thyroid Tumor of ikt
J^eck. Incuion. Jif.ctii'try. — A lirtle, lieflrty ol*! ladT* «ppl
d6t entered tlie Hosjiitnl on June 11, I8fi0, whli u larf^ tniuur
ocpnpying ihe whole front of tha nerk. PXfRiidhi^ from the <iif
to the sternum, projct^Iing uul beyond the cbin in front. It wi'
evidently & §&<?, but so distended th&t nl Hcut it mi^ht eofiJv I'
mieraken for a tioIiJ tumor. It begjin in the mtddlv of the nwk.
wben elie wiu* only two years of a^, and inerensed elowlv iintJ
June, 1859, Since then, it had nearly doubled in eixc, Hir
*ikin over it was red, bnt moved freely on the eubjaccnt parW-
It WTU not tranxlucent, and no flnt'tuntion rould be f^lt in it
Thero waa nr> jtnarmin. She e<jni|>lmne<] of fulno^d in the hc^J.
apparently owmg^ tn the obatruetJon of hlood from pressure «o
the great vesfleU. On the IJllh of Juni*, I punetured the tu-
mor with n pniTill trnenr, nnd dretv off twelve nuneeg of dark-
ihin, chcM^olnle-colored fltijil. The ranula was left in the wound;
but it escaped in the night, owing to the wanr of nppo^iljou '*'
tween the wound in the skin nnd the ^nc, nt^er the escape of tbc
fluid. I did not mnke an incision into the tumor at this timL
wishing fi]>t to te«t (he hemorrhai^ic tendency in it ; as 1 hiil
once or twi<:e brfore observed, in these eases, that, after tlif
pressure of the fluid wa« taken off from the internal pnrt of thf
Rae, A troublesome blectling look plHce from the ere<Hi]c ti»«lK
pervadinjj; It, On thi^ 20(h of Jime, I mnde a fn»e inctBiun inii>
the tninor. on the median line, tmd evaeiiad^d tn-veml ounorf vf
bloody serum. A tent was then introdoeed, and rctnintMJ it
position by adhesive pliisier. On the 3Isl, the putient w»»
comfortable, biJt ha*] a sli^^ht fenssition of gidiline<iB. The dis-
charge waa of a purnleiit nature, nnd grailtially increased, fn-it
d^y to day, in (jijantity, becoming very offensive; eo that *^ii
June 30th, finding her suffering from great prostration aud diitf^
507
jtea, 1 ttgtih\ freclv incbed tfic aac, and covered h with a large
totilticc. Slic was llicii put upuD u course of quinine. On tlie
f.£<l of July, thci-c wuft cuaaMi^raljIe li enictrrhEi<^e i\\,m tli^ wouDil,
'liich vrtiA checked by expi>dLire to the air. Oq tlie f »llowi[ig
fday. am*clier eli^ht heinorrlmge took place* and a tliird one un
[the Gtli July. L^upptirntlon was free from the sac, and of a
latural 4;onaUtencr. After this time »he improved, and, un
July 10th, waft ftdviacd to leave the Ilciapital, and go into the
country. I did uot KoJtr frum Lhi« (luiient ai^'aiii uiiIlI Nov. :f4th,
rhen her physii^uui wrote mc " ihat the tumor liad cntirelr dia-
dpj>eared, and the wound healed up."
P Cabb CCXCUL — T/iijroid Tumor. Tuilct removed.—
A woman, 35 year^ of age, noticed, in October, 1840, a email
aivclKng in the nei;k on the right side of the trachea. In No-
vember, 1851, tliifl havln*; become very painful, I removed it,
at^cr a long and careful dtseection. It proved to be a cyst in
the right loltc of the thyroid glandn Four moiiths after, another
tumor a|jpeaml in the game situation, nnd slowly increased until
May, IJJ.jS, when it was the size of an apple. It was flnctu-
ating, and unaccompanied by pain; but respiration waa im-
peded by Its preasin^' on the larynx.
The patient being ctlierizedi & vertical incision was made over
the tumor down to the aac, whidi waa then laid o|>cn. About
ei^fit ounces of a dark-brown fluid eacai>ed. Considerable
liemorrhagc ensued from the interior of tlic aac, proceeding from
vcsaelfl which it was found iniposaible to flccureH A otrong U^-
LuL'c was tlierefore applied to the mouth of the aaC| and the
patient removal to her bed. It was found that the sac occu-
[lied the poniiion of the rl^ht lobe of the thyroid gland.
The ffnc at once HUeil again, and tho ligature v\hich con6ned
the mouth of it tlirCiitened lo give way, but for(unjitely did uot
until suppuration took place. For five daya al'icr the operation,
there were repeated hemorrhaged from the eupcrficial vcAsela,
vrhicli were greatly cngor^ied, and which were checked by ti»e
application of a solution of the pcrchloride of iron. Ihe suppu-
riitlvo proccoa obliterated the aac, and she waa di6char<^ per-
manently cured in four weeks, and 1 have aeeu her fre<|ucntly
5iac€, in good hcalUi.
SOS
TLNORfi.
ThyroM tumors, t\a aur^eons well know, ore altrnjs trouhl<>
Bomc to deal witli. Tlic trcatracnt by &(*ti>rj ia not uiialtcniW
with tlangci-, and I hnvc seen serious hemorrhages resolt frt>m
ita UPC. In one p&liont, a very inurkwl protnifiion of ihc e^o
(eiophllmliuud) co-exbtcd with it, ac<iornpriiiit.>(l by an anaemic
condilioti and sonic ccrcbnil dielurbfltice. This patient urf<mlJif
dcflirctl an operalion, bul I did not eoo llic way clear to ju*Uf'
inc in inicrterin^ with iho tumor. The treatment of ihei^eiu-
more, whether solid or encyelcd, with the long-continueii intcnttl
or external uec of iodine, requires judgment and CAution.
f
Case CCXCIV. — Titmr^r of the Neck^ involving the Aril-
larif PU^ne cf Nerv€«. Jiemovnl. — A woman. 4t> year* flf
ngc, Jipjtlicd to me in Oetober, 18135, for a peculiar-looking;
tumor of tie neck, i>f thirteen yeara' fliandinir- Some time be-
fore, she hod been run over. A hiirfte etnick her with IiIa hciid.
knocking her d^twn, anil the wheel of a carnnse pnasoii over hfif
sLouliler. Shctrtly after the uei^ident, ti aniidJ hard tumor ap-
peared, above the left clavicle, very near the ncFomion, This
c<viitinuei.l to grow until it nltuined the eiiEe of a ^ose-cgg. It
prcfduccd much pain in bcr arm, and partially pnralvzed it.
It Inv Tery deep in the outer triangle of the neck, wo^ a Hide
moTftble, and fili^^htlj fluctviatinjj on prcesurc.
In order t^> remove it, a criieiol incision was made fio as tD
freely ejipoae the tumor. Tliii^ was eompoeed of a thick mCy
which was partially embraced ly filaments and nervca of UkC
braehiai plexuSi By a very rareful dieeectlon, the nerves vrtrt
gradually detached from the tumor, and tlie biie di6:dectc<] oat,
leaviiLjf the hracliial picxua exfjoeed- The hemorrhage %vne quite
free, and tome large ^eesela re<]iiiroJ the li;:ratiire-
The ^ac eontaii)ed a ttirlid, ^croue Hujd> In the inttaini
tory pn*co«a which ensued for the reparation of the vvoiind, tlie
pain in the arm waa temporarily a-^crnivated, iiccampanicd ivilB
crampa in the thumb, index and midille lin^orf.
She gradually recovered, and waa diselairged in about threo
weeks, I saw her some monlliB afterward, ontl preeoribcd for
her a number uf times; the power in the arm becoming i^-ad-
ually restored ofler the remoral of the tumor.
CYSTIC TUMOlt OF BREAST, 509
Tlie €Xtt(^t wny in vrhk-h the p.isenije of the wheel over the
ihouMcr cniucd the lumor is diHicuh ii> exjikiii, cjicept that
\t was hy soma e'^tsum of IiIochI iLt the tmie, under llie fuacifl.
Case CCXCV. — iftfihoceh of the JWci-. Lj^ffrtmmn-
tion. Suppuration. Itmnoval of Sac. — Ayoun^'umn* 28
yenre of Bfj^, hud, for a yeiir» a tumor in tbe lower trinn^le of
the neck. It tomment-'eJ quite emiill, juat nbove the ':ln\'i<:le.
^Vhl;ll I fiL^^t j^nw hiiu, it hnd int^rensctl t^u as to oct^iipy nearly
the whole of one side of the neck ; extending from th(^ c^kvicle
to the mneloid procoae, nnd from the (rnchesi. uiidornenth the
stcrnci-mn^toiU uiti-^clf], to the back of the neck. It omi&eil him
much pain, and, from the pressure on the trnchen, difficulty ct
respirution. By my direction, he enlere<l the Hosjiitftl for
treatujent. Shortly nfter> it suddenly became tenae fuid jifiin-
ful, and the spot on its tiiirfHt-e red ; ahoAving indi(rftliona of suj>-
pumdon. It w&fi chcre(^>re lipened, nnd n gi-cHt tjiinntity ot
sero-purulent matter dischiir^ej. It hml once before hoen
opene<l, and n qimnttly of mtlky aenim evncu^iieJ.
Tlie tumor uow "^adimlly contrneted, and the pniient hnd
mni'h relief. At the end of iihoia three weeka^ it hiid contnicted
to ihe size of a largo apple, and It wua dctenmneil to attempt to
remove it,
Tlie dijisectlon wns very long nnd Uboriouj^, iraplicntinjj most
of the large hloiwlveaaela and ncrvcfi of tlio neck; the Jofliimmn-
tion, wliioh h^iJ iMken jtlno^ in the sic, having glued il to t)ie
surrounding pnrts. A e^mplom which occurred during its re-
inovnl 19 worthy of notice, whirh I have obi^erved before in
removing impirtfint turaora involving the nerves of the neck.
Whenever the tumor wiia drngjpcd upon, respiration was ao mitch
affected that it was necessary to suspend the operation for n
time.
He remained <;uite depressed for nn hour after iho operation,
ntthough he lost but Utile blood. The recovery, however, wns
good.
Case CCXCVI. — CysnV Tumor of S^^ea^t- Jl^jnoiaL
— Aprit, lSi3(}. A stout, henlthy-looking German womim, 45
510
TUMORS.
*
yfora uf age, (ttMere<l the Ilogpitnl for a tnroor <ri' the bmA.
of wliidi aho gftve llie loU^wiiig hi^lory : Eighteen ytftra UW.
af\er her tirfil (^onfiii^ment, ahe applied a piippv to hor brcaui h>
draw ofT the milt- In^tend of drawing off the milk, he bil of
the nijiple t^t tyim|"leiely that the milk could nt^t be drnva a
alJ, Soon after, the hreasi In?giin to swell ; and, ut ti*e eod^
three months, hroke.
After this hfl'l hejilod, a smnll hard bunoh wus notioMi m
Eulj^dmoj? of the ^HufiJ, insiJe of iho position of tlje uiiiiJf.
With the hirth of eo^h one of her children eub8c<}iicntlr, sU
hnd a jiiinlliir n-bspesa in the bjv-asf : and the tumor alowk
iocreiis^jd in i*ize. Dunnn; this period, her ^eiicnil JtesUtli rr-
mnined very good? nnJ ahe suflered no pain in the breast, ti-
cept at the IJine when it wtis distendttl with mi.Ik» and brxikco.
In ihe early pnrt of March, 18<^fi, nftei* exposure I41 rovtw
weftlher, thp hrenst becanip swollen; and, to relieve it, ^
applied, by the aJviee of an M wonj.in, a strong CAuetic jtrrp-
nration, which was kept on until cliree duys before ooming to dv
HofipiCaL
On entrnnce. the breast presentett the following np|>eHnitJcc8£
It was very niiM-h enlarij^ovl, and rlie akin ilennded for n apaoc ol
six indies in drciimrerpnce in the centrCj where a pedunciilaicJ,
ovoid, bleeding maas, the sizo of an orange, protvnticd- Insulo
of this, covered by the t^liin, a hard lump, the size of a hen'*
egg, r^ould he felt. The patient staieil, that a etnull maM*
nttadied to the larger one, had douglied nway 6ve dAj^ beTon.
She had no pnJn at any time, oxr<?pl from the use of tlie caus-
tic. The skin cf the ghnd, outside of the denuded poriioD«
was not di5f?i>loi'ed.
The piiiient being etherized, the ttimoi'fl, with the surrouadin"
glaiid-tiAfiue. wore rnmoved. Very plight hemorrhage eQau«d,
requiring fonr ligatures. The tmnora were found to be coin'
poised of proliferous cysts.
The wound united wltnoat by the first inlention ; ^^d tlic
patient letl the Hospital, well, in the course of a few w^ck&.
Case CCXCVll. — Erectile Tumor 0/ B reus t. Jtvuioval,
— July, l*i62, a hoalthy woman, 47 years of age, entered the
TUMOR OK RHEAST.
fill
^Hospilnl fur n mmor of the brenaf. It B|j|ieEired, twc* j'Oaw
bt^furt^, as n smuH, linrd, painless lu[np In the rii^Kt bron^l, near
Lo nipple, find mOTGnsed in site elowly. In June^ 186^, nftcr
an PXJJininiuion, jisiin wjia iir*t felt ; and for ibe folluvvmg tnonih
tlicrc were, nt times, severe Innctnaring piuna in tlie breast,
wliich WHS iibout doitblc tho naturid sizc^ nud m(Kl(?r:iicl/ bnrd
on pressure.
The pnrient wfls etherized, nnd the hnnlness entirely subsided.
An eiqilorntory inoi-iion wna tht!n nmde over the mnn>r ; and,
after dissecting thi-ough the ekin snd adipose tiesue, a durk-bhie
AubstEitiee was found, whic'h pi^vcd to be q iiieiss of dilntod veins,
flbrnit the size of the little finger. The rL^ai of the tumor wft»
then earerul]y dissected out, and found to be of &n ereeiile ehur-
noxer, occupying the entire gknd. The whole msiss was removed,
a few smiill arteries re([uiring ligature. The pnticiit made a
rapid recovery.
Case CCXCVIII. — Chronic laflantmat ion of the Breast,
re»e7nbtiti^ Scirrhiis. lietuovnl. — A woman, bom in Eng-
land, appnrently of Jewish origin, appheil to me in January,
18ijU for a tumor of the right breii*(, which> fo the ti»M<^h. gave
the ordinary aeneatlon of Ecirrhufi. Her physician, n die^tin-
guiebed prnetitioner in ft neighbormj^ town, bnd exumined it,
and adviaod its removnl. !5he was twonty-tive years of age 1
with an exntrniely delicate and tninspftrent skin. Her heidlh
bnd generally been good. She had boon twiee eoufined, and
had bnd one or two uiiscarnagea ; bLit, although well developed
in every reapeet, nevci' bad any milk. Nino months before, she
WHS confined, wbtn a swdling look plaire of both hrea^itB, but
without nry uiilk in cither. The right brerist suppurated, and
was opened in Iwo or thive placcj^ ; it remained in n »<orc e1;i[e
for two monilis, when It healed, leaving an induration- This
enlarged from that time, and became more nnd more trouble-
some.
A turnor of the sizq of a small potato was discovered in the
axillary side of (he breast. It was (jnilo movable : the skin over
it wfl* retracted, and adherent in one or two places i the nipple
•0 deeply dmwn in as to have entirely disappeared. The tumor
A!2
TUMOK8-
coiild not he diHtin^iiLFiheil frum scirrhns ; still, thfi hit
tlii^ ciisc anil nge nf [Im pnticnt eceuiud a-^aiD^t it; but m
breast wji» entirely tt^elcris, And ns ii wns the sourcse of
imfiuiun to lier, I ndvUpd its reinovul.
Tlie tumor waa reniuvol, together with the nippEe find «dl
cdC skin. The Jrody uf tlic tumor was coin]>osed of a tranvpaiiii^
fibrous tissue, which creaked under the eealpeL Near the
fiice wu.i nn abaceBs, tibnut the j^ize of n cherrv* fillod
unhealthy Wking [iuh. Althoiiglt. when trxpitted, the Iudv
filill gnve to the finger tlie Bengnliun of Beiirhus, yot, on exmniia-
tion with the niir.'ro?4i^ip8, no esineer^ella could lie fViiind in ll
The [kit ( on t hnd n gotid recovery, and was ecco, ia
186S, in H state cf perfect health.
»f
Case CCXCIX. — Cancerofthe Breaxt. IiejitovttL—\
the £7th Deecniberf 1801, I ujiernteit on ihe f<dlowiii^ cnee : Tl^
lady wita 40 years of age, unnutrried, and very dcUcute.
or two of lier family haj died of eancer of the tilerue. And
now has a cancer of the breast. She perceived xUc tumor r*
ibe ftxiLnry side of the left breast four years before; it tlw
beiD_^ rjuite small and movable. One year before, it enlArr^.
adhered to the skin; and xvas just on the point of tilcenti't
when I operated- Sbe had pain in the tumor, nnd in ihe hns
of that eiJe. I rernuved tho tumor, the nminmnrv gland I*
whit'h it waji nttnchtd, nnd the ,^kin over it. The wound wa*ap-
proximaieil by sutures and adhesive stra|>s, nnd a buti<lage apiilioL
On cutiing o]H?rL the tiunor, it was found to be n scirrlioai
lump, iiiToIvin^ the edge of the mammary gland ; the skin owr
It being destroyed and the edges ol" the skin ineorporiitctl wilK
it. The wound healed well, A slight imtntion, and ^^xudatiun
from the eurfnee of the scar, however^ continued for eomi
monrlift. She then improved in henltb, aud now, at tlie end of
five yenrsi is perfectly well-
Casr CCC. — Cancer of ike Brtattt, folio win fr tmm^i-
ttUlif an Niir»iiig. Paltiaiive Ofiertitian, icith Iter.urrtnct
of Didf^rtfte. — A lady was brought to nie hy her i>hvsjriau.
with a Beirrlmus enlnrgezneut of the left breast ; the ekin \mr\z
CANCER OF BRBAST.
fil3
covered with cunccrous tu!>erclea. There wii3 also a eli^ht
enlar^ment of the glnrtct:i in the nxillii. The tum^ir wiia quite
painfuJ, as was tho arm of the same &iJc, nnd @Icc|) ititer-
ftred with from thi^ chubc. There wns aleo a slight eough.
She was a smnll, rnther delicate w-iman. ri>rt_v"-fivc ycnrs old, and
the mother of eijjht ehildreu ; the diaeiise having appcitred nlout
four months before, immediately after wcaninir tlic Inst child.
The operation for il^ romovnl was perfoTmt^l on the 7th of De-
cember, IHOl. The hreaet, with the skin over it, anJ the
dieensed glaud in tho ascilln. being removed, eufticiciit intcgimicnt
remained to allow of the appn>ximation of the cil^es of the
wound. The hemorrhngc wim eonsidcrable, as is fhc oji^e in
most of these tumors of an active growth. As the vvoman was
thin, I determined to make nti attempt for union by the fir^t
intention : the ed^ee of the wound wore therefore nieely approxi-
mated by menna of ejturca ami filaetcr. For the first two or
three daye, fthe had a fehrile Action, apparently dejjciiding, in a
£pi3iit mco^nre, on the efFcel of tfic ether.
The wound united, almost by the firnt intention : a part of
tlie ekin, however, in its centre, where tlio traction waA ttie
g-reatcat, elonj^'hcd, Abont the tenth day, ehc was able to eiC up
and take solid tuod, and on the fourteentli wa^ able to g-n out
for a abort walii. Shortly a^tar^ ebe left the llospitnl with her
wound nearly healed, the pain relieved, and her cough entirely
gone.
I saw her again a few montlie after, with a recurrence of the
tittieaao in the eiciUrtx- I should have stateil Wfore, that J had
infi>rmcd the patient's friends, previoua (o the fir,*t operation,
that curicer occurring in thia way, either dui'ing or immediately
after nursing, ie generally of the most Lintavorable dciseription,
and is almost certain to refrur : if, however, ihcy elmse to have
an operation performed, to relieve her sufferings and to give her
a Icmjwrnry respite, J aaw no objection. The operation did
have tiiia effect, and also relieved her cou^^h. Her health had
been unite guod after the healing uf the wound. I did ni>t
advice a rcpeEition of [he operation, aa I ahould Iiave dime
under other circumstances.
314
TIMORS-
Case CCCL — Confer of Br^u*t Mekite yurtin^. h
moval. — A iady, 26 yenre of ftge, of ^ood shape, ut^ »)n?
heultby, wna delivered of her firai child in 185!*, In Au;*
18tiO, she |»«rceivc<1 iliAt lier nglit bi-c^rii wt^s fiwollen, boi a»
tinued to nur^e, and in January iipplicd to me n-itb u ofi^
trated caneer ol" tlw? whole of tKe glnnd. It did not thco^
her much pniiif but her hcallh was t'hdhig, J advieed vratat
her child at ctnce. SuhAcqiicudy, ahe came Co nte ik^^ti, tii
the (li^wflse in i\n ntlvnnced suie ot" 'levelopmont- Tbe*
brenst wns solid, nnd migliF well be trailed ^^Irrhou^. Tht ^
was oovcred with cancerous tubercles: tb^re wns no enlwyti
glnnd under the Asilk, The pnin in itwn« exceeeivc, ofn
ing, stinging cbnrao(er, ntid dnnbg up throu"-)! tlio nerves
the shoul Jer-jiiint . She was \ery dcr^iroua of liaviti" tht
ensc removed, and I finnlly ngrccd to do it, in order to
her n tempomry relief: at the same timp, mnkiii** her fidlv
doratand that diat wiia idl she could e^jJOf^t ri»ui it, When
cnme to the opernlion, her courage failed, utid the dctenDiiM^
to nbnndon the idcn of hf>ving it removetl. I cUd not see bcr
ngnin for two or three week*, when »he called on mc, and ^^
tlmt the pnin had become so intonseT nnd of such a btiniui<r,
grinding character, as to deprive her of «le(>p, nnd rtxtAs
life intolerable. She begged, therefore, to have the opcmllaa
done J otherwise, she feiired ibjit she fihould die from excessive
pain. The whole buhsiance of the breaet, together with thi
skin, waa of the most excessive h;irdres9 : \l nppeare<l eolidW
tuLherent to the ribs. The |>:uient had a hluUh and idiui^^
asphyxiated look, but waa still in tolerable fleah, and nj^|
pretty strotig. She wns fully etherized, and the whaJo tunoc
encircled by an inciaioii. A little dissection Avas now mnde
under the lower edge of the mass, bo na to afford n good hold
Upon it! nnd the flepanition was completed, partly by tearing,
and partly by the handle of the knife and the fingei's; this
being considered the more effectiud way of goiiing rid of
tliseoHed tissue. The siirfiice expoBcd waa about the size of
common dinner-plale. Tho hletding after the opemtion wne
excessive; but, tvhile engaged in taking up the ves^ela whi
required ligatures, the pulse failed, and the pnlieot was seea to
ttlLS
i
CANCER OF
515
»e 111 a state of crlla[>we:, requiring the applicntion of ammonia to
the nostrils, frictions, ^., under wlncli Irentment slie rcvivcil,
I have oQCC or twice observed this condifion, wlicii exteoffivc
wounds over the region of the heart have been expoj^ed to the
air. In the present insinnoc, theae snme syruptoma recurred a*
Boon na the wholly surface of the wound waa agiam exposed^ The
[vcmaimng vcascb were therefore secured, taking care to uncover
'only JL fimall surfiure of the wound nt Ji time. In the subsequent
Idressingfl, inatead of uftiuj^ cerate, flour woe applied to the whole
^eurface, which waa removed from dnj to day. as appeared to be
required. This method I have frequently adopted in dreaeing
Terr large wounds reauUing from the removal of the breaat,
when it is im|:ortaiit to avoid tbe daily exposure of the aurftice
in drcaeing. The eecretions are afjoorbed by ilic ilour; and the
email masr^es iUns formed roll off from the wound* and can be
easily removed, and replaced by freah applieatlona. She waa
■ftt onoe relieved by the operation, and wa« placed in a atate of
comfort, when compared with her previous condition of torment.
It required three or four weeks for her to i-ecover so aa to be
*«ble lo go home. Tlic v^ound waa then Iwo-lhlrds healed. I
never hcanl from her afterward, but have no doubt that the die-
eaee returned.
Case CCCII, — Cancer of the Brtat^L Operation. Rt-
nppenrtincf of Cancer iit oth^r ptirtii cf the Ji'jd^. It'^ptnUd
Operation. — A lady, 45 years of age, of fine development,
who had alwa,v0 enjoyed good health, called on me in June,
1858, with n tumor in the right hrcnet, of a year's standing. It
was evidently scirrlious, and was rapidly npproacliing the surface,
I removed the whole breast. The tumor being large, many
ligatures were required : the wound healed kindly, with the ex-
ception of ore spot, where there was much irritation, whJch.
after five or sijc weeks, almost gave rise to the idea that there
waa a recurrence of the diseaae ; hut thid wa* finally relieved by
the discliai-ge of the knot of a ligature. In October, 18511, I
waa called U^ see her^ to examine a large, hard, scirrhous masd
in the axilla of the same fiide, of the sj^e of a double 6sC, quilo
tnovablei but evidently implicating the nervea and the axilJarj
xrwoKS.
artery, I ^Jviseil an op^mtion, anO, ufter making the pjiIctdI
inciBions, removed the Uieejifle prindpjiJly by CDiicleatioD wflfc
the fingers ; exposing all the great nenee, arlcrj, and ^dat o
the aiilla. The patient remained quite well until Augunt, W>,
when, Ql'rer tnudi fuirgue from travellinp-, an ulceratioa K-
curretl in ihe axilla, which I at first fcnred wae a return i-f tk
dibeaBc, but whieh healed up kindly, leAvin^ no iadximwt
January, ISGl, I was requested to mc Jicr on accoui:! lii
swelling jiiirtly over the epinoua process of one of the dord
vertebne. I at onoe detwied a eoin-hous lump there. Sht,
clI this time, wa^ complaining of ncural;riG pmna in the left
ehoulder and axilla. The eicntrijt of the breast and axilla wij
perfectly sound. The tumor at first fleemed quite indeGuiti!, bia
jp^dually, after some weeks, became delineil ; and. nl hct rr-
quesl, I proceeded to reiuove it. The diseacM^ eeeined alaKM
confined to the fascia over the veriebrro, and came out in a wlai
disc of About tlie size of a dollar. It waa about an inch ihtd
in the centre, and Capered oflf towards the ednr-a ; the t^kin ■»
not imphcalod; and, after the removal of the diseased niasi,
the flurrouuding parts were fonnd to be quite healthy. Thr
wound healed well, and there was no return of tlte diaea^e Ir
cally. On the Itth of T>eceniber, l^<il, after evJiuplrtininif for
two or three weeks of a sen^e of numbne^d, ntteaUed wrih noi-
ralgic pains in the muscles of the thighjj, toother \rith a uniwl
paralyeis of the fleior muscles of the n^ht ihigh, she wua telixA
with an epileptic convulsion, which lasted betvrccn one and t^
hours, in the course of which the right thiph was broken nrar
ila upper third. The cerehrtJ irritation sub&idcd darinu the
course of the night, bo tliat on the next day hut little evident
of it remained. She did not, however, for a week after com-
plain of her broken (high, 1 did not think it worth while to
apply any appnratua lo the limb, and she did not discover vhtX
had occurred, but simply placed it on a pillow ; in ^hicli noa-
tion^ with the toes a littk everted, it united ia a couple of
months. During thia period^ ahe hnd two or three epileptic
attacks, whose violence was mitigated t>y the inhalation of ether.
On the 7th of March, 1862, she had an attack which Wti-d i\a
greater part of die night, leaving her tnind in a wandeiiii^
CAN C Eli OF BKEAST.
517
Btntc, in which condition ehc remnineU *il tho date of the present
[record (Marcli lllli)» recognizijiK tVicnJi* with a smile, but
MHifTcrinn; from nn entire loss of mcm<>ry. She haa now a. cno-
'Ceroua luberolc under the ekJr, uvcr iho ripht acnpuln, and a
>canccrou8 mnse in front of the left ernpulti, on the buck. Dur-
iin(^ the whole of thi^ long period, ehe has never hnd dje sli^hlcst
dn, ftnd hoa submitted to tho Tnnous opcratiooB with for-
titndo nnd rp^it^tititjon, And* in fiu.1, wn^ never aware of tlie
exiiet nature of Jicr ditJeo&e.
She sank nhortJy nfter, and died without aufieringp
C\SE CCCIII. — liecurrajii Omxcer, Lonp-coniinued Se-
cretion of Milk* — -I wne reque»te<l in Fehnmry, 1851, to eea
a woman, 64 years of n*^e, from wlioin I had removed the lelt
breast ten resirs before, for a csiiicerous tumor of two yeu.rfl'
stundin^- She was tlicn n widow, and her youngest child waa
35 years old. After weanin;* this chDd, she had milk in tha
breast which afterward? became dleeosed* for throe years. She
had renmined well after tlie iir&t 0[>eraiion until 1850, when two
Jumps appeared, one over the pectoral mnaele, and one in the
iL^illa ; the former heja^ lullicreat to the skiOf and hod been
tampered witli by caustics- These lumorj were thoroughly re-
moved.
1 saw iier a year afterAvards, in a good *lnte of healcli, and
with no return of cancer.
Thia patient had been subject, for many years, to obstinate
constipation, often going sijctecn days wiihout an action of the
bow^cls* This condition had lately been completely relieved by
tho use of a ^lass of wine daily, with a Bmnll quantity of tlie
sulphate of magnesia in it.
Case CCCIV. — Cancer of the Breast. Long-coyitinued
Secretion nf Mifir. ~ln 1852, 1 operuted on a woman, 60
years cf a<;e, to remove a small cancerous tumor of the ri^lit
breast, of a year and a half standing- This patient had con-
tinued to have milk in both breasts since the birth of her first
cbild, thirty-seveu years before. Her mother had died of can-
cer of the breast, and one of her sisters of a cancerous ulcer-*
ation of the nose.
518
In iinother inst;Lnce, I rt^iacivi^tl a cnriccroiia breast, in whi(^
the milk li:id Ih-e^d i-etalned <jn tL^jt aide fur twcntv veara.
Case CUCV, — Tumor of MnU Breast. Rcmovrtf^ Hr-
coverif. — A mnn* G3 ye^ra of nge, enlcr^l the Ho»pitAl, Jane
16i 1865, \y]\i.i, ^ibrriit fuur inontlis befarc, had noticed u jiiiinll,
hard tumor, nhuve and to the outaide of the rio^ht nipple.
Far the firat mouth after it* appearance, ihe only tienr^Tttion in it
was one of itching. It ifterwnrds rapidly inciL^asetl in siic,
becoming softer, and ut limes puinful. It vt-aa nbcjut the size at
an egg, circumscribed and movable : there were no external
eigns of inflnmmatory nction. He had geuemlly i>een lienllhv,
Abrjut fifteen years befi^re. Dr. J. C. Warren rcnki>vo<! n can-
cer from hie right lower eyelid. He aaid that an uncle of hi^
hnd a large cancer on his lip, which de*tn\Tcd him.
The patient being placed under ether, the tumor waa removed
by two ellipticiii incisiona. On examination by the microscope,
it proved not to be malignant, but consisted of a hypt^rirophlfll
glandular »tructure> The patient did well, the wound hcnlln*'
up very rapidly.
Cabe CCCVJ. — Ittmttrhtible 'rtimot-in the A^jtMUi ^ coming
on after JVftrflnjr;. — A delicate lady, about 30 y^enn* of »^.
ailer the birth of her second child, had a tumor, one and s. quar-
ter inchea wide, and three inches lcng» appear in earh aiillan
region aa aoon aa the milk began to be secreted in the brea^u.
Thcae were oblong, flabby, and not unlike the breast itself in
a flaccid state, but without any thing corresponding to a nipple.
and were especially eularged duriug lactation. On tiie milk drr-
ing up, the turaora diaappeared in a great measure, Icavin^r.
however, distinct rudimcnta in their site. At her next eonfiais
tnent, ahc waa delivered of u stillborn t^hild. The secretion of
milk which cnaued waa attended with aimilar phenomena in ihv
axillic, the awcllirg being much greater on the right eitle Htun
on the lefl. In addilioHf on the right side, a amall, hard li^rhi-
gray tumor, of the size cf a pea, ftirmcd upon the apex of Ui*
Gwelling. Thia soon became the ee&t of the most intolorable
lancinating paina, particularly at the men&trual periods^ attended
I
I
TUMOR OF AitM. 515
Uh fl ajmpathetic fiffection of the oiher nxilU, and ainiiUr pnlns
f n severe charnctcr in the region oi^ both ovuriee. My friend,
r, Charlee G, Putnam, her physician, who hns hod a rery ex-
uaive eTtpenence in affvctiona connected with prc*;nancy, had
never seen any thing ainiilar to this i mid he rctjucated me to visit
&e case with him in conaultntlon, thinking that pc^albly it mi^ht
be on€ of the pnitkfitl aubcutimeoi.L'* lubercle» uLich arc often so
much aggrnvntcd during or prccedi^ig the piicqicral Mate* The
whole tmnov t'ecmtxl to be compo.scd. 6rst, of the ti^hby tkin ;
ihcn of a collection of glatidsj, eo *ofl us ecnrcely to be distin-
guL^hcJ from the cclluhir tiaauc ; and, imjihiiiteci in the apex, the
einnll, hard, nnd paiiifnl lubcicle juat referred Uu From my
cxpcricQCO of the painful BubculjEneous tubcrde, often faund
in the cxTrcmiticfl, 1 was confident thut this tiuncr wns not of
that character, and dctenuined to make an incision in it. When
thia wni done, a quantity of milky Hulcl was projected with vio-
lence n (iietmicc of eevernl feet, and the tumor wholly eubjiidedt
On ihc folluwin^ day, she was entirely free from pain*
From thnt time, the neuralgic condititm of JijTcrent parts of
the hody, which aecmed to emanate from tliis ^mall eyet on the
apex of the axilbiry tumor, cejwed; nnd she very mpidly re-
covered her henUh.
Ca3& CCUV'II, — Lutrj^ Tumor oj' tfc: Ana (ace woodcut).
Thifl old lady, 75 years of age, inlbrmed me that, twenty years
before, her huabimd, while in a state of iartonity, threw nt her a
caimou'haiL which hit her on the nnn, near the axilhi^ Slmrtly
afterward, the tntnor be^MU lu make ltd appearance, uud in-
crenacd until it attained an cnormoua elze. It oppcnrcd tu be uf
B fibro-collular eharaeter, and of aUml twenty pounds weight;
hanging down so ihul, when the nnn vsas licld nt n ri;:lit nn;:le
with the body, it rested on the flcal on whioli she *al, drugging
down the integnmenta and other a true tu res in ita vicinity. Ver/
Inrgc TCaaela entered it from the axilla, and could he diatitigiiiahcd
pulsating in its fluhfltnnce. The tun»or wa* earned by the pii-
iicnt in a large sleeve ; nnd, when I aaw It Grat, it Itod an uleer^
alion on the aurfaet, caused by being prcycetctl from her alee^e
upon the grate^ while ehe wua ihrowin^j; amia upon the tire> Sli?
had a second iQmor, ftp[tareiitly of a. simUar description, on
ber face.
A verv atrlknkg daguerrot^pe waa takea of this patient aD<I
the tumor.
Prom some BupEratitious feeling connected with its removalj
she derlioi:d iiiivinv jt upcrnted on ; und it la pnncipally from
tilt lonnner tjf its occurreni^» lis apparent 8truchirp, and its
uncucuiiLou Mze in thld fiituntioii, that I have tliuught it wortJi
wliile to reliiie it, and have it depicted.
Case CCCVTII. — Unchondroma of th^ First Phnt'tn^ nf
the Middle Fiiujtr* Ampiitattoti. — Miiy, 1850- The aul>-
jeot of llic di^enae ivaa a girl, 13 yenrd old. When two yc4uv
of agCt a small, hard awclliag zLppeured uii thtr innur aide of the
ADIPOSE TtTMOn.
£21
Irst ]>lml!mx ()r the mulUle finger, Thia elowlr increased, and
jrotluced no inconvtnicDce, cxce|)t ironi its aize, wtiicb more or
)&$ iiitcrfcYcl with tit? nioduQ of the Jinnd.
At the time of tlio opcrntion, tbc tumor waa the size of tk
ill npp!e, involving the whole bone of the firat phalanx, And
t>t' the ^cctjiul. The finjj^crwas ibrced out of its pUicc, nrd
ly dirt^ndly acrosa the little and ring finger. A emnll tumor
|i>f eimilar description occupied the lower phnliin^ of the fc»ro-
iiijrer. On the ring:-fin^r waa another, ii etill smuilcr oae,
'iniT under and concealed hy the l^r^r tumor.
The finj^cr was reinove<l. nnd the heud of the metnciirpul
bone flawed o9' to alluw of the iicee^eitry upprujsimjUion of the
Esdgea of the wound.
A section of the cxci^ iMirt showed n uniform appeamnce,
like the interior uf a tipc apple. The pcriphtrv wns somcwhnt
elliptic, like the more deiicntc layer of l>one or cnrtilugc. A few
epicjln? of bone were iiitcrHperaed through the iatorior* The
elinft of the bone had dtfta[ipenred> The metacarpal extremitj
remained.
Case CCCIX, — Cnse of larg^ Adipose Tttmor betice^n
tfte TAitntb and I'^orejiii^er. — A. woman, 73 years of nge,
entered tlie Hospital, April 0, 18U5. for a tumor, the uiae of a
billiard-ball, of thirt_r-iiv-e ycara' ^landing, ^raaped, a» it were,
between the thumb and forefinger of the left hand. When first
noticed, it wra the si^o of a bean, and inerpiucd until it at-
tained the above dimensions; becoming trouhleaome, nnd pre-
venting llic use of the fingers. The skin over it was thin,
dry, and wrinkled. It waa caaily removed, jieclin^ off rcftdil/
from the mitecleSt and not involving any important vcascia or
ner\'Ci9. The wound healed well.
An adipose fimior in this situation ia rare : and I remember
Imving Been only one other, which was in a child, and auirounded
the firflt phalanx of one of the fingers.
It had ;:rown very rnpidly^ entirely enveloped the bone, wwM
round, cCafltie, <|uite painful, and was «uppo£ed to be (afler
repealled cxnminationa by cxpcrienceil surgeon*) malignautp An
inciz^ion into it eecmed to justify thia opinion ; nod it was de-
52£ TITUORS.
cklc<l to remove the fin^jer oi ihc joint, whifli wna dune. On
cxnniinationi it prov^ to he an adipoBe tumor, etjrroundin^
find ^Un^iii^ l>^ht to the bone. The pressure of the tendoaa finU
iflfcin over it hod coDiprcssetl it in «uch a way ua To pvc il lh«
appearance of n cancer when explored- Amputation, however,
^vn» tlic imly remcJy. The operniion was nijt perToriiLed haatUy.
hut after the patient hod been under obeervfttiOQ foine time.
The finger was accordingly amputated, but one vessel r«quirin^
hgfllute.
Case CCCX,— Cy^> Tftr^tor of the Hemi. nf the Tibia.
AwputfTiion, — A man, 3<J ycflrs of age, camo undor my care
in May, 1853. Eijrhtecn montha before, he rcceivcii a ^ei^re
blow on the upper part of the ri^lit filmla> [iroducnng nn in-
Haromation and e^iellin^ there. After the iirai fiyiiiptoms had
FuhfliUcU, a hard Bwellin;,' v*'»6 diecovorcd, which ^julually in-
creased. In March, Ifi^^U, ho enid that the tumoL- waft «bcmt
hjiir the eizc of an apple; "that it had the elastic feid of a
wimigal)/' nnd aeoracd to liim n^ if, with slight pressure, he
oould force in its walla like etiff paper- Biiatcre were applied to
it, whii.'h inHnmcd its eurfaec. In April, an h&%\c was eir-
ployed, whicb nia'lc an opening into St, from which ven& di*-
chnrged about hidf a teacup o£ clear aerum, followe*! bv niort
or leas blood.
When I first aaw him. his ffcncrnJ hcaltb was rpiitG good. He
was able to widk witli some limping, [he knee being very ^ligUtlr
bentp The upper and anterior part of the leg wae occupied
by a hninl swelling, which entirely ubeeurcil the course tjf ilie
upper third of the fibula. The surface of the tumor waa covertil
by an iuHamcd akin from the application of vesicating eiibatances
in the centre of which was a small openinjj, obstructed bjr h
alough. Upon prefigure on iho limb, a quautity of ecru-puni-
lent inatCer run out. The forefinger, being ini?inuateU vcrr
slowly flud carefully into thia ajiorture, tnivcrsed the tuiuor
through a mnHS of loose granulated aubfitanee, ami brought
up agjiinst the iilna, ^vhith ielE quite smooth, \is if covered by i
Bcroua membrane; and, the finger being swept around, co-
countered an elevated eup of bone. The hejid of the fibula wv
CYSTIC lUMOR OF TIBIA.
523
nowTiere to be dieoovercil : and thavi^h, nl one part iyf the tibia,
a Jittlc ronglinc^Jd coiilil be detecicd, na Kmt^e ^pioulu; of bone
were anywhere to be obaei'vetJ. The tioger being withdrawn,
a. slow stream of venous blood ftjilowed, and continued lo flow
for one or two ininuU'^.
I inforrni?d [he pniient of the nntnre of tbe di8C:iae, and ih^i:
the only remedy waa nmiJutmion, — na o]nnion agreed in by the
other BLirgcoik^ of the Ho^pjinl. who suw him on tbe (Jilluwing
day. I mv^clf iTither inclined to favor the ideiL that the disease
was what hns been called spina ventoaa; and that tlie sup-
piimdon of the tumor ami the rrranidated cont^nie were to be
attributed to the infliimmntory action bTtniii;ht on by the iasue,
thna giving It n midignant aspect, — an idea which some of the
gentle men favored,
Jn n<ldiiion to what has l>cen stated above. In regard to the
use of the limb, it may he mided, that the power of flesion of
the foot was entirely destroyed, ao that it htrng loose in walking ;
Q fact whieli was explained afterwnrtU hv the entire destruction
of the bcniiea of the musdea hy the pressure of the lunior.
The o|>enilion was done on Saturday, May lith. The pa-
tient hein^ etherized, the tiimof was fin^t s!ic open, in accordance
with A promise made Eo hJin : and, the upper pun of the iibula
being found to be destroyed, together with the miucles in front
of it, amputation was at once prot^eeded to. In onlcr to obtain
n long htumpj the firt^t Incislona through the tkin were made
ju.flt over the upper edge oi' the piitelln. There wm very little
hemorrhiige, and not more thwn lialf n dozen ve*iaels required
ligatures. Four euturoa were inirodin^ed in the flaps^ but not
tied, smd the wound left open lih the ntlernoon.
The diaease presented very curious and interesting phcnomena-
The tikiii, being disjieoted back, disclosed a large cavity, filled
apparently with old coagjia. These being reniove<l, at tJie bot-
tom were portions of the sac, of the color and consisiencc of
that of an nnourism. The lower part of tlu^ sac wna formed by
the upper pnrt of that poi'tion of the fibula wliich had been left,
ihrcp inehos of it having been destroyefl hy disease. The por-
tion alluded lo was lined by a smooth tnembrane in its centre,
expanded and rough on its edges. At the upper part of the
ENCEPHALOII> TL'MOR.
525
I
mor, on the otiteide of tlic liciul of llie libiii of tlie nrrht log,
wiih nil opening <■« its cxioninl pnrt. The diiieaso begun fivo
months before by a severe ^>ain tleo|j in ibo limb, wluoh j^rudu-
ally increivflt»<l, ant] at tbt; SJiinu time ibc bone enhir<reil nl ihnt
point. About tive weeks belbro, tho tumor had acquiiXMl the
aisc of a krge a|>[jle^ nnd^ the pain beiny vurv eevcie, tbej
Applied to n fiUrgeoD, who mnde a tree incision into it, %vitlL
partial ivliof fur the lime.
Wht^n 1 ^aw him, the limb had become contracted and u^e-
lese: the pain was very severe, requiring the use of opiates,
And hi 0 henlthu'na b^ginnin^ to fail. I informotl h]^ parents
tluLt tiie only remedy wnti :im|iutation, and that tlie didi>!ieo wha
probablv nf a muli<;nant charac-ter. The parenia consented to
the operation ; unri the patient entered the Hu^pittil, where the
operation wrtE dune on Nov, 4tli,
After he was put under the inKuont^e of ether, J first ipude an
incision into the tumor, in order to verity ihe diHguoais, which I
fonnti to be correct. The limb wna therefore removed juet above
the knuo.
Ofi making a eootioTi of tlie tumor, the greater portion of the
bony enlibre of The tibia was tbund dct^tr^ived, and its place
oceupiL'J by a large cncepliuloiil mnsa, iiitcrtf|K.'r:i<'U evcrrvrherc
with .HmalJ grnnulci^ of bone, foi-niing a disease wbicli, under
the old nomenclature* would bo dcnignntcd as o^teimareuina.
On thu day tblkjwiug the operation, he was ^jcricotly cumfort-
abli: ; atiJ he Ukado a I'apid reeovery.
Case CCCXir. — jE^ucep/inloitl ViimQr' commenciiig In thi^
I*<rptileftl S/f'tce.. A-riffttitiifiou, Hecoi'ery. — A hvdv, *i2
yQnr9 of age, requested me Co see her, in coneidtation with her
]ihy£LL*ian, in August, 1853, About three ycnta previously,
being then in good heidth, ahe percoivod a smidl tumor in iho
pi>pti1eiil epacD af Ifie left leg. This* slowly increasing, pro-
duetHJ more or le^^ pin, and embarritdHment in the motions of
ihe limb ; and finrdly, when 1 saw her, hjtd ntluiucd tnormoua
dimensions, extending up on the thigfi, and nearly dciwii to tho
ftnkle. The tumor wa» tenee, elastic, and the surlaec of it covered
with largely di In ted veiim. A eertnin amount of pulsation was
(
fiS4 TUHGRB.
wound WAR n iiTnall pTC<!4* of the hend of the fibulu, iKis?
eighth of an inch in iliiokncfls^ wEiirh siill rciuAtoed itudp^'
lh(! lidirl iif ihi- (iiiia. The inTier pnrr of the cavitr ici^ ToT
ri^riut.'r] Jiv ihr tihin, onvcrLxl hy n smoDlh tueDibrane, at <^\
before, iind Ra?me(l to he nf a fomenhac fluttenod cup eiui|ie, Ti»|
rciniiintkT of the tsac in front, on ihe outijide aud tjMwfaw>|
yk'nis furmed hy thf; inle^iiments and de^enoratetl tDU£CukrtsA
intL^raiiET^ciI with i>\ecea of Lone,
Some of the genllemen who esamioej the jimb Bocmri ^
think the disesiae ini^ht po^isihly have heon na nncuri^RMl t*
mor uf the bone ; n^lthough ihe wunt of tVi]>e urtCfial bea^
rhuge, wh«ii tt wafi upeoLi], iliJ not fiivcir thnt ideft. AcanM
loic^roBfopit' exjiminntion, mndc nflcrwrinJa by Or, EUis* llilT<
n new li^ht upon it, nml seemed to verify lb« noctimcr of tk
fir^t diii^noitU, Till; apjmrent LTmirutA, boiiii; plaoeil in focK-
were found to consist nJuiost enth-ety of jn^'eloid etruc(urv, tJ^
the whitish-yellow aiibstnneo iniers|ieT>ed with it, and ntoct
might eitsily hnve been t^i.ken for erirfphidoid matter, woa fntA
tu he oomposed of fat globiilea. Mr. Paget, io his ^ SurEjicaJ
Piitholoyy/' mentiunj* an almost siniiUrly det?ept*ve c^c, is
thvev words : —
'*None who exammpcl tliis ilisEft^ with »he nnkM eye «lont; ftlt bjtt
doubt lliat It wuA an example of mfUuElury cniiccr, with r v»(rs fibunJa;!!-
ly formed in ii- l^lt, oo minuter iikv<'^'ilipitir>EiT none but the flvni'-nis
Vfb'ich I flJiJilJ pJ-eaeniJy dsjcjibe aa cLn rwctcr Jsiii^ oi' Liae nay^eJoni (uiD^n
could be found in jt. Thest;, copiously embedded in a dimlj gnmukr
substance, appeared to form the aubetance of the cyst-walls, and of
whatever EoUd material existed between tbem. The white, braiD-hke
masfl was apparently composed of similar elements, in an advanced
fatty degeneration : neither in it, nor in any other part, could I find a
semblance of cancer^eells.*^
The pntienl recovered well ; and bo far as I know, had no re-
currence of the disease.
Case CCCXL — Encephaloid Tumor of the Z/efid of the
Hight Tibia. Amputation. — Ahoy, 16 years of age, of deli-
cate complexion and light hair, was brought to me on Nov. 1
1859, by his futher. He was suffering at the time from a Jorge
ENTEPHALOID XrWOR.
535
imor, on the outside of the lionJ of ilie ilbia of the ri^ht l*^''
O'
I with an opeiiinir oo ilB eKtermJ \'aTt- The (lisoase bcg:m five
DionCh^ before by a severe pain doop in tlie limb, nhich grnJu-
fclly incre!t^o<], niid hI the ^nitic time the bone enlur^ed Lit tlint
point. Almut five weeki^ beforet the tumor bad aoquireiL tha
BlEC of a. hirge apple; nnd, the pain being very severer ihey
applied to a nur^eon, who tim^e a free incision into it, with
partial rcbof for the lime.
When I saw hini, the limb had become contrncted and uae-
^lo0E : the pfttn was very severe, requiring the use of opiates,
and his hejtllb w!ls bo*fiiinin^ To fnil- I iiiformed hi^ imrenis
thnt the only remedy wna imputation, and ihut the di^eiise waa
probablv of a inulignnut eharaaer* The parenta coaficntcH) to
tlio operation; ami the patient entered the Hospilnl, where the
operation was JtHie on Nov< 4ih.
Al^er he wus put nndor the inrtiience of ether, I first made an
inciiiion into tiw tumor, in order to verify the diajjuosia, wliieh I
fonnd t(i be eorrect. The limb woe therefore removed just above
the kntP-
B On mnkinfT a Bcetjon of the tumor, the greater portion of the
H bonv ralibro of the tibia was found dciilrovcd, nnd its plocc
H occupied by a large cnecphnloiil ntuss, interctpcrded everywhere
I with ^mull <;rntLitIca of bone, forming a dieeaee whieli, under
I the old nomenclature, would he designated as oatoodureuma.
^t On tlie ditv following the openition, he was perfectlv^ eomfort-
^p'tUe; and lie made n I'npid i-ec-ovcry.
Case CCCXII. — EnGcphahid Tnmcr eommen'^ttig tti thf.
Poplit^rd Sp'fc^. A'ltpfttfiiion^ Heeovsry* — A lady, \i-2
yeare of &^e, refjiiealed me to eec Ler, in eonenltation with her
lihyaician, in Au^'iiet, JJ*^3. About three yeara previously,
bcin-; then In good health, alie perceived a small tumor in the
popliteal apace of the left lejj. This, elowly increasing, pro-
duein] more cir lesd pain, and cmbnrra^fment in the motions of
the limb ; and finally, when I ^aw her, had attained enormous
din»enaions, estendirig up on the thi;;b, and nearly down tu the
ankle. The tumor waa tense, elnetie, and the anrfaee of it isovered
with largely dilated vcias, A certain amount of puldation waa
536
TUMORS.
obeervcd in it, wludi at first. It-i] In tliR siippoi^iitiiin tliat it
an Bueiirifjn ; i>iLt, im rni^f'iil eMiEiuiuctirin, jiiiil lon^-oi^iu^nuotl
pressure on the fenKirnl artery, which ilid not at b1] lUruiBub
lis size, I fdt cuiitident llint the; pul^atiiin nrn^(.> fnitn the ooii-
tiucmirut uf the luiiLc>r by tlic fu^clci i^vrr tiic poulitenl art^TT,
which cunuiiuuicutetl ili^ impulHC to it. The jinln id it veos
e^tt^cHMve, and extenUetl duwn the I'lnih to the foot, and could
be ftJIeviiittjJ fm\y by opiates, nud waa gnuluHlly wearing her
out.
Tlje (lcci(»icin arrived at »aa, thiit ihc afl'ectinn was nmU<fTmM.
and afa|jiitiitinii of the tliigh the only remedy* lu view of the
slight liupu uf recoveiy to he ci|.>eoted iVum removal of the limb,
tlie [ULtieiit wuH ut first undcridiid whjit course to pursue ; but, nl
the end of u month, bui[i;^ nearly worn tiut by coniinuod and
LEicrt^aalug pdii. b\iG demaud^d t]je opi^rutlou. Tlii» wns \»^'
formed on Sept. ^4th,
Tl;e Ihiib bein^ removed about hrtlf-wiiy up tlie thioh, niKl at
some diatuucc beyond the tuiuor, it >\JLfi foujiil tlmi rlie trrcaf
icti^ds v>erc matled together by iiiHuoiinaliim ; niul iho arierv,
being ^jarateil aad tied twice, broke tlirough under the lii;nliir«.
so tliat it was found necessary to plun^^e ii needle, iirraed wilJi i
li^^atujc, deeply iDto the muscles, und tie tiie artery^ vein, ttuil
mnseulai' siib:ft;iuce in one Luasj^.
la *pile of tlie uiifavomble nature of the operation, ciie patient
had a ^ood rccu\ery, though ihcr lij^ature ilJd not come away till
after the kpse of etffht luontha. On diasection of the tumor,
after its removal, it waa found to spring from the neighborhood
of the tibia, wha'h was more or Ivso disejiacd. witTj bony pri^
ceases projecting^ from it, Tlic l^jwer |Mirt of llie femur, on irhidh
tJie tumor Iftv, wiia more or leas eroded. The body of tbe tumor
was composed of a lardaccou^ hiuking Aubatanee, in I em periled
with bony spicukc. in the eent]~e of whieii was a eavity coniainitiJ!
fibrinous clotdf vi'ith walla reaenibliag an aneurisinal caviTT.
The iHJplilcal artery was found Jn the back part of the tumor,
whdc ihc nerves had beea forcibly pressed from their nstiund
position, and so dra.gfrcd upon as to explain the torlurintr pnin*
xvliich had so much c.^hanstcd her. The tanior, being csamlnal
by Dr, J. B. 8, Jackson, was by him pronounced iimlignaEi;
C*NCEH OF FEMUR.
5S7
iJ, bein^ emrained by Dr. Sbiiw with the microsoopeT he made
le followiTi^' report : —
''^ Composed of vrell-miirkcd caaccr eli^moQls. a,n*\ n'oulfiinm^ a lar^o
[Uanlily of fat in Iho canccr-rclls, la the poriiflU of iho uimor from
tr. J^ickeoiu which I Huppoi^o lo lia \\\g Bnmc, a i^iimlar BLnn^Uirc vrns
tund t:oiilainiii^ nu cDornioiis quaniily of fnf, so as lo ob,=L"ure ihe
[View of ilic cells at first Ai^Lt : thU porliuD was wLiEer tht&a thftl which
rou eoDt mc.'^
Ittnutt'ks, — From the m&lignant chnrocter of the tumor, I
hftd but little bope of the tiltimate reoovery of tliis ^intictit, am]
vas much surpmcrl on a visit to Lrnn, aix yciire atterward, at
beirg lolU ebe waa in a state of perfect hcnith. Though I had
been cojK^tanllv in her vicinity bcft^rc. I had not inquired nfrer
her, tnkiii^ it fur gnmtod that ahc Lad succumbed to the Jiaease.
|0n ft vbit to perform on operation, two months afterwardi I
took ocovflion to call M\^yix her, I found her in good health
ftnd epiritfl, and greatly increased in weight, bo as to be from
ecventy to eighty [lounds heavier than at the time of tlie oper-
[ttdon. The Htump I examined, and found in a pcHcctly healthy
condition.
The case \& oti inetruclLire one, aa Bhovrin^ iv good recovery
imJ stftte of hedtb at the end of bia years, atfter an npparenllj
desperate operation for tlie cure of a malignmit diaeuae,
Case CCCXIIL — j1/(i/^;h««^ Tumor of ihe Condyhs of
iht Ft:iaur. AntjmUilion. — A bdwrer, 35 yeara of age, en-
Icretl the llo^piliil on March l»t. 185E^, for a ftwelliog uf the
kneo-joinl, whieh he etuled had been of four month*' dunuion*
It firtft came on after & severe blow received by the p!ip(>ing of
a block of iee, rthieh slmck hhu on the lower purt of iIil' thigh.
ThU confiui^d biLM to ihe houjw for a few iky&, niid be wa^ then
able to limp about till nearly the titne of hia cnlrunce to the
Hospital, FiiiJilIy, he wa* obliged to rclinr|uiflii walkin;;. and
conbne hJmaelf Iei the betl* on aeeount of lameness und CAccsaive
pain in the kn^e-joint.
When he entered the Ilot^jiilnl, the wlnde knee-joint wiia oc-
cupied by a hard tumor: the leg waa fllightly bent on the
H
628 TUUO&B.
thigh, the lower end of the Temur projecting a little fbmrdi,
as if displaced from iu natural appoaitioD with the tibift. Bdow,
and on eitch aide of the patella, wu some elasticity ; aboft. It
wofl quite hard. Various appUcationB were made to the joint;
itd motions were restrained hj a splint; and, finally, two deep
iaauea were applied in ita neighborhood, and the aurftoea spria-
kled every night with half a grain of the aulphate of moqdiiM*
Ail these means did not have the slightest effect in nTi*tg**^
the pain, and he expressed himself as uni^Ie to bear any further
the excessive suffering from the dieeaae.
A conaultation of the aurgeons of the Hospit^ being called, m
is usual in such caaes before proceeding to extremities* the fbl*
lowing suggestions were made ; That, from the -excesaire aaf-
femg, the diaeode might be an ulceration of the cartilagee of lb
joint, or poaaiblj it might be of a malignant character ; and tfait
an inctalon should be made into the joint, and its condition ei'
plored. If it proved to he an ulceration of the cartilage, tlat
the ends of the bone should be removed ; otherwise, ampotatioa
of the limb should at once be performed.
On being informed of the nature of the ca«e, he agreed to
have done what was thought proper. Hie following open-
tion was therefore done on Wednesday, March 80th ; preparation
having been made beforehand of a aplint, well moulded, to ie-
ceive the limb In caae the joint should be e&ciaed. Bein^ ether-
ized in his bed, to save him from the pain likely to be caused
by his removal to the operating room, he was carried up stalre.
A firm pillow was placed under the joint, ao as to aupport it
in a bent |K>sitLOD ; and an inciaion wna mode, commencing tX
the inner condyle of the femur, carried down with a semi-
circular sweep over the tubercle of the tibia, and terminated
opposite the outer condyle. The llgnment of the patella wis
now cut through, and the joint partiiilly exposed ; a g:reat mah
of Huid titking p[ace as the capsule was opened* The head
of the tibia came into vietv hi a perfeotly lienllhy condition. The
flap bcin^ raided, a most beautiful and highly colored tumor,
covered with delicate synovial inembrnueT having lar^ vessel?
running in every direction over its surface, very much Uiettendedt
and formed by tlie lower end of the femur, was seen. The
TUMOR OF SAnTOBlUS MUSCLE.
N
tumor extended quite up lo the lop of the flvnovinl saf.. There
being no question aa to ita mflligiJiincy, the [mtient woe inimoji-
atcly sli|ipcil down upon the table, and hia thigh ampuluttMl
about the ntiddle. More iLrtcriee roi^uirod li^^ture tbfin in enit-
nary casea of nmpulation from ftcciiicnl ; a \'act which Is fre-
quently obacTved, when n hnih has hcen amputaleJ for mnhgnnnt
diseiiae. The bleeding having been checked, and the eurfacfl
teiiig quite dry, tlic wound was brijught to^tlier wilh two or
three sutures ; and a, ci>rnpi-cdSt with hauduge, earet'ully applied,
to givG the stump support.
lu the afternoon oud evening, the atump hecanic distended
and painful, so that it wiis ucccesary to open the wound ii^uin,
find upplj one or two li;:;nturc8. It wae tbrmerly my habit at
the lloapltal, m order to avoid an occurrence like the present,
to leave the wound open for fire or Btx houra, and then Imve the
dreefling done niter all oozing of bJoo(J hud ceaeetl. My reneon
for relinquL^hing this practieo was the excea«ive aenrtLiivcne^s of
'patients fur a lew hours after operations, ju^t ae they recovered
from the etFeeta of ether, and their uuvvillingneaa to bo interfered
■with, But where there i& evidently luueh dnnger of bleeding,
J consider the dchiy a lesacr evil than the re-opening of the
stump, aejirching for the bleeding vcbbcIs, and perhaps opening
fre^h ones* while clearing the wound from coagula, at the same
time nmning the rl^k of eubeeqiictit suppuration, and sometimea
of an ill-formed atump.
The patient made a good recovery.
Cash CCCSFV, — Tutiior connecied u-ith tfte Sartortna
Musoie^ ^condary to Cmicer of tho Breast* Op'^rntioH. En-
fniHCO of Air into the Fetw- Jlceovcrif,- — This patient* 30
years of age, had a tumor of the breaat removed five year a before-
One of her sifters had nJ^o been aubjcetcd to an o}terntion of tlio
breast for an cnccpholoid tumor, and svaa well, and present at
the operation. Another aister atso had a tumor of the breaat*
The tumor in question appeared about a year and a half be-
fore; and, when I saw it, was four inches long and three iriehes
wide, commendng ju^t below Foupart'a ligament, and extending
down the thigh.
67
I ' 11 III
Jll
1 1 urn
*355 ± 22S ^ g 5222i
■-■bkh
A ^n
iffiOfa i^Aoio-H
■SS 5 !3 Sitasi;
r "1 V'^ I
a^
OrERATIONS FOR CANCER.
5d7
* ■?
I-
U]
a f £
*? . , . -_
E o ■ ri H5
If iii ,
'^ ■- - £ '^■o ' d
• t E Q,;-3 B"
3^
t i
I i
So, ^ V X
El
s'i'l = 'i;=l g'
II
i
I.
1r
I ^ ^ ^ ^ B n ft Si C4^^«
*Jti?4 ^ —
ill
elll i
-a
3
i ^ 1
Is
3
t i s i
■ * 4 ■
SitiS
m. M. ^ t
D 9^ 9
R1
X
h
s
4^1 r'«^
^ "C 5 S
SIS s
huh
-n
££
■ I
I nil
5 -s^
''m
% ,
_j "^ ■ »»
■c t
i S^J
I
I 1
Ilia
^
zi
t:7i-^S39:^2^ S7SS 8 3Sj« SS 8
e&X2 2 ,
= ..:.! = .. =il. == = =
II
68
5SS
TmOKS,
nLolIuD <rf the limb.
On tbe upi^r &&(! inner siik of tbe ihi^i was aWgr,'
Acribed, movable lumor. ^itoaud deeply iu ihe llab, «^'
citenaor uiJ adductor muocJcA aiul ^^r^nt "resHti*. ll Wl
deep MtLiation-
Thc j>atient being etherized, tbe thtgli waa ratmieA «ir*i*|
and partjj^ flexed oa tbe abdumeD. An mciaum, eigbt id^M
Icn^tSi, WIL0 DOW made, over the middle of tbe tucmiTi ikMl
the skin. Tbe i'ascin waa iheti divided, which i^pond 1^^
ductor longue nnd ^raciliB rousetctf, eprend over tbe Ciuaor&f>
fan. The adductiir l.mgua lw?mg cut Uirotiglt. tlje
ma^ue waaesposed, wliidi, being divideij, brinighl the
into view, with its layers of ccJIalar mcnibraiir. It ^"v
Jaid bare, and gradually dU9C<^tcd or sepantted. vritb the
and fingers, from ite invcdtinenta ; U^e heinorrbage bciti^|l^'
lilac, Dininly from lar^ TeDoua lrunkr<, »oiug of which hd^
be tjed. An oozing of hjood contintiitkff, the uiteriijr«fA>
wound wofl lightly li^ucbcd wUb a aolufion of the pcrchtoride'
iron, iitid a ti[H>ngei enveloped tn ji linen clotli. t4rj]i|MMtf4r
IniroUiiccd to fill up the large cavity and produce coiuprimtfj
Tilt turakjr was found to be fibroua. ll vraa »p|ierir&] in ^htfc-
about Uie size of a large cocon-nut* It Iny agaio^t the boacrt
itfl inner side, prc^sinj^ the vetieeL^ outvarda. Towanla tlir Inlitf |
part uf tlic operation, the circulution became much i1oimt»(4,
and the face very sallow, Under tlic use of sliiuiiliuit*. in tk
courae of a few hours tiie circulatiur wne fully restuirvd. 1»
three or four days, there wa* coneiderable swelling in die th!^
which waa relieved by a free suppuration. The wnund, aftff
tliia^ healed well; and, at the end i>f &\x weeks tVnju the tlmC
of ibe operation, he returned home [*erfeetJy rcstortN], in )a^
sptnta, taking bia tumor witJi bim.
Case CCCXVm — Uncommon Tunwrof Thit/it, Urcot
trtf. — A gentleman applieil to nie iu Junuriry, J81JG, for
tumor of the leg, which hud njipciLrLMl under tJic foUurt'lij^r L-ir-|
cuuiatanccfi; About three luontlid bcl'orc, be wiu token nitha.
.Of S
i i^i i i i i
ill I ^ « e
« S B
B mj ^
111
I'll- 1 1
I
1 .
5i Jl J
U ill
ly i ih s sii J I i i
4 I ^f^ ^8 H
s a ;i »
im 3 82fi £^ £'£# 8 P~ i5 ^
A u a :s
9 ^=38 3 Xfi3 " fl^A 8
8 8 ts
ji^i x^ h. h xx3^ ;< ^sa a ^s^ a »■
4 £s 83 3 s £sas § 5§S 5 SSS S S 3 5 3
r
1 i IJ
%:.
i
i
S? S ?S Ee^S^Z 13
g'»SS ¥
S87S
S 9
SS3«
kl kh^hOM hb>B^S B^
Di]S^^ "^
^h]>:
■i^ h
k:a»
p^n Da-«4^4 i-'^a4^-' n
O? — ,ft« Jj
fp at o
^ a
siafis
5=::=: f
2
PAEffFCL CUTANEOUS TUBERCLE. S35
of veflaelsT principolly venous, projccied tdrough the
ind. These, together with the body of tlie tufoor, were
lisaectPtl out, with some [ipinorrhnge. The opi^mtion waa »p-
linntotl by Dmhrflcirg with a llgnttire the base of this cnngeries
lof veaaeU. A severe ottnck of mtinmnittCion followed, which
uumtcd in an abscess lu the f^hcck. He left the Hospital
LweU, in A fortnight. The nucleus of tlie tumor wns composed
of n fulty siibstjince, quite finn U'fore romovitK hut cnsily broken
lip by the fingers nfler it wiw dissected out. The greater por-
tion of it was made Up of erectile ti^^eue.
Cask CCCXX. — Painful Cufaveont Tufiercfe. — A wo~
\KD, 30 years of age, had a smalt, projecting, nipple-bhnped
tumor on the skin of the right nrite^. Ir waa of five yenrfl*
itAuding ; nnd she complained greatly of the suffering occusioucd
by it, which wiw of the most in*iuj>fmnnble kind, nnd occurred
in paroTysmB. At these periods^ she would uot allow any per*
son to come nenr her.
The wound was examined, after the excision of the tubercle,
for the purpose of discovering if any nervous filament had been
pressed uj>on by it ; hut none could he detected. Its tcxmre
was librous ; at)U no cancer-celU coald be found in it, under
the microiicope- The character of the pniin waa the same as that
obiorved in the suhcutaneoutt painful tubercle. Entire relief
followed ita removul.
The subjoined tables give the immcdinte result in one hun^
dred and fifly-five cases of midignnnt diaeaae, operated on hy
myself during a |>eriod of twenty-six years. The tahio, for
the last thirteen years, consists only of Hospital cases: and
the whole table eomprieea only those patients who remidued for
a time under treatment ; many who submillod to minor opera-
tions, auch na cuncer of the lip and of the inleguroenta, leaving
immediately after the operation, am) no record of tliem being
preserved.
The cases up to 1852 wore collected from the Hospital re-
cord*, by Dr. Albert A, Sawyer, and tlio remainder, by my *on,
Dr, J- C. Wairen, formerly houae-aurgecns at the Hospital.
r
539
TUM0B8.
11^ i
I
11
ii
It
mimi^:
-r. ^
SK sb:
J ^ I-
IflJifl
■it
III
J5; '
U
£
■u--'
--S5 = ' -
iiii
» 1 ;
Cl^
<t il^.i SiMJi Itti lift
tfCfJiC HCif JI3Q le^v^ fir-pirq
■a s
^ 3
11^^
3U5I
II , Jl
8
II. .
Isiilll nil ill' &= -11^1111 =
K^ -; = Jl t- =
^ss nsss -iSSt^^ ii
»^
^ rsis-
pa-= S3
^s
I ^S^ S^^^ @5^S^^ g^^S :^^S£ ^^ S^^??«^ &^
s;k.3T h^k.7 h^bbh3 35r^!i- sra-sa KR
Ba:^*;si;^
55 »
11
OPERATIONB TOR CANCEH.
537
ri
i
£
is
e
^ in i
iii:
iillk
IlllfS
ilir"
1
: :^-S :
U =1 g
f t
-:;»»=* 1:
irh i
Q^vntfAterTSS C4Zv4i ff»
CT E ?
til
ii
m
S2
n 3 J] 9
J3
££
t|Sfi
. liJ
dbnnn abac:
»a9
g|§§ mil;
A S S^^^S tl7,-^^333dl 23SS 8 SSi3 SS 8 S&3S 3
s h;?z[h x^:rb.kk:?se; ■i;?:ik;Ei;
hiS'-k.si R*. "M >i.s;h^ ■.
» SScSS ^ScS?Sg£ai3 SS3S
^?SS£ SS S SSSS £8
1 3 1 5
is
68
OPERATIOHS FOR CANCER.
All
I
n I
li
II
-- □ .
Ill
-=5
__ . 2 5
E =3
1 = 1
Q ^
E- : =
eI;! iSilS JiH
3 I 1^1
5 a«U32 !ii53f.^ Vi;"'^ :S
3
1
k
1
CHAPTER XIL
GUNSHOT WOUND S.
Since iho Ente war, gunshot wounds, nnd other wounds p-
diiPCtl by warlike vpcopons, hnvc received an iurrcased inittft*-
anJ are now bcinp extensively illujstrnteti by tlie elaborate "iirt*
published by Surgeon -General Barnes, under the fliTectii>a ^
llio American GovcrniucnL Some of iho beFiutiful photo^ptiit
illuatrutione of important surgical cn&cs ond oj>crntIonB, by Dr.
George A. Olis» Surgeon CS. Volnnteore, and Curator of thf
Army Medical Milium, which surpass in the art ativ thing <i
the kind which hns thufi far been QCf^oiiipUshcd^ ha^e dre^dv
appciircd. Circular Nu. U — being tlie prcliiuinary- fiUTgioI
rep£>rt of Dr. Olis tg ihe Surgeon-General — ia of raftai
vnlue. The annie may be eftid of the medical report by Dr. J.
J, WotfJ^viird. ^The bnttle-field liJsls of nounded, for the ycin
1864-S, irclude over 114,000 names."
To ^ivc an idea of the nEnoiint of material wliioli iireEeaU
itaelf for ub^crvntion, 1 mrike the following quotation from Dr.
Oua*fl vnJunble report i —
*'In comptiriftg (he numbers ofcnaes of some important injury, a*.
for ox»inpLo^ guoflhot frnoUiroa of tha femnr, it i^ found, thnu ■□ iba
Frendi Crinie»n nrmy, iliere were 459 such injuriea, nad, ia iho Edj-
liflh army, 194 -. whili- iiver fl,000 such cnaes hai-o been reported to
ihia office. Or, if one of th^i mnjor nperatfcms \p et-lecf^d for wia-
purieoQ, na <^xcii^\oii of the htiul of [lie Lullutu^i tlin Critut^nn reiunu
ghtt IG of iliege exci^ion& in the Bntisli, nnd 38 in tlio KrcDcU array;
but ihe ri:'r[s[f!rH of Llii^ [ilTiec ronijiin the rieliiilcd bi^lorics of o7*
sucli opcraiiODS."
The Crimean war gave rise to ore or two valuable works
bringing the subject more particularly before the public thao it
/S
WOUKD OF HEAD. 543
nt\ been since the splentliil ivork of Lirrey^ and tho&e of Gu-
rio, Honnen, mid others during tliG war8 of Nn-polpon.
In regnril to the destruction of life, eniised by tlie- pasHn*'e of
rojectilcB from Hrp-armn nenr tlie hni\y wlEhoiit ttiurhing it,
ere hna long esisied a popithir duljsion. In iminr rn^c^, it lina
heen prf>ved by dissectii>ri, llnu the hndy Ima boen fitnick by the
tall, whicb left no externnl mark* *if its passnge. Lnrge effii-
ions of blnod liiive iK'.en fuiiiid in the thoracic and nbdoniinal
Cflvities, organs riiptin'e<l, mid bone* ftrul muscles diflorg!nii:£od,
ichout any abnvaion of the inte^nm^nt outside, to indicAte
the paint where ibe misMfe struck. Tliis is the result of ibe
^elastidty of the skin, vvhlch in itself offers but little resislan<"e,
jielding to a great degree, vrhile t)ie Hrmer texture uf the Imnea,
muaeles, nnd orgnna, does not permit of .so mnclt relaxniion. It
Uiny fairly be sjijd that no one was evor killed by the wind of a
cnnnon-bnih
These n?m;irkB nre confirmeil by conversaliiinp wilh rnililiiry
ftnd n!iv:d aiirgeona who liave bati the pxporienee of tlio whole
wnr^ and who have hjul nn oppi>rtLinily of \vit^Le^sing imd learn-
ing, by personal experience, the etfeet of the pnssngp, near the
y, of pmjectilcs of a larger «i7G llian any ever used in war-
before. The testimony of o^k^tk and soldiers is to tbe
sunie effect.
In tbe enrly port of the war, fipfiire the subject bai] received
much ntfeniion in tbi?i couniry^ I published some casps of gun-
fthoT wcmnds, also of injiiries iti' the nerves from weapons; ihe
restilta of treatment of the bitter, at that ilme^ being very
mongre, A few of the fonner cjwefl. wirh aidditiunnl ones^ nre
here presenleJ. The latter have Jilrendy been given.
Cask CCCXXL — Bullet spJK htj romhtg in ConMct with
Bonf*. — An occurrence vrry r^iuitnou wirh the or«lin:iry spheri-
enl bullet is to sjilit on eaming in contnet with bone. The fol-
lowing case occurred at the biitrlr of Bull Run t Lmufcnunt
B- was struck on the left side of the os frontia with a round
bail, nod WHS supposed by hia eornradca io be mortally
wounded. He was ninrle prisoner, and taken to Richmond, A
prcijeetion wna felt under the «ca1p> about four indies from the
J wound in the integuments, and fto inciaion made over it* frtm
which half of the bullet, with ft highly polished cut Aurlkoe, m
removed* He retnained seven months a prisoner at KchtnoDd,
during which time the wound in his forehead continued open,
and suppurated freelj. He was troubled with acme uneasineN
iu the head, and occasional headache. On his arrival at Fortmi
Monroe, after his release, this discharge atiH fx»ntinuing, b«
WAS examined by Dr. Cuyler, United-States Army, who ^
eovered a metallic substance deep in the wonnd. This vai
skilfully extracted. The patient states a small portion of brun
escaped at the time. On examination, the extracted bo^
proved to be the other half of the ball, flattened on both Aukfli
and having embedded in it a portion of the skull. On the not
day, a piece of the inner table of the skull, which had ben
driven before the ball into the brain, was also extracted* Afta
the removal of theee substances, the wound healed.
The patient afterwards came under my care, and t«muDd
for some time in delicate health.
Dr. Fox, of the Naval Hospital at Chelsea, show^ me a case
in which a ball pcnetmtecl in the middle of the arm, and mi
cut out over the scapula. In ita passage, it struck the edge</
the scapula ; the ball being cut nearly in halves, and flattdwd
out in thi^ position*
In ahnoat every instance I hnve met with, when the round
ball encountered bone, it was cither flattened, or, if it met ll«
j edge of a bone, as of the jaw or rib, it was split.
I f Case CCCXXlh—GunnhotWoutid in the ^eck, At die
i battle of Bull Run, a man was struck in the neck, just bebiad
} the angle of the jaw, over the point of bifurcation of the carotid
I artery. The ahot bein^ fired from below, the bnl] penetmted in
? nn upward direction, and struck the edge of the juw, which cut
it in two, one portion rcmnining in the neck. The other and
larger part, pnsscd through the base of the tonf^uo carrid
away a portion of the alveolar process of the up]>er jaw, and
escaped tlirough the check. The hemorrhage from the wound
was at first rather profuse, hut waa checked by pressure with*
]iatjdkei^:hicr, and did not recur. The wound:) healed kindir:
W0USI> OK 0» CALCIft.
545
nit an Mbscesfl fi>iTHftl in the neck, wluoh wns opened* and por-
tions of lead and spioula of bone wore reimjveil from it. After
tne or two ahsceeaes of tlu« kind hiul formed, he recovered.
Case CCCXKIU.— Gutu^hot Wound in the Leg, — A mun,
27 yeara of age, was hit by a bullet on the inside <jf che left le*,
ibout its middte- The bnll pnaaed llirough tlie tibia, producing
eonipimnd fracture of the hone. The frjieruri? united rtficr a
■verv lonjj time, aa nho tUe wound of entrance, X'he wound of
exit, lnjwever, reinnined open, and when I saw him, eight month*
ftl^er the rei."eipt uf the injurv, W'.is of the size of a hnlf-dnlljir,
And Ijod on unhealthy look, re^einhling cpitheiial ciuicer. The
l^es of the wound had alreudy been dlejaectcd up, in the hope
of relieving lenBion, Jind produchig si heiililiy 8(ale of (he wound,
I determine<l to die»iect out the entire ulcer, ivhich was done-
,In the centre of the wound, and between the bones, a black suli-
ftanee was diA(^overed in an encysted state, Thi» was at Hrst
'thought to l>e powder, but wna afterwanla e^tplained by the pa-
itient fltating, that when in lUehnumd. on aecoimt of a aloi-jtrhy
oonditiou of the wound, be had been tu the habit of flprinkling
it vviili ^'harcojd, ^Joine of the granules of whicli hud been covered
up, and reijiiiied there. The wound, after the operation, look
en a healthy netien, and soon closed.
Case CCCXXTV. — Gm^shol Wound throvi^h /I,* O- C'al-
CX9. — The following case exemplilies the very slow way in which
w^ounde of a spongy bone take on the healing process : Richard
Roe. a private in the First Regiment JljLs*;achueGtia VciluniecrH>
was struck by a bdl in the lefl heel ; the ball jtik^^ing ruund the
OS calds, and coming out on the other side- The enemy were
firing up fn>m a hill, a little below. SliTirtly afterwanl^, he ex-
posed (he other foot^ when another ball struck him iu exactly
the same spot on that foot, past^ing through the o« culcU, He
was carried a prisoner to Richuiond, where he was under the
care of Dr. Charles Bell Gibfcon, of the Confederate Anur. In-
flammatiiU] was so extensive, and the pain so severe, that ho at
one time rcquesTL>d Dr. Gibson to ampututc the foot, which he
very properly deeJmed to do. The patient came under my euro
about m monlhs uft^rwartU, having regnioed hi^ Zihertr.
pruLin^ the wuund, I discovered a lar^^e piece of dclachetl b^|
The wound wns pnlnrped, and q portion cif bonp, th<* eiM oR
cUei^tniit, rtpmovcU ; mid th^ bone, ntiicb wue. rou^h in ono
Dinde emtxith. Al^er this, the wound ^rsdutiJly healed, £4>
at one time, he rjitild use his foot in wfllking. If ihen
inlJsiTiied nfjuiui ^nd began to diachtir^e, 1 ndvUed him to
the IL>^pjt:df two monihA alter the fir£t operation- tTlic boM
waa then ex|>o^ed by a large incision, and the whole mtcrior oi
tlie cnvity ex(*a^ated uilb a chisel nod drill. The mouth of (k
aperture in the bono \mib unide niLch wider ihnn the inienW
In April, 1862, nearly nine nionrhs of^er iho aceident^fl
wound was nearly healed, but ttill painful if he Aticnipto^i
walk ; and it was difficult to say whether he \^-ould rceov^r with-
out the removal of the whole bone. The rest of tl>e foot wai ift
n perfectly heahhy state. In June, 1862, the wound hnd wb-
ti-ncted to SL smnll point, there was n serous exudation froi
and be wae able to walk nbout. Now, IStiT, it is pcrfccUv
In moat cuees where 1 hnve had to operate for caries ofj
OS CftleiBf reiwQted operalious huve Iweu require^!.
Case CCCXXV- — G^tnahol Wcuud m the Thi^k.
Trnee oftJiG Bail at first to be discorertd ^Injor8.,
lit the heiul of bia re^inieuE at tlie battle of iXew-bcrn. recci^
hall in the upper and front part of the thigb, nhout two iLdiQ
below Poupart^s lifraracrt. The whole regiment, at the
were in the aJvunce, and were expoeed In an open field.
reclining position, firing on the enemy, who, in return,
firing down upon them from breastworks. He fell a h|oi
the leg na if from a stone, nnd was not awnre thjit he
wounded, until, on ren»ovin<: hJs eont, he ^aw iho bloml doi
freely. He went on j,^iving his ordera until he boc«iac faint,]
waj* t:iken to the renr. The wnuml, being probed bv the nP-
geon, wfiH hmnd to extend in mlirectioii downward and lui
for three or four inches- The bail could not be found id
wound, nor could any irai^e of it he deleeted ekcwhere,
only eensaUon he folt, in addition to a general w^ant of powi
the liiub, woB that of slight numbness in the calf of the 1^ aoi
]
in the foot. Perf«cl rest of llie limh was enjoined
inn mm; and, Jihijrtly aft^rwnj-d, he was Ijr(nj;r|it linme m a.
transjjikrt ve^^el, with i»(lier woitniird soliJierA. 1 enw him, la
|DOtiipuny with h]6 phv^it^Ian, Dr. ChiLrlea Gurdoti, itbout three
^weekrt aAcr the date af the injiirv. An extrtvated ulcer, of the
BLzc of it quiki'ter of u dollnr, nturkeil die nitunlioii of the entrnnoe
(if tlie hail. IJodeniealh it, in die celluliir membrBDC, was a
IdepOMt uf lyjiipli, wliiuh, on being moved tif imd fro over tlie
muectea, gnvc u,t iirst the ^eii^fition of the picj^ncc of a ball at
tliat .4jiot. A HmaJl piidiole In tlie centre, from which issued a
serous fluid, at first eeenied to conSrm this view : the history of
I the wound, however, was oppo^eil to ft. A probe, bein;; ^titly
pressed into the openji]<r, ciiuouutercd uo forei-rn subatauce. The
pntieiit beiu^' of £iie phyalciL] development, nud quite free from
fat, the coulimr of the various uiu^clea waa strongly marked. A
careful exaiiunallon was uow tiiJidc of the whole liiuh, coiu-
mencing at the toea a,ad guing* up to the ^roin^ Enakiiig such
limni|iulutIo]is \is to Imve no one of the uiu?^ctes or iuterniuaculEtr
Bpciccfl unexplored. Xot the sli-rhtesl pam could be pr">duceJ,
or indor:Ltiijn felt, to mark the pre«cnue of the concealed bullet.
Finding no tmee of thu ball, JL wus decided to allow the patient
to uftfi the Ihiih. On fir^t making' an alti^mpt tij jit:iud, he found
much dilfit;u1ty in Join^ IH^, bi:itb from the stillness of the ivound
^feaud from tlie dir^nse of the Hmb ; but, heiug supported by twu
persons* and making an eiFort, he wa^ gradually enabled to
move EU'ouiid the room- 1 advised \i tontiiiuauce cf this eser-
^P cise, ID order that he might re-^^in, aa sogu &a poAMble, the power
of the niu.^t^les, :md wUh the hope* Dliat the muafudar Jietinn would
Ibriug the hall from its hidiug-plnee> TIuk proved to he the
Giiae ; for, iu al)out ft eouple uf weeks, a hiird, movable sub-
fitance, which felt like half a, sphere, was found trnvelling np
the limb. The bullet, it was hoped, would follow up the trac^k
(if tlie woLuul ; but it wa.* wjon di*^c^^vc^ed that it was very mova-
ble, quite under the reclns muscle, and eoidd not be distinguisfied
Int all uht'n this niufi<'le was rontraetod. After arriving iiiiiler
the oEd winuid^ it was thought jHissible that it might re&t there;
but it was found that its disposition was upwards, towards tlie
groin. Major S,, being very desirou? to gel rid ol' it, and re-
joLi his regiment* decided to have it removed.
548 GUNSHOT WOUNDS-
The ether being given, the patient waa placed on a table, wit
the light from above ; anJ an incUion was made through ^
skin, cellular membrane, and faecia, and the muacle uncovered
No cicatrix could be found further, ae a guide. The ball wa
now fixed by an aid, and the muaele careJully cut thronirh;
veaeel tliat ran across it being tied, so aa to prevent any deep
seated effusion of blood. The ball, from its coDstant dispositia
to change ita position for an inch or more, caused some embu
rassnient. It was felt to be resting on the bone, and wa« tbo
fixed by two fingers in the deep wound, and the muscular fibre
over it cut, and its blue coJor was seen through the delicate b
vesting sac. It was uecessary to divide this in several direction,
before it could be pushed out with a director. It >ras a roonJ
bullet, flattened on one side, as if it had struck the bone, ud
then glanced down the limb. The bone, not denuded, coald be
felt beneath. The wound was brought together by adhetdn
straps, and a cold water-dressing placed over it- The mo*
rigid quiet was enjoined. The limb, on the fbllovving day, wia
aore and swollen ; and, on the fourth day, an ahscesa formeda
the situation of the sac which contained the buJlet, and ^
charged itself through the wounds By continued rest of the
limb, and absence of muscular motion, any eflusion of pue under
the muscle was prevented. The patient completely recovered.
In the present instance, and in one or two similar onee, n<^
tenderness in the trnok of the ball pointed out the course whidi
it had tnkcn ; and this fact is important, as the want of ina-
bility iu the track taken by it is occasionally given aa an anzu-
mcnt that it has not entered at alL As before stated a pjJr
was felt in the calf of the log, at the time the wound wasiv-
ceived ; also a numbness of the foot, and soreness about ii»
ankle. The former disappeared after a time ; but the sorenes?
of the ankle continued until the extraction of the ball.
Cask CCCXXVf. — Gunshot Wound front a Conical Bul-
let in (he Cajf of the Leg. — Lieutenant C. , of the Second Mi*-
eachusetta, whose regiment had fought ilurin^ the whole da^^
as rear-guard iti retreat, the ilay before ihe battle at Winchesier,
and probably saved the army, arrived in canip at twelve o'dix*
at nig'ht. haying cuftrdied thlrty-fiyc miles without food itnd
drink, eic^efrt tlie muJJy water of liie rcHulelde- Lieutenant <J,
that! char^^G uf tlie ca^nip-gLinrd i'oc tfie night. At four o'clock
in tbe mornlnj^, llie battle begnn, anil looted four hours; and,
when the re^^iiiicut was in danger of being auvrcuudcil, the onlcr
for retreat waa given. The re^jimcnt fjnued, and niaruhtJ
ckiwn tbe luJl into Winchester, regftrdJea^ of the enemj in full
pursuit, wlitMverc firing intc^ them. Lieutenant C- was in coin-
»niaad of the reur company ; in faet, the [ast pcraon brintring
Up the rear. He received at tliid time a shot ia the cnlf of tlie
leg, diC aenanliun bcin^^^ that i»f a violent blow with a cliih, which
kiiock&d Iiim di>v\-n. lie attempted to ri^e, but, after sturubliiig
a few etc|>s, itil headhjn^. By this time, forlnnatelj , tbe ecr-
tgcant of Ilia company perceived his eituatiant und, being a nixa
of great size and alren^'th, took him in bis arras, larricd liitn
about two hundred yarda into tbe alrccta of Winchester, :ind
idcptiBitral him in the only ambulance- wa^on that happened to
be there. A. nmnber oC other wounded men were put into the
,Bame wagon, some of ihcm lying upon Wim. He contrived to
MLt bi^ head out of the front of the rehielc, t4o aa to ^t air ; and,
in thi6 position, with \i cnaji lying on hia wounded log, remained
intil tliey arrived in W ill ianie port, on the following morning,
\- — aomc twenty houi^e. He waa ho completely pinneil to tlie
^apot, that he was unable to ebenthc his eword, which lay drnvni
'by liifl side, juat iia he w&a placed with it \n the ombulance.
On the paeeage through U'inchetlei", a shell, apjurenlly
Lhrown at the ambulance, which, if it had penetratcdi would
have di^fltroyed all the wounded within- killed a man lying within
two feet of Lieutenant C. On the afternoon of the following
tyi Lieutenant 0. hatl hia wound exunined* It waa found
fthat the ball hud penetrated at the outer and upper part of the
left leg, passing through the belly of the gaatrocntndue muscle,
in the vicinity ^ji"^ the great vessels, and had been stop|icil by
le bone. It had carried in with it a patch of the troueera
^ftnd the drawer^i, which were of tbit;k knit woollen* wiihoiit
taring tliem. From tlie swelling of the wound, the whole of
khis plug, nearly ua large as the cork of n quart boltle, had
been eomplctcly wedged iato It, ao aa L>aly to be witlidrawn by
550 ouuaiiOT woi7?ffi>8-
free incisiuni*. The wi>iiri(l remainwl quite jwiioftil for iff
dnya, until supjinrjition hai\ trnmmcnc^ ; nnd, after (K* M'
fi immth, sfi)wl\' lienlfnl, fhv! ]i;ilitiit ^i>ttiri^ nbout on enrr^
TUii W'^ ^\i^A ^omEwlifit lM-nt« uml could not en^ilv bc litsv^ <
tlte Htjor, isn aooount of the cimtraction of thc^ injut^ mu-^
The CJUP ii* ^ivpti 9(:»m*?whaf in detnil, to ehow to irful rcn
the ac»l(Jier U cxpoaed, iptkpeadciitJy n*" the daDjrcr frw t*
wimndji. Thrit a yoiinj^ man, scarcely ei^htee?i, dtuuld br b
tr> mjirr-h thirty-fivp milrs with hi;* re^ment^ con^ianilr f sfc^
mill uirlimji t5ioil, Icwp jTimril nil ni^hr, en^ra^'^ ia i i^'
liiwi.in^j; tuiir hfiun* tlie next riKirning, be w^oumlo<J, and, "'-j
suftenng and blpedin;^. lie twenty bi*iir« with m. mun on hi* '■■'
Ji*n linib^ villi rMtlhin^ to Kn^^uiii hiTii^ cxrept t^ti th*; M^ind '^'
n iWftilow nf wiiinki'j, — shows htiw mndi the human inm'^
1>ctir when nM^UEpd hy H]>irii und deieriiiinaiinn.
"fliifl [mlh*nt wnfi jilUTWHrilH wonmlcHl in the unn, injiinnirTy
nerve ; and the ense is reluttnl in rlio chapter on injuries i^ cv
nerves. SuhBeqiientlvi he waa twice under my ran; willi *»ni^
gunahnt wfiunds. It is a curinu!* fin-t. thar, }>oforc the WMf i
hnd hiin iti chnrjre three tiuitu, willi thu'tiire of (he li'tr ■*' *"^
being am uncommon in^tane^^ lA' ri'peaied itijiiric^ r^uirin" ^^
gical dAfiisTnnee. He finalU' ffll n victim to the resuiu of flP*
sure, iTiourrtti during SherrnHn's <?aiu[wugn_
Cask CCCXXVU.— Wound in Chent ft-om Orap^^ghoL-
A s<»hlier. 3M years of Ji^e, wan hron^liL irilu the Ilospititl on ■*
count ijf a wniiEid in [Im rfim-nv, rt?(?eivi?d « weefc before si ti»
battle oF Newhern. The bnllj whieh wm an iron one, wci^itt
Rix ami a half ouneeH, ^tnii'k liiin, ^is he wa« in tt Etoopinif poii
tion, in the left axilla^ wuuniJing the tle^hy pnrt of the anc
wliicf] was hi cmilJK't with tiic side. It foiled in the nbtJ, utd
ahl^ ran between the tjkin and the parletes of the thorv
and made its uppearanee under the nkin iif the 8lorniim whei
it wnts (Mit out. The rihs were hmken at iheir juiictidii wil
the fiteriiutu; the lunga wnundei.1, and he e^^pef^tckr^ted blooi
In wliat innnner the wound in the luai_rs was prothiccd it v,
iinpnssilile to sav, — wheilu'r hy the liall ur ihe fractured rib
When he entered the Hofipilal, nu teudeniesa or IqcilJ nppca:
WOUND OF PELVIS,
551
Eanct! indica-led tlie track of the bnll ; eo ihut it cnuld not be
,4ftiil whether it hnd gone througli the cliesi, or had run along
[on the outside of the rib». The wound in tlie axilla healed
rajiiiilly, bnt on the Btemum very slowly. There wna no fia-
tiiUnjB 0[>eDinir loft, itnJ no discharge of bone. The patient
recovered alowly, his principal Hympiom being gvent debility.
Case CCCXXVIII. — Bulht iu Pthis. Excruciating
hiti in /Sciatic ^erve. Operation. Redef. — J. Y., aged
S, received two balla at the buttle of Williamsburg. One struel;
m on the upper and hnok pan of the left arm, nnd went hobind
the U>ne, cotiung out in front ot the chest. The other entered iin
inch above a line drawn midway between the trochanter major
and middlo of the Bacnim, in tlie letl hip, nnd di^nppi^ared
there. He wns disabled, lliougb not in great piun at first. A
week flfter, he wiw seised with the moj^c exertieiatiiig pain in the
course of the sciatic nerve of that side. He was taken to Balti-
more, from wliich plnoe be wna brongliC on to Boston by steani-
ibcat and railroad, being curried oWavs in his father's arms,
\to lessen the jar fi'om tlie motion of imvel. I saw him about
ten day? after the reoeipt of ibe wmmd. His left limb wna
drnwn up, nnd he could not make the slightest movement witlj-
out severe p^in. A probe, passed into the wound, penetr^ited
'three inches, when a hard suljstance was encounicreil. Whether
fit was bone, or the bullet crushed ngaitiat the bone, could not be
determined.
The following day, I had him removed the Hospital, &n<l
■niiide an exploratory examination under ether. The external
wound beinrf enlarged, the finger passed through the gluteita
|jnaximii8, under which was a t^avity. Sdll farther on, through
a narrow ^[iaoej the pelvis wns reached, and a smooth opening
which appeared to be the sciatic nott^h. On the inner side of
Fthe notch was a hole, through which the hnll had penetrated into
the pelvis ; ilie apieula of bone lying loose in the neighborhood
of the sciatic nerve. These wore removed. Another smooth
ioavity, which would hold an ounce of fluid, had been formed
under the deep raoscles, A probe passed easily two-thirds
through the pelvie cavity^ without encouatering the ball. A\'uter-
552
GUXSnOT WOtTKDS.
ilreesiniTfli, find a poulli^^ iif)«rwnrr1s. irere pat on tlw viV
and tho pnlipnt vvas rnudt rolicvcJ b_v the operation. TVp
pipul k^aiii^f< iit' imtatiim apponrai tu bo the fnk^^meste ni^
]yin^ on the ^rctit nerve- The sitiiiLtion of the ball tk^*'
appear. The patient rorurnetl home f^rrontlv relieved; wL
fur OB I fi»va ](<arm-<], tie bull never tuodo tie mpttmR^'
causi^d him farther tninblt.
Case CCCXXIX, — .V^^*r Toff A iodfft'.ff in tJtfTfm
— A floldipr, about 20 yeftrA of fli^r. entered the Ho»prld<*>'
len ilius uficr the batelo of Williflniwbur^, havio" TT«ii«
wound fr<»m a JjuUh* whM^h "Tnn'k the ri^ht eido of the ^
jaw, aud passed "iit Throuijh the iippor lip. Tfio jaw ww*
tered ; nnd, wht-n he onterwl Tl»f* lliispital, there wcrr puwt
d<?|>oBiH cornicctiiiff with \\w nock PMi?rnally- nm! lJ«' »■
internally. Tht- pmieTit was etherized; hikI, ihr vrrtunil ^
eiplortxl, pieces of bone wvm found evcry-whcre burji^ b
Miih^tiLnc^i^ of the Hieek and the snrronrtdiiiir poft i>jtrt'> T^
n'erc ('i:triicied, and thi? waiiad liealod rapidU-, Some »"
afterward, lie prp8ente<l biin^Of nl the Hospital, with » ivfiUi
ill Mio lonrriic, the wlffe of whiob bad h^eii xvoundcd hv iJm ^
let, nnd whi^^h^ unnl lately, ho had Iteen unabJc to pTfiDi'i
On examination, a Lard hody was found emb<^ded in the <^
etnnce of the orfran, whioh, on being cut U]jcin, pr(>vcil lo t*'
molrtr loolli, which had !.>ecn knocked out of the jaw, and ht^
in the tonp;uG.
Cxm CCCXXX.^BvUet lod^p,d in th^ Oorpus OiOf
nosroii. — I wae invited by the late Dr. Fox, 8iir^oa of*
L^ni led -Slates Naval Hoapital at Chelaea, to see the followia^ii
lereflting m-^'.y anil operaifim : iin 30th May, 1862, a miui abna
;ilj years of n^^e. while enga^l In a boat attack in Florida w*
tired upon by a party from ahore. One bullet puaaed ihniu^
the loft leg near the ealf, and was cut out on the opp(>siie ok
Another struok liirn at the outer and upper part of the wn
iinib. p!U(J*efl rhroogh the thigh, eruergiui; near the root of ti
i^crotuin in the fold of tbe thit^h. It then entered attain no
the same spot, and dir^appc!arcd, and he had no hirther trooh
WOUND OF VERTEBRAL ARTERY- 55S
m It For the timo. He rcturneil liomi*, nmi came under the
arge of I>r, Fux. Afti?rwftrUs, the bull wiis discovered at the
'-rooi fjf rhe pema, in (he corjni* cflvemoaum of the left Bide, from
, which |ihiL*e it gradHftlly worked over ro the right. The mun hml
no ditticulty iu uritintini;, and ito [mui durinn; erection. The point
of the hiillct, which wns si .\Hni*? one, was lownrds the bodr.
^St wan firmly heU by the fingerit, niiil then cut down upon. The
akin wiLs first divitlt^l, then the Rtrong^ fibmits coi'erlng of the
cflTcrtiiius bi.)dv : nnd, allhou<;h the inciaion was qmic free,
the foreign Buh^taiice re*ifited the use of ordinary forcep*, the
elastic finfe nnd eueiion of some crf the ti^siiefl operating to pre-
, vent its extractjou- The wuund being held well opeo, a pair
of bullet fon^eps iraa introduced^ and the bid] slowly extracted,
OS if frnm a l«vl of India-rubber. There was no violent rush of
blood from ih^ QTcctih il-wiie, l>ut a slow -continued disdmrge
afi from R large vein. This was c<mtrolled by means of a apon^rt*
and bandage. A graulnal Kupptjrniion, with apjinrcot elimi-
nation of the sac* whii'.h Uad formed nronnd or been pushed
' before the foreign ho<ly, fulloweil t and the patient recovered
in the most satisfactory manner. The cnee m important from
U» rarity, and for ihc practical flirts which it. tenches in rcgnrtj to
' the danger from interference with ihc erectile tissue, which at
^ first woLild appt^r likely to be more con^^idenible.
^^ Cask COCXXXI, — Gttintkot Wound, cutting off the
^B^ertehrul Artenj. — Corueliu» Mahoney, 1 1 years of age, was
^■fought into the Hoapilnl on Lho "llnU of Mav, liStil, having
^TBCeivc[l the cJiarijc of a pistol, loaded with stones, acciilentallv
fireil by a com pan Inn. One of the atones gnizud liis forehead, a
neotnd stnick him on tlie cheek, and \\. thinl penetrated the neck,
jibout half an inch below tlie niastoid process of the tern|toral
bone. He received the charge wbtle in a stooping posture, and
was taken up bleeding profusely. When brought inti> the Hos-
pital, iho bleeding w»« nearly checkwl ; watcr-dreusings were
applieil, Lind the patient kept vet^ (piict. 1 saw blin on the ful-
hiwiiig morning ; and, as there wa« a dirtpOKitJou La heuiorrha^,
lie was eiherized, wiih the object of removing tJje foreign bo<ly,
if there wua one, and cliecking the bleedbg. A fioger passed
70
cess of the second or tiiini cervical vertebra. The
now returned violenlly, antl but little doubt exist
vertebral artery had been cut off, A systematic ph
small bits of eponge waa made, and the bleeding chi
questioning the father of the boy, it was ascertained,
they were engaged in arresting the bleeding- at his
a handkerchief, a small pebble was discharged into it
by the great force with which the blood gushed forth
29th. — He had passed a pretty good night, an
from pain, except in his lefl shoulder, Pulse re<
from 140 to 120. Towards evening, he became
dehrious. He remained in tlii» condition for eight <j
ranging from 120 to 140, feverish^ and at times
head- On the 4th of June, be was somewhat b<
bandages had been cut off, and the spoogea remove
wound, on the 2d. On the ai^moon of the 4th,
hemorrhage took place from the wound, anaountiii
ounces, and producing great depression : aaaistance
tained, it was checked at once by plugging with a|
On the 6th, at two o^clock in the morning, a tliir
occurred, which was promptly stopped, about two
blood only being lost- Some of the old sponges wen
and replaced by fresh ones, dipped in the solutiou c
chloride of iron- From this time, he lost no more
the wound suppurated well, the sponges being all r<
the 10th- From the attendant inflammatory action
was drawn down to that side, but gradually rightet
wound had fully healed. Before he lefi the Hospital,
on the 2id, a piece of bone was discharged, which.
UASE CCCXXXII. — CompQUii'l urarture of ;^f:iut from
l*i»iol-nhoi, Xjosh nf C'Grvhral Substance!. Death jii^s
datfa after. June 4, 1^51, a man, 54 y&tra old, won foucd
lying in a ehopf liavin^ ntlf^inplcd euLude wiEli a pUtol. The
boll Ii!lU entered tha hend at abi^ut the middle of the nght
temporal foesa, luiikinrj a lar^e, irregular wouud-
Under ether, siit hours after the wound waa received, efforts
were made to find the ball, and remove it. The wound waa
^enlar^wl, aud a pair ot' dresaing foreeps passed in, whieh met
'ith no reaigtance until the opposite aide of the eranium waa
►ached- The bdl could not he found, A piet^e of ihe roof
|of the ri^'ht orbit, howovei", was extracted, whic;l» had been
Iriven into the brain. The examination woa made with great
ire, and occupied but a brief time.
After the effect of the erher liatl (jaseed away, the patient
remniacd in a ecmi-oonjscious condition, but answered quej^tious
rationaliy when nrouaed- There were no flip;ns of local or gen-
eral pamlyais^ except in the upper ovelide, which were fallen,
and the eyea, which were pvoirudiug and fixed. The lu'ine was
paaaed without diffieully. The patient stated that he could eee.
In the evening, the ejelids became verv much Gcchrmo.4od and
Bwollen ; and about a tablespoonful of eerebral substance wuB
discharged from the wound. During the nigljt, he had sev-
eral nltackfi of general subsultus : pul^e ISO, soft and reguhir.
P Brandy and water was given.
I 5th. The subauliujd diwinit^hed in frequency and severity;
pulse 22t mind clearer. Has taken notliing but brandy and
water.
*!ih- Fflsaed a cpiiet night ; pulao 100, mitk-ptmeh ordered.
^P 7lh. Uat her weaker last night; pulise 100, ret^pimtion 36,
flubi^ultus inoreaf^ingf enema ordered-
Slh, Very rostless lost nir^ht, tr>'ing to n^et out of bed;
aubsultus lefijj, pul*e 112, respiration 28, tonguo dry j etill eaya
tliat he can see, but unable to raise eyelids. In the evening,
he began to grow weaker, nnd aank into a comatose condition*
After hve o'cloek the next morning, he failed rapidly, and died
at hall-past seven.
The foltowing U the report of the autopsy, made by Dr.
deeply, lacerated ; a thin layer only being soflened
on the confinefl of the injury. A small fragment
a bullet were found in the bruised Inyer.
" A small portion of the Left hemisphere outeide <
the lateral ventricles was soAened, and filled with
A large opening cxiated above the right zygoata.
orbital plate of the frontal bone was nearly destroy
left badly fractured.
** The surface of the ethmoid bone waa also injur
regular portion of lead was found among the fr^gji
left orbit- A fracture extended Irom the large
the right side, across the frontal bone/*
Case CCCXXXUJ. — EemarkahhCase aft^j
lodged in the Nasal Fo^aa for a great ien^t
Fissure of the Hard Palate. Operation^ C?ur^.
35 years old, came under my care, who, seven y
while shooting, had his gun explode; the breech-pi
and penetrating the head, producing a severe woundn
ball was destroyed, the upper part of the socket en
as to expoae the brain, and an opening made in thi
of it, communicating with the naeal fossie. Hia n
very alow ; and he suffered much from pain in hii
vertigo. The nose was obstructed, so that he vrai
breathe through it.
Fourteen months afterward, a soreness waa felt o
palate, and a forei<;n body seemed to close up the ft
BBElXB-rni IN W.V&AI, FOSSS.
567
*sum» It is Uiree and one-quorter inches long, and ibreo
'inches in cireiiml'erfnce.
The eoLulitlon of the pstient, wlien he entered tLc Hus]>i1jl1,
vrn» as fLrlUiwe ; There wiia u fis^iirc in die palfitc; llit; eye-
flnll was guiie ; liie eyelid«, apparently iiTiinJured, n^mained
ipen; there was an opening at ihi- buck [inrt of the socketp
com in 41 ni minting vrith the noi^e and moutli ; the up|ier eilge oJ' the
aoeket wms irregidu-r, where the Lune hud hecii destroyed, and
the hriiin expOHed. lie ruuld not speak intellii^eitlly without
pressing bis finger into die socket* and clofling the lids, so hs to
prevent the [lEi^tiiige uf air ihruiigh fruiii the mouth. Kven llien,
on aiccounL of die fr:4»iure in tlie pjilnte, Jt was nut easy to iinder-
etaral him. Swallowing wue difficult, and reriuircd n cerlnin
position of ihc head to effect it* The first indieaiiun pE^nia] tii
be to obstruct the passtage of air tliniugh the sucket. To cflijct
diis (the pulient being etltenzed), the tnreal cartilages of the
eyehds were removed, the cut edges brought together by su-
tures^ and r<)ll(hlii)n applied. His ajieerh wat* lit tmce improved
by this o|)eniti<m.
The ibilowing week, the fiflsnre in the jralale wns n]«nited
upon. It lequireit much ilisseelinn to bring its eilges in r/>n-
tact, on account of the callous imd unyichling condition of the
soft parts. This was, however, finally ctfeotcd, and the whole
£ssure cIoHeih
The fir;^t operation on the pulnte failed, from the patient^s
having peraiflted in diewing tobact^o, and eating' solid food. A
repetition of it, however, with better liehnvior, wns auended
with success. The eyelids nnileil. with the exception of a very
small a^)crture, which, for a long time, rcsLdtetl all alfenipts tn
close It, and gave issue to a glairy Huid. supposed to come
frijin tho remains of a portion of the lachrymal gliiiid- The
hole was finally i^dnreil lo so small it size that no air coulil (lase
tbrongli it. The patient left the Hospital quite well, with his
-voice almost completely restored.
Dr. Henry G. Clark has kindly furnished me with the notes
of the following c&ae, which I saw at the Hospital : —
$59
GcysnoT wouxDs.
Case CCCXXXW.—Gnn/ih'^lWottfxf in th^ Backtfh
Jfeck* Lo^'i of Bone from iSpiitat I'rocesttcg. &ttndim,
n^eovnrt/. — "The pwlient, Cuptain O., wm« wuundc^l it tk
batUc of Cliirkmimit^'n, S^|it^ 1^, 186v^, by n ^Imi^-bull. vbi
cnter<^ the neck fit the nppor part, over the f^fHuci poMio;
forwnrtLa to the ri<^ht until it t'ounU a deep lodgpemcut oiukrtfa'
right car. Oct. 14f l?4t>3, he entered the ^liva^achuactta Gevril
HoBpitivI.
'*Ho wae a stout* heftldiy man, hut had bcon suffering fU^
from ewelling nnd iriflankmntiuD nloEi;^ the track of the btdJ* i^
tlywn tho ueck iiudtii- (he allele of the jww. Thciv woa aEfn-
Joii^ opcmn;j: nml n ciciitrlx behiml the i»r, tho fHijnt at nbia
eeveml un^ucccssfLi] attcniptfj hnd hf<-n mnilc rti oxtmct ttc U
" TiiG |>aCifMiC hein^ titiit^ri/.eiK s^ful the tistuluut* oitfiiui;^ c--
Urged, Ihtf truck of llio \M whb pjtplurod with Iho Hn-^cr nai
forceps; nnd several em nU picees of bone from tlic f^piEtntUf^
oasse^, mid bits of elotli, wem r\^ui't\'ft\. The htisc uf the o^as^
WW discovered to bare been ;^hz(.h1 ; but the baH could not bt
fbond. An incision wa» then made intfi the fistula, hc1i>irtii*
ati^dc of ific jaw, nnd the bfltl fuiind lyin;:^ two inehe* hdov, la
A ftorL of pouch, diret'tK' over and upon the cm-otid arftrr, W
CXtrJiotrd by the f*>reej«i. It was grooved from point to bw
hv ftttrition. From the extent and h^rdnc^a of the Awclfui:.
tlie b:ill uuuhl not he felt enternfllly.
"The wound wns tboroucj;hly cleanEed; and the patient Irft
the Hospital on Oct, lDth» rapidly eonvaleaeing, and aftcrv>-ardi
wholly recovered."
Cape CCCXXXV.— ffu^*A*>^ }VoundofJVecJs. Bnli a-
trticteU three months a/ler, at Bane of A*ci% in Contact tcitk
iSpine, — At the battle uf Frederic ksbur^s in May, 18(13, an
offiecr wne etnick, by a plungin;^ nhot, on the left elde of liic
Jower juw ; driving a portion of the bone, with three or fwir
teelh, doxvu into the ncek, from which t!»ey were femoved. Pome
wcekrt aftcriv:u-ds. by !in operation, Thi? bail glanced down ibe
neck, and disappeared apparently in the thorax. Si>me tbrtc
months later, wliile lie was [inrtidly rei.Tjverinp: from the effecis
of bia severe injury, a hard Bubstance wti« felt, just above the
WOLMl or KECK.
559
[iiviHe, mnlcing its wny iipwiinl JietweE'n the two ln?n(ls of f!ie
:;erno-maiit.oi(I nxti^dL*, Alter moving up ior IihIT nn indit il
roA Eirreaied, antl remained HULlionary fur une or two ihoiiiIibt
nil October, 18ti3, vih^n I iirst siiw Jiim. During liiir* pericni,
£nlfbrcd from o^FJiiinril pAins in llic left aids of the l'Ilcsc,
[yA|>n(r]ir anil various 8ym|)tucia inilicnlive of nervous irriliiiitin.
[l^e wiiB ocr'o.^iiino.ily tfelzeJ wkli severe pnin in the ]e¥t iirm. with
iimhiliiy tci r-MfiL' iU IjU'iing » while, and tljL'Ji imj^^ing ulf, but
lie hniJ at nci time ihe free use of the linkh. On examination,
tlie iiiiist:]ea heing relaxed, in tfie di^pre^aion htu^tween tfie two
[iii'^iTtioTis <if (he sr,erTio-tun^toiil Enu^i-le. n hard 8nli?<tiuire could
be fdt deep in the neck, iyln'^ <in the b*x]iej4 of die veriehrse,
and reeiedin^ n little on pressure.
The pnltfiit wn« etIienKed with grent dif[i<:idt.y. It licin^ one
of those en^ej« in wliirh the ether euuues great Irritiition tti' the
,]un^ ; luid it vvaa only nl^er a Atru^^le of ten or lif^een miniiiea,
tliiLt be became sufficiently ijuiet, fi-ont hl« eou^di, Ui idhnv the
Oj>eration tti prot-ee*!. The veina of the neck were, iu e<mse-
qciencc, imieli distended with bluod.
An Incisiion was made, juat on the ontside of the gre;it ve.^-
I, two or three Indies Iji leni^^lh, dividiik;; a l;brge vein in the
time of till? diH^C'etion, by wliioh a slii^lit delay wus oeea-
«)Gned. chiefly owing tu the struggles of tlie pntient in hrentliing,
And fnnn fenr of ubaorptioik of lur in the vinlent nioveineniA
of retf[>iralion- It wa*i, bnwevcr, wjnn lietl, and the dissection
continued downwaida and to the outer aide of tlie large \ew<'lf*.
The foreign bixly whs now exposed, covered by n thiek, while
euveh>[ie, which \v\iA eiOier the ttae mjrroundiiig it, iir the in-
tamal jn^TitUr vein lying empty and Hattenetl over it. A hole
waa tbcrefore earctully wratcli&I In it< when a qnnnliiy of white
niilkv Nobstunee esejiped, tLhoiving that the ludl had been eoii-
iniiied in a eynt or nac. The o|>cning wan then enlarged, iiiid
the bullet pried out fnnn it^ lodging-pJaee by the aid of a
furcejif4 nial dheetor. On panning the tlnger into the ftue, it
was found to reach the ExKlies of die tertcbne. Tlie bullet, a
conical one, xvaM flatteneil on Uie wde where it hml tmpin^d on
the bone{ and die ct;p-cihaped cii\ily in its barte wna tilled widi
a tliick white jia^te* louking somewhat tike mortar- It hud
560
GnSfinOT WODND3.
jippnrcntly penetrntcJ the cheat tu a certain extent, perhitris
ploti;^4iin;;; iilj tlic |)loLirLi, tind hud tlicn ^mdiialiv worker! ifs
wiiy Tipwardfl, until it hod readied llic epoi when? it vrua f>mi<l
en-^ysted. After n fow Uavfl, during' whith there was *omc
ditliculty^of J4Wid]i>wiiig, reirbvery tat.*k place without other un-
toward svm|>riirnA.
He vieiied van, n year af^er^varde, id a good condidon of
healili.
Case CCCXXXVl— Wound of Chesi from I^isiol-fmlU.
D^ftfh ^ifjht 1/ears /rfi^r. Pi^ioi-bfiils ei'^psuJcfl wii/ttn the
C'h'^st by t/ie I^leurti. — lo a fit of jcnlousy , iv man fhot hi*
mUtreitd, corain;; behind her while she waa fitting on a low
bench, fLud tii'iii^ down upon the chc^t. He then plfured a
pietol to his heart, and puMed the trjfj^'er. In the act of di*-
clkar^ni^ the [Ui^iol, the luu^/le heontne u Uctlc elovatcd, so ihut
the hidlotd ju«E e$c:iped the heart and great yeea^le in iheir pa»-
fia-^e through tlie chest. Buih theee patients cnme under m?
care at tlie time.
The woman lived tliree dnya, oud then died in grent n*^nv.
On a posl-niortem exdiuinalion, it was tound ll^at tmc of ll;e
bullets lind passed tlirouffh the cnvity of the che^t, and lodg:oil
in tho body of a dorsul vertebra. This vertebra 1 now b«%c.
with the bftU deeply embedded in it, A second bullet struck
the firel nb, wae cut in two by it ; one half inivereing the lop
of the rib, the other trftverfiin;^ the lun^, being fjund loose in
the canity of the cheat- The heniorrhnj^e produf?ed by thi.^
wound filled the chest, coniprot^t^ed the lnn«, and waa the iiu-
mediate ciiuse uf her death. The third bullet entered ijie neck,
and ita course could not be traced.
The man, immediately on being wounded^ had p"cnt craphr-
Benin cf the wnlla of the chestT followed by entire Hutncds oa
percU8£ion of that aide. After a very severe illnese, he rccoTCwd
Euffieienlly to be brgught Co trial ; and, being convicted- wm
jaenteacml to the Stiite Prison for life.
I saw him at the prison abouc four yeare after. lie then hwl
a couBtiint, dry cuu^i. On niiscultation, the re^^pLmtion vtaa
found rough on tho left siiJej and somewhat bronchial. There
ll-OUND OF ABIJOMKX.
561
waa no rale. Pemiaait^n TtiveaM notliin^ &l)Ti{jrm:il, Ri8 hciiltU
was otherwise ^[oikI-
Hg (liail fliiddenly, eight years titter the crime was camniitletl.
On oxarainnnoii , it wjis eupjHJsal l>y Dr. \tirrin, Sur^^tou lo
ibe Prison, that aome disenw^ of the heart would be foiuid tu
expluin hin death. No ^uflieient HIsphsp, however, cindd be de-
tected. Tlip vnlvtw of the hen.rt were thii?keiied, hut imt enough
ti> impeik' clieir Rc-tiiin. In tlir upper lohe i»f (he laii htng, ii
cii'iurix. showiag the couriw of the bnlirt, was diKtirutly viftihle*
The bnllfi. having tmversu] the lun^a* hnd IcKlgBil in the Mv ot
the eliesl. From ihi.* iilaoe^ 'hey had bt'i'imie ^rtdimlly de-
tifhed, and were fniiud sUfipended from the Aider* of die diest,
like cherries limiting from a tree, having earned the pleum
beliire tbem, and bein^ enveloped in thul membrane.
I
Case CCCXXXVII Gnn^hol Wouttd of tfie Abd<»men,
JltHoiccil htj littMHfimtt FiKhiUi. Jierovenj. — At tlie ballle of,
Chan(?ellorsvil[e, Mny, 18l^<l, a atrong healthy m;tu, 25 ycurs*
ofuirc, war^ Htruulc on the riirht of ihe abdotaeii nenr the uiidaJi-
C119 by a nnisket-sbot fired from tin eleration. U penetrated tfie
|)eritoneal envity, pjifi^ed ihmn^h The pel vis ^ and nnne lait
throutfh the middle of ihe ritrbt iiimn. No verv seveiv irt^ritiijihia
oceiirred, nnd it was not until ntler eeveraJ dny» that fecal matter
appeared at (he wooed of evil- Pierea of bone were oecnsion-
ajly discharge from the ennie aperture. A|\er sevend mimtlia,
this wound heuleiK and dl^charge^t of pus and fece^ eame !4way
from the wound of entrance, in tfie front of the ihdoioen. i
HrHt saw the [lalient in JannarVt 18^4- He wns in good fieahh
and 8pint!i, witli the exreplion of the annoyaure from the wound
juHt d&4ml>e«l, and a Inmenef^s in the right lower extremity,
resulting fmrn it. A small boii^'e, ietmdiiced into the wound,
peneirnted abtatt eight inehes in an oUiqtie dirtK^tion, when it
eucountercfl dejid bone in the neigh ho rlioiMl of the pelvis. Alter
one ur tw<i explorations with die houpe, a lon^ pair of iil3<]fhlly
eur\e<I fureeju^ opening only at the extremity, and made of two
biTinehes rolling on each other, was careftilly introduced, tho
edge of the bone seized, and »m,ill fra^ment« of it removed.
From a fear of wounding ibe intestines, however, the operation
71
AAS
OtTHWIOT WOUXDS.
wiifl not persiHte<i in> A jmiillice was applied to iherj
the hi[), whirli wnn lliUft made to open agnin ; UTiA, ^'
UBiTuw (!aJI<]Ufi fi^^liitfi, llie lioiie ciiuld be felt, hv ihr jWrr/
somewhat LtvonJ the rencU of the Gn^er. Purttmu gf W
■were nirnin removtsi : hut, na the main tVagtneni •eeoicd U
nn^ilur in form, and was in the immediate neigKbcrKoud if
oipcuin, in which |mrt of the intedtiiie the »|tetiing
exiaied, no further nliem|it van niii(ie ; die *msG \mins
one in which great caution was iieecsBarj.
Early In March, thp wound of exit was diJjiied po di to
the forefinger to penetniie its wh<jle lenj^lh thruug-h ihe fiitok*
pflssjige; but the dead bone could tiui be reaclie<L ThefoTTT|F,
being pnf^fled in^ woidd ocentiitmally grasp the ed^ of tiicton
which HeemiK) to he nttitdicd to the |>e]viiA, iind involved rnik
folda uf the inie^liue, frofii whieh ii was dangeruiiEj vioJcnfti*
remove it^ It waA therefore decided to leave the caMfvik
.time to natiirOt with the hope ihnt the fni^rnieDt imglii Mf
p4.'r vine paturaled.
A few days after the last eiplorntion with the forc^eps, ■pP)t
wns introdiu^nt, nnd it wtui fmind ihat the fragmciiii of httut b^
wholly disiijipeured. Forty-eight hours later, cm visiting ti*
p&tient in rhe morning, he, in grent delight, held up & |ii«**
bone which he hnd pnssed the day before from the rectum, »i^
out pain or impediment to il» paHMge* The frnpuicnl ■'
Bomicireular in form, conijirising a portion of both the inutr 3"!
outer surfitcea of the iliun^ nnd mensured about two inehe* a
length, by thrce-qunrtera of nu inch in breadth, lotjking 0^
unlike n portiun of the first rib. The diselmrge frvib Mt
apertitres at once diminished ; and, at the end of n week, H^
were Ldmo^t olo^etl. lie left the HuspitAl, il:ircli 28t}i , Ving
odvieed t[> nuuntaia the horizontal posture, and a\oid TOOch
motion until the wound hud become perfectly sound, and ^
danger of tetirin^r throii-jh the adhesions was over.
1 &!iw ihi* patient, in lJ^*ii5, in a eomplete gtato of hetllh.
Hi* wounda were henled, and no funetional disturbnnce depen-
dent upon them remained. 1 quOBiioned him purticulnrly M W
colic, or other syuiptoma wliich might arise from a ooDtnMUJ
iDteatine, but could diacuver nothing.
.SE CCCXXXyilh — Bullet pa^sutg Ifirotr^h the Elboic-
IT joints 'ti'<^ lodging in the iLiice-j'jiiU, Recovery. — A yoiing
tt officer, -1^ veara of age, wfiile fitoc»ping; down, ut die buttle of
ilieUm, to lie hia hnndkercliict" around the tingh of the miin
icxt to liira, wIki wna bleeding tu d(;atb, hia Ic^^ having l>ccn
[enrricd nwny br a oantioii-bBll. received a ahijt. which passed
liapionrtlly throHp^h his clb(>w-jvint» nnd entered and lodged in
lia kncc-jointn The clhnw, at the time, wna bent; and, from
lie iiofliiion he wus in, kid flni against the knee-joint. A^'rcal
)Out of blood at once took place from the inner wound in the
nrm, indicatinj; that flr>me large vcsael had been cut off'. He
checked the hemorrhage with a leather strap, buckled tii^ht
iftround bid arm. Of forty in hia company, ail but ten were
illed or wounded. He limped otf, on his injured leg, to the
[nearest ambulance atation, where the wound in bift knee-joint waB
[examined by a jjui'gcon. The prohc penetrated tlie joint freely ;
|;but the ball could not be detected^ From the etrongly bent
'position of tbe limb, it had apparently escaped the libia, and
Ipjijj^ed in bct>Tecii the eondyica of the femur, where it waa
:urely Jo<lg;ed and concealed. His arm and leg had water-
Mrcepingfl applied, and vrcre put in aplinta; and be was imme-
diately placed in the ear^, and tran^[iorleil to Hoaton, where he
arrived in the course of a week, wttli many other ^»ldiers. aotnc of
whom had receiveil equally (»crioua wounds, aiid to whom tlie
danger of transportation, except under existing rircumfltanees,
would ha\c been considered nlmoi^t n fatal movement.
H When I flaw him. be wan lo an extremely feeble condition.
Belonging to n fresh bod^' of troops, he had been marchetl, some
days before the final battle, and fought fi^r one or two daya
before, subjected to great Heat; his principal nouriahment being
gifcn corn, which produced an almost eonaLant diarrlicea. It is
probable lliat to thia condition he owed his safety. In addition
to the above wounds, he wiia eufFcring from a contusion of his
aide.
The knee-joint, I fonnd, wa« free from pain and in flam at a lion,
but the wound on its outside elightly auppuratcd. It was dressed
with a ham ajilint, and kept in a atate of cntli-c rest. On examin-
ing the elbow-joint, I found it quite If>o«, both condyles broken
J
5fi4
(lUNflnoT wooivns.
nfT. rlie joint wnvilleii, with an effusion or the inside, a hul
brilr* IigIqiv tUi? jcjint i.in tlie iiuUiile, inid ulictvo it on che^K
bIiIe. The elbiivr w^lh mnde iitiEikovikble ivith splina: ^M
ahvr a. iiiiyk-rnte ;inii^unt of inflHrnmntinn. whirh nt no timi
&rm>uiitec1 to any ihin^ tlirefltenm<r, liolh tlie knee-joint an4 Um
dhiMv-jiiint tVv] \H^rf&:t]y ivi?l] ; 8m tiint, at tlie end of two luikttt^
he wii» nble to g'o out of ilcxira. He linrilly roooverctl fill th
rai>Tiiins of the elbow-joint. Now, at iht end of (our vonrs, hi
vrnWf ivithout the l(?ii?«c ^ii^ri of Inmcncj^H, the l>iill dlilj remainiof
in the knee. Tlie power of entire flexion of the leg unlv iia
willing-
I
Case GCCXXXIX. — Ptn£ol-hti!i pajtfiny through £,*.
Recovery. — Siiine years since, a man wa» broiijjhi uilo
Hosfutal, who hi«i re<ieive(l, from a jiistul in carcles* hand^.
a shot, wliii;h [in^^wtl directly through the right si^le itf ilie rlie^
and lodge<1 under the integuments of tlie b;ic-k. When I ^M
saw him, he was breftlhin^ with <Jr11icidly, In a deadlv fnint am
ibrion, his head liavifiir fallori on hm che^^t; atitt he whj enilti
up frcply frothy blond. He wa* very inudi Jepresscd in
desired his wife to lje sent for» nnd Meeioi'd to feel that hU
Aolution w\w> iLC-ar at hand. I eiidivnored tu enmurarfc hi
mueh as possible ; and, after having administered etiinulnn
bring np the L"iruida:ion, remrH(.>d the bullb^t fri-inii hi« b^c^k,
st<>pped the action of the chi^sL by broiul strips of ndhesivc
ter cjirrie*! Itvo-I.hird* around the bi>dy. He eventually rG<N>t
after an attack cif plcuritis and pricunionilia.
The history of thi^ man was a L-uriouH one. He btul b<-e
California on a gold-hunting expedition ; and, \^-hil<^ then*. hg4
imagined that he coidd turn the waters of a smnll stream
riv<»r hy nieiiMi* of an Tndill-^^d^be^ tui)e, and ihus expose
^cJden j*iind hent^tlu For diis piiqmae, he liuil returned to
Dustonf and had cammed to be nmnufaclured nueh a tube, i
hundred feet long, luid six or eight feet in diameter, T\m htA
been nicely packed on board a vcs:*e] : and he was on ihc rvini
of sailing on hl:^ return, when tJie ca[itain of the. ship, jdavi
with a pistolr atrddcntalfy Bhot hini. as aboYc related.
i
WOUND IN THE (3KOIN.
565
Case CCCXL. — AntpHtfittnn of Thi»?i fof Oinishot
Wound, jtTodneitig F^rucfnrc find Dititortian of Thitjh, und
Anahffh}iiA of Knee-joint- Appearance of Bont rrinoved, —
May 3-4, l^iifi, a vminfr mnn, 20 yenrs of n.ge, ontcrecl the
Huripitul to hftve his le^ nmpEiidteil Tor gunshot wound uf
the thigh, receiv«i thri;tj yenr* Ijtrtore, wliirh h.iil hrokeii the
ilii'gh, ami loft ii m a state uf neornsis. The hall slnick him in
the hiLtrk pjirt f>f the thigh, ra.ther hpli>w the niitlilie* from whirh
j)ln<;ti ;i nuiiil>er of piet'es of" duad Imue were eTtnirled at the
time. During thi^ confiiiemcnt, the knee-joint hecamc unchv'-
losed, Almiit iL year before, he hail an wtUt^k of ervKijuOiW in
the leg: and six munths after, while jumping from a step, he
Btruck his knee, anJ hnd not l>een ahle to uac the limb sinc« ;
a dusliiict anap Ij^lrig heard in it at the time, Tiiere were m>me
ai^^iiH of n tuherouloud de{)OH^ in Im lanu^g. Hte hi\ ]e<r was
shorteneil nbi»ut five inchea; knee arichyloW ; the niiddk- pnr-
tiim (jf lemur whs thickene*], aa if large qnaatities of bone were
thrown out tliere. On the inner aide <if thigh was a eimtrix
iiijirkiut; the jxiint of entrunee of llie ball; on the outer, one
Hhowing the point of egrefla^ and a ^inn^, with dead bone, eould
be felt at thi^ point.
On the 2Jltb of May, the thigh was amputated by Bmall, oval,
anterior and poaterior flaps of skin ; the muscles being divided
at the bfisjp of those by a cireular cut. This patient reeovercd »\t
as to he able to leave the Hospital in about four weekti. The
following were the ii[i[ieaniu(*e>i '»f ihe limb removed : —
The knee vrnn benl, and die inner condyle anchyloftod to the
tibin, and the patella To the femur. The femur, where it had
hien broken by rhe ball, wim overi^hot about three ini^hent. In
the up|ier pnrt of the lower fragment, whieh wns behind, was ik
circiilar a|»erture the niKo nf a inri>ket-ball, Masses of lead
were here everywhere emheddt^I in ihe bone.
C\SF. CCCXrj. — Ciitfc of Guvi'hni Wfjund in fh^ Groin;
(Ac Bttti lodtfinif on the Capgule of flit" IHp-jotnt^ and under
ihe Great VkfiMett. Extrar-Uon tJiree iceeLn aflttrwarih. Re-
copfrt/. — Oiptain il. M., 23 years of age, at the battle of
Geltyfiburg, on the second clay, was stationed with his regiment
511(1
HlTJiHllOT WULNIJS-
iu tlic Sci'ontI Division, Swimil Corps, nn the cre?tt of tbe
oecujiied by ihp left centre of the nrniv. Oiiriog tfie mo
of the thirfl dnj, the enemy had ranasetl his artiUerv oppiuitc
thlfl front ; and, hI one oVlorlc, opened upon it frctm 145 pjOB io
position, for the purpose of clearing tlie way for tho advanw <A
hU infantry- Our bnttene?* replieil, and a must terrifio cannon-
ade wna Itept up fnr nearly two hours, after which the Eisaftiil&fl
mniie ; nnd, ihe hend of the enemy^s column havinn; i>i?netrfw!
and ohiained n lotlgfrnent* ^'ithin uiir liiLe;:f on the ri^ht of ^hf
regimeutf the latter was onlcrc^l to change front obliquelv ia
the rii^lit tinil rexir, in ordpr in meet it, mnl rhock tta fiiftlwr
advnnee. In this movement, nnd nl short range, thia offijH
received aLuIIci in hia groin« nl oncedmbling him. He wu^l
ried to the reiir, where his wotind wujt cxainined by a ffur^toir
Tc was pnil^>eil, and a finger introduceii; but no tracM cF ifae
iwdl could be found. Tie arrived in Boston ahum a woek afto--
wards, in a state of grent suffering. The witunj Wfts ft
below Ponpnrt's ]in:;iment, the fluclllng not excesftit-e, bul
motions of the jnint e3ilreHiely jwunfid.
He wnH placed in a po^ltJEm where the limh eotild har«j
most perfect re?^t, mid :i{>pli cat tons need to reduce intlamoir
tion ; but. aller two weeks, symptoms of acute iTiflammat^
of the hip-joint crtming on« nnd the pain becoming aIiiio«t'^|
cniciating, I cut down nnd reniovi."!! (he hall, which had takes
BornL^what an irregular L-<iiirse, lyin^ directly uj^on the capsule
of the hi[>-jiii[it, which had not, however, appjircntlv becti pene-
trated- The patient wna then put u|ion a fi"nciurv*bed,
posed of a triple inrlined plane pkced on a eocom! pi
Bimllur to the one nued in a niKe of fnit^ture above, bo tliat
whole body could he moved wilhoTit disturbing the joint.
thifl posithiTi he remained for many we<'ks, lieiao; Dnnhlo to allov
any one even to tmich the bed without experiencini
sutTering, and requiring the nse of ether when lits clothed
clinnged.
At the end of one or two Tnonthe, the indiimitintion ha*
subsided, I broke up the adhei^iona to the joint, while ho vu
under the influCQco i>f ether. He did well, and got on ■
bul, from an accidental fall, not being aufficiently careful ii
after
i
]
wou!n> m THE onoiir.
^^ Case CCCXL, — Amputation of Thigh for Ortnahot
^^iVvift/fl, prffr/ttcittg Fract^rf and Dhtorfion of Thitfh, and
^^Anchj/fuftiH of /iJiec-Joinl . A.pj3f:ai'Uncc oj liattc Temoved* —
■^JJay 24, ]8(rti« a juitii^ mau, 20 years of age, entered the
^Hospital lo hiive hia leg ftiiipiitateii A>r gunsliul wound oi'
j^the thigh, rcctived three vcara before, wliirh hinl broken the
- lliigh, aiid l(*1\ it m n j^tate of necrotfia. The ball atruck him in
_^ the buck prut of the thigh, riither below ihe luiihUc. from which
place a number of pieces of dead bone were extracted at the
time. During the confinement, tlie knee-joint bcciimo nnchy-
loscd. About A year before, be had an attack of ery^ipelaa in
the leg; mid aix tiiuntha after, while jumping from a &te}>, he
struck hi* knee, and hnd not been able to uec the limb ajncc;
^ ft difltinet snap being heard in it at the time. There were some
" Bl;;;'n» of a tuberculous dejjoait in hi* bings, Hia Idt {c<^ W!\s
" ahorteneJ iibout five inches; Wiice anchvlosed; the middle por-
tion of femur was thickened, tm if Urge quantities of bone wero
thrown tiut there. On the inner siile of ihjgh was a cicnliix
marking the iK)int of entrance of the bdi; on the outer, one
showing the point, of e^'i^i^r^i ;iud a z^inuct, with dead bone, could
be felt at this point.
On tiir 2{)tb (if MiLv, the llngli wufi ampiitati^d by smalU ovaJ*
anterior and [KJHterlor ttaps of pkin ; tiie nm^cles being divided
at the bnB€ of these by a circular cut. This patient recovered 8i>
a9 lo be able tu If^uve the lIo^[iitJi] in abciuL fuur neck^t The
followhi^r were the nppOJiniuces of the limb rcmovctl ; —
The knee waa bent, and the laner condyle anchyloaed to tho
tibia, and the patella lo the feamr. The femur, where it had
been broken by ihe ball, was overshot nbout three inches. In
the upper part of (he Lower fragment, wiiicli naa behind, wus a
Circular aperture the aize of a muskct-balL Mii^ece of lead
were here cvcrvwhero embedded io the bone.
Case CCCXLL — Ctt/te of Giinnhot Womtd in the Groin;
the Sufi IfnUjinrf on the Cnpaidr of th^ Uip-joiiU^ and under
ihe Great Veaeein. Entrnctian thret icecLa nflerwdrdf^ Hc-
covcrtf. — Ciiptain II, M,, 23 ye^ire of age, at the bnlilc of
Oettyaburg, on the second da/, was stationed with hia regiment
566
orxewoT wounds-
I
1
in tlic Pocond Diviejon, Second Corps, oo the crest #»F the
ocfU|>ied by the left centre of Che t\vmy~ During llie mo
of tlio third dny, the enemy had rnnaaed his ftrtillcrr
tliifl front ; (inJ, at one o'clock, opened upon it from 115 gwn* ffl
position, for the purpose i>r doarini; the way for the od^'uic^ "f
hia infantry- Our Liittories roplieJ, and a most terrLlic c&nnaft^
rule wns kept up for nearly two hours, after which tbc n9«uill
mrwlc ; and, the liead of the eocmy'* column havinj^ pcni?!rn
anJ ohtmned a lod^^Pinent, within onr Hnes on the ri^ht of
re-^imeni, tlie latter waa ordered to chim^ front ohliqtiely to
tlie rl^ht nnd rem", in orJer to meet it. an<l rheok its fur
advance. In this tnovemert, and at eliort range, this a
received a bnlbt Jn his groin, at once diaabling him. lie waa
ricd to the rear, whei-e his wound was examined bv n ftu
It waa probed, and a fiajxer introduced; but no Irnce* of
hiill could be futind^ Tie arrivet) in Boston about a week nfttr-
warda, in a «lnte of grent BLifTenn^- The ivound w^e a \
below Pouparl*fi lirfnmcnt, Che awelling not exc^eeiv^, bul
motiona of the ji^int extremely painful.
He was placed in a poBition where the Hmb coulfj hate the
most jx>rfect rest, nnd iippllcations u*ed to reduce inHiim
tion 1 but, iifter two weeks, eymptoma of at?ute inf!aiiiRjAl4
of the hip-j<ttDt cominn; on, and the piin becoming- nlino^t
enidatin^, I cut down and i-einoved the ball, ivhicb had ta'
BOmewhal an irregulnr cour?e, lying; directly upon th^ ca
of the hip-joint, wliidi had not, however, apparentlv been
Iraletl. The patient waa then put upon a fraetiiro-be<l,
posed of a triple indineJ plnne placed on a second pU
similar to the one used In n case of fmeiure above, eo that
whole body could be moved without disturbing the joint.
this position he remained for many weeka, belnfj; tinablc- to all
any one even to touch ihe bed witliouc experiencing
iuifering, and re*|uiring the use of ether when hie clothes
changed.
At the end of one or two months, the inflammntion havi:
Bubsided, I broke up the adhesiona to the joint, while he w»
nnder the influence of ether. He didwpll, nmJ got on crutch
hilt, from an ^cidental fall, not being aitfliciently eAreful in
WOUND OF THiGa,
r>6T
use of his orutchea, the joint wiu wrenoh&d, and the iiL^nm-
mniinn reprodnced.
He Eiltimntely recovered with & com^iletelj strQight limb, but
Blif1^nG(1 bip-Joint, hEring imwilLiiig to j^iibmiL to the con^ncmenl
and uni:e[lainty ufFeretl Uy uiiolbur operLition to locsen it.
Cask CCCXLIL — Gunshot Wotmfl. Ffacfure in Higkt
Femur, til Itn Upper Third. Greirt Siippuratwn. Con-
Jitipment for ncarhj a ^jtar. Greiil DUlortian. Operation
Jor Ncctitsis. Suhfi^fjiiGtU Death from Exhmtniio'iX. — A
dislingiiis»bcii officer of iirtillery was shot bellire Peterahurg,
JuTic 16, 1864, by a Minir? bullet, whidi poB^ed thruuglj bis
left thigli, and penetraicod tlie riglit, ueitr tlie fold of tbc rmtes.
He was (rnrried lo a Hos[jitMl ; arid, ut the end of four weoJc*,
the bullet wa^ extracieil. He euffereil luuch frtuu his wuumU,
and frriin beil-^urea, which formed on liis hack. At the end of
four weeks, he was taken to his home in M}dno, !u au exhfuL-^tod
state, where he began almrtly to improve. Four weeks afier
thi^, while eadeiivoriog to turn in hiH bed. be beard a hmd snup \
and [[ninediiitc'ly bis rjvht foot bcaiiiie i[iverted, and bk thjgb
shortened two or three inches. In thij* condiliou he remiiiiit-d
until May, 18ii5, nearly ten months and a balf after the receipt
of the injury, when he was brought to Boston, and pbtced in a
privnle n>oin at the HospiCrtI, under my care. He wna then
very feeble, with a great discbarge from the wound in tlie outer
aud lipjier part of riglit thigh, and apparently failing. The foot
was fitrungly everted, the limb bbortened, the knee-joiut partial-
ly auchylose(], and he eouLd mjt he moved in bed without the
^rentest diflicnity, Hk waa kept idi^'e only by means of fomt of
the moet nourishing character, and large ijuantitiee of atltnu^
lants.
A consultntiou being bebl on bid case, the question was pro-
puited whether to amputate the limb near the bip-joint, or to
make an nttempt ki remove the dead bone; and It was decided
to attempt the latter. On the 7tb of May, a free incision waj4
made on the outaide of the tliigh ; and a large sequestrum,
locked in between the upper and Jowcr fragmcLtd, was success-*
fully removed. On removing the sequestrum, it was found that
568 GUNSHOT wotrHDS.
the npp^ and lower fragments touched each other, but were
united only for a space of about a quarter of an inch in cir^
cnmfereace. It wu therefore decided to attempt to remedy ^
great deformity and ehortenmg which existed. This w&s done
hj slightly twisting the foot, and the adhesioas eaaily gave way.
The foot was then brought up into a proper position, and, by
exteneioD, the shortening reduced to one inch. The limb waA
next carefully secured by splints and bandages, and the patient
transported to his bed. He passed a comfortable night, and for
a time seemed to Improve. Two weeks afWward, however, be
had some hemorrhage from the wound. He graduallj failed,
being worn out with the combined effects of suppuration, bed-
sores, and the bleedings which occurred, — whi<^ laat, tmder
other circumstances, would have been of no cons<kquenoe, — tnd
died May 2Sth.
Autopgy. — The upper fragment, about five inches in lei^th,
was turned outwards and downwards ; and, at about two ■"^ a
half indies from its apex, there was a rou^, irre^ulv anr&cei
the seat of its attachment to the lower fragment before the op-
eration- Its contour was quite irregular, and showed signs ef
previous disease, as also the marks of pressure made by the
pointed end of the lower fragment. The latter was very irregiH
lar in aspect, having cavities left by the removal of the seques-
trum* The interior of the bone was completely disintegrated
for some four or five iuchcs, a sanious discharge oozing from it-
The angle made by the two fragments was very strongly moHced.
The adjacent part of the thigh was completely riddled with bur-
rows, one of which extended as high up as the ci^st of the
ilium 1
CHAPTER XIII.
MISCELLANEOUS CASES.
PEyETRATlXG WOUNDS OP IHE GHEBT AND ABDOMEN.
!nESE are rare In c\v'\} practice, but I h^ve met witli wveral
mgeroiis woiinilji Lm[»lii']iLing tlic ciLvitieH of the ijlie::4t and
lomeiii — more e^pi^cinll/ ihe former, — which, cnntrary
■ ihe uj*ijrtl]y receivfi! oplniun, have recuvered under jiuliciouH
ire nnd iimnngemenL Since tlie war, imporlsint discussions
IVQ h<!en held on ihia suhjecL; and in co^^es, for insttTince, where
ills hiitl pas?cil i!irtii[^r]i the ehesXy followed liy rLH:<ivery, ihe
lijtgQosis U\ts Leen ([Jie.*tioiied. 1 wiw ^dntl to find, however,
ml innny tli^tlngiii^hei] surgeons hnd been hrouvht to the same
inHusioiw, in the greiit fidd of imjuiry winch wus ofTereil to
lein by the war, thnt I hjul a^lrenxly arrived ut by the smnll
:|ienence in these woontls presented by L'ivil pnielice.
Tlie eiperienee of ihe late wnr also shows, conlrnry to the
ipulnr opSnimi, the ranty of woiinda by llie snbrc arnl the bnyo-
ict. Out of 87,822 waunJs tlint were clnswified, tliere were
LOli 8itl>re woutuIh ni^d l^*! Liiyonet woimdit : 11 died of the
former, nml Ct of the bitter, making 17 in ulL
ftiilhrie, one of the most (listingiiisbed of English tiiiliury
flurgeons, teatlfiea lo the great rnrity of this lieacnption of
wounds-
In illustmlitm of the nhovc remarks, I woidd quote from C'tr-
culiir No. 6 die following n?snlts of gunshot woumls in the
c!ie&t; and although it may be eaid that theae wounds arc
diEK'ix'iil fmni womnls m:nle witli it [Munted weapon, yet the
diuiirej- would he in favnr of the former r —
*- or 7,0G$ guaahot vrounda of the th«9t whteh hnvo been examined,
nnd truiiscribed from tit) reports belongiag fo the pHriod prior to July,
72
i
I and sufTering.
570 HIBOVLUmOUS OAAsa.
1864, there were S^OS that either penetrated the tltonde ctTitjor
irere BccompHuied bj lesions of (bo thondo vin^nt Tlie renltt bn
been Bscertained in 1,372 of these, md were fatal in 930, or 73 per
cent Tho 4,759 tIeAb-woirnda pref>eDled a rerj wdkU ratio of mnlil'
itj. It waa obeerredf however, that Ibej wera commonly long in bcd-
tng, in consequence, no doubt, of tho mobllitj of the tbcmCTc panMts.
" Of 2,707 goDBhot wonnda of the abdomen, reported fivm the ht-
ginning of the war to Jntj 1, 1864, there were 2,164 flcvb woon^
and 54S cues in which the pentonenl cavitj wan penetrated, or ibe
abdominal viscera ipjnred. Among tbe flesh-woandn, ]14 fttal oici
are reported, which were, in most inatancea, caaoa of alougfaing, fh»
iDJuricB of the abdominal parietea bj ahella. Of Ihe £43 penetratMf
wounds, the reealts have been ascertiuned in 414, and W9T9 fiual ia
308, or 74 per cent The number itf lecoreriee ia unexpectedly laz|S,
but indndet only caaes in which the reporta showed* bejcmd qaalia^
that the abdominal cavity had been involved,"
The following cases, which happened to be in tbo Hospital
under the core of mj colleague^ Dr* H. G. Clark^ and mp^,
m June, 1859, (the notea of whidi I made inimediatelv aAo
wards^) are cited in coDfirmadon of what I have now said :
Case CCCXLHr. — St<df m Abdomen. Secovery. — Tht
first case vraa that of a young woman, about 25 yetm of tee,
under the care of Dr. H. G. Clark, who, about a month be-
fore, received a stab on the upper and left side of the abdo-
men from a drunken soldier. The knife cut through all her
clothes; made an inciaion from three to four inches iu length
in the upper part of the abdomen, through the ekin, fat, and
musclea ; and apparently penetrated the abdominal cavity. The
wound was brought together by stitches, and the patient aeat
to the Hospital, where ahc arrived in a etate of great eshaustiop
A few days after her entrance, the wound was attacked with
erysipelas i and aljc underwent a very critical inflammation of
the abdominal parietea. The peritoneum, however, seemed to
escape ; and she recovered well.
Case CCCXLIV, — Stab in ChesL Recoveiy Xhc sec-
ond case was a sailor, about %b years of age, also under Dr-
PENETRATING WOUNDS OT CHEST AND ABDOMES* 571
iClnrk'a care. Abuiit twu wt^lts before, m a ilrmilteu frsiy, lit?
Ireceivcil a atalj from a iar^e kLiife iti the cheat Wvvceii i\u'. t<!xLli
acventh rib of tlic right aide, oldo a aecood slab in the
upper jmrt of the cibdomcn. He w^ia at the time aulfcriti^ iiDd^r
na attack of ;iii ^MlmjulLC Dnture. Tbu wouad in the chest
pccetl'ated through ihe rjb*, cutting off the inferior intt^rcoatiiL
ftrtcrv, which bled furioiislv, and, whca he entered the lloa-
'pitnU could only be sfuppcd by ibruating a bit of sponge intu
;the wound between the ribs. Tliis elfecLiially aluuiichc-d the
bleeding* The wound lu the TLbdomen gnve no ayniptoniSi At
the end of three daye, a poiUticei being rip^died oA'er the ^pon^e.
It £»i>ftci]ed and came away nithont hciuoirbage. The patient
durin;^' th!d time waa very anthmatict and the action of the lung
on that side eecincil nearly eu.*|>eiidcd. He expecLonited fively
a muco-purulent matter, but attributed his aymptoma p^lllcip^dly
to previous diaawe, and recovered without further bad *yrap-
toma.
Case CCCXLV, ^Suth in JVecfc atid Abdotnen. Recov-
try, — The thiid auso waa that of a youn^ man, 19 year* of
nge, who. the day after leaving the llou&e uf Correction, engaged
in a brawl, and received a &tiib in the icf^ aide of ihe neck and
upper part of tlie abdomen* The omentum escaped from the
abdominal wound, but. bcin^j return<'d by the phyt^ician Grat
cidled* \\\^ wound wa^ PCAved up : and tiiid, aa well od the wound
in the neck, which had cut ihrnugh the moi^toid muscle without
injury to any important wlery or nerve, was elused with aillieBjve
plutfter.
The [laticnt wju placed on bid back, kept on oatmeal gruel.
And no medicines uded. He liad no tendernc^a of the abdomeui
no fever, anj, at the end of a week. a[>[»eared perfL^tly rccov*
ercd. 1 kept him very quiet, from fear leaD adhehious formed
between the omentum mid abdoiuinal pariclea might be torn
away, and r»enoua uymptoma induced by too early and too active
movcmeatd.
CvsB CCCXLVL— ^m6 U C&e»t. R'^cot'^i^.—The
f^mrth cftac wn^ an Italian, 20 years of age, stabbed ui tlje chest
S7% HlSOELLAirSOUB OA8E5.
\^ ft dmDken man. The wound wu Wge^ and appeared qdto
deep : it wu eituated juat on the edge of the felee ribe. Eito
from fr^t or bleeding, the pmtient, when first lirougfat into Ai
HoapitiUf had the aspect of having received a mortal wwmL
Bot on the following daj, no symptoms in the Innga hafbg
appeared, I was convinced that the knife had posted betwcs
the int^umente and ribsr and that the viscera of the cheit asd
abdomen bad escaped injiuy. I did not* however^ make asf
examination, in this or in the other case, with a probet-^
a practice which I conaider unnecessaij, intermeddling, and,!
may almost say, criminal ;' as k might in some instsncei ooK-
[dete the passage of the wound into a large cavity which etha^
wise might have esc^ed, or the screwing of the probe icnsi
in the chest or abdominal cavity might of itself be prodoctht
of serious consequencee.
This last padent also did well.
HIP Ain> SPIVAIi DESEAfisa^
The present Improved method of treadng hip and spinal &-
eases may be adduced as one of the greatest triumi^s of dw
modem school of pathology. Hip-disease^ as every- one knom,
was formerly treated almost exclusively as a local inflammation ;
and the patient waa confined to hia bed, tormented in turn hj
the severe pain caused by every motion of his diseased joist,
and by an appalling routine of leeches, cups, blisters, setom.
and issues. Dr. Phyeick, of Philadelphia, demonstrated the
great importance of rest ; which he eecured by iQeana of the
"carved splint/* accurately fitted to the hip, and confined bj
bandages. The carved splint ia, however, an expensive ap-
pliance; requiring to be made expreaaly for the case in whir^
it is to be employed. Tiie full benefit, therefore, of this
treatment vrna only realized afler the iutroduction of spliaU
of gutta percha, at the llo&pitul, aonic twelve or fifteen years
ago. The real thus secured by the ijmnobility of tbe npparalu^
aif(>rds inuucdiiUe relief from pain, and, with the aid of bauketA
which I hnve hnU ni:i<Ic for the puqiose, admits, even id bad
cases, of the patient's being readily carried into the open air.
573
or even tvanaported grent distauces, llje recent invenlioo of
the lEuiifcycd iii3truiueiU& of Dra* Davie and Sajre^ whiirh, in
uijiny cnaci^, admit of a niotlernte Jc^tcc of locomotion, liaa
given ft new impetus lo the treatment of this dipeaae ; avoiding,
in even a, greiiter degree thun lieforc, the injurigu^ confinement
in Led to which the palietit waa formerly condt-amed. In those
cEuea where no splint can be borne, great relief h experienced
either hy llie appiioition uf a ainiplc weight attached to the foot,
or the ejctendion a|ijrarutU9 of Delimit, tu separate and prevent;
friction of the indamcd Hurfacca. The constitutional treatment
must, of course, be directed ta the pte5er%'ation of the stren^'lh
during the cour»c of a long mid tedious di^ea^e ; and it Is hy
the mecbiiuicid apphaficee jast mentioned tljjit we aire enabled lo
Avail ourseJvea of the ineetinmble benefits of fresh air and gen-
tle exercUe* so eaaeatial to the tuainteoance of health both of
body and mind.
Carie» of the «]>ine naturally falla into the same category as
hip-diseascp Mechanical support fchouIJ be given to tlie bitck,
in order to prevent the breaking-down uf the inflamed vcrtebi'ce
from tlie weight of the upper part of the body ; the patient ii
thus enabled lo move about, nnd preserve a fair degree of
heidlli during a hmg nnd trying disease.
Muny sei'ofaCoua iinfeetioiis of the kuee, and other large Jninte,
are to he treated according lo the bame principle ; auAtuinin^r the
ayateni by Invij^'oratiiig remedies, Jind sfcuring' iimnobility of the
affected joint by proper Ukechnnieal appbaueea*
It ia dtill a question how far we can enfcly venture in at-
tempting lo destroy the jiJliL'sinns, and eonsefjuent Smuiubility,
caused by disease of tltc liip and other krge joints. Some ei-
periuicnts have been tried, whh a view to deciding this point;
but tlie rule of practice ia, a* yet, by no ujcaus teltled,
1 liavc, however, seen In tlie practice of Dr- It- Brown, of
this clty^ amZ ll(^i^Ied him iu the ojienitioa upon, a immber of
cases of children aulfering uuder falj^e anchylosis uf the joint,
l\us t-cquel of hip-dirHeasc« iu which the adhesiunfi have been
broken tip mi(!er etlier with graLllyuig results-
The diai^'DOsifi of incipient bip-discnsc ia n subject of mueh
importance, and sometimes a nuater of consideiuMo diffieulty.
hii
^ MISCEIOu^XEOUS CASES.
llipre being aucH ft variety of ^rmptomfl conaect^d willk it.
endly, there ia n pEiin ip the kiiecjumt ; fiiini<>time9, tliotrk'
mrelj, in tlic \u[t JlscIJ'. In oUuts, lliere ij* u L7uiu|ilclr jic»
nit)' fiom pniii, antl tlie otiK eyuipCom i» Jnuiene«a. TUfcfi*]
iu^ uiuIIkjcIt i\>r clearing nyt tliif j>uiiili I Iiuve seldom htjn\
Tlic (latlent bdn;^ IniJ upon tlic bau'k, auid |li€ llmU fq
rekxcil, ilie eouiiU liuib if^ ^rtt «eizej, Aud fredv beoi 9^]
m
it neftrl^- or quite touches tlie abOooicn. The ffune iiiu««t{
being aitcaipteil with the nthcr Itnth, it will be finmd thtiDtj
flexion bf the Vnnli iet nhnotsl invaniibfy iurre^ted at or aai*
right angle with the binly ; th^Ltrp|) [ have seen one or tau 9-
<;cplioii9 tvf this rnle. IK the flexion is compleie^ iiihI if, *ii*
to it, there U wt )>ain rrum deqi pre^^nrc in tlie gruni, tk
cuLisc of ihc lameness miiv bo searched for clM^wbere.
A qneetioa, wLii^h hus been muth (UdcuH^&ed, m, wfcj f
llie diecnHKl limb apparentlv lengthened in anniu raw*, ui
shgrLeniiJ in ulhers, S\j I'wr as 1 Itave obseno<l, the folliin^
is the cAjilaiiation i When the disease comes un itiaiMioitalr. sid
^viih hut httlc pain, ^u that the pnticnt \s nblc to keen nboal, ik
limb is earned in front of ihc other in walking ; nntt the itelvE*,
in tliia way, gradually' becornee deprcaned* l^'hen tlu^ affct'
tiuii is !U.'ntt\ an<l attended ivilli miicb sufltTing, the [Wilierilh'*
ia brtl i>rj the si>iind side, drawing np the af1ecCe<l limb; 1^
being llie most canifurtahle pudiliou m ihiHt hs iti some filhtf
iaflamnkatory affeetions of the lower e.\Eremltie9,
Hip-4lisea>*e U not nnfi'er|nenlly niiftiaken in ohiJdiV!!! fnr di'-
loeiilion of the }ii|>-joint; and 1 have hiid ;i iiiiiTibor of cn^i
under my rare, uf pxitienC^ who havt! siiHered an A^^rmvation
tliL'JT difica>:c rrL>ru alienipts having Ijeen inmk' l» refluoo n
pns^d du'^hrejiliiFiL, ihe Mniptnias uf which liad i^oine on nut loni
after the reeeipt of a fall. The dingnosis i« at r>ncc c1t?ar«d bfl
the nse <if' fiher, whieh relaxeii the iirilaled niusclcs, imtj k-
niQvt's the di*lorli[»n.
T do mil ])nipose to adduce eases in illustration of thi« ve<7
cninmoi] alTection, but would reilenite what bai* alrerulj
Raid in re-^'ard to keeping the joint in :l *tnte of (K^rfuei rest. Ii*
Hueli upplianees ns will allow t!ie patient to eiijoy the invigoi
ing intiucaee of the open air.
J.LJ Lk^-L
GANGRENE OF THE ATPEKUIX VEiailFORflna.
575
ArPE?n>ix VERaiiFORMia,
V6E CCCXLVIf, — Gangrene of the Apprndix Vermi~
Ih^ybj'^uV — 1851, Jimc- Tlie piitient, a, geiideinfln 40 ywira of
:i<^r, Imil Jilk^jija been ^ulijt^rl: lo nliat are riillnl bilii>ijR I'um-
^g pljiiiiU, Abuiit Tour yeiLC» Lcfuro, lie wiva ;;(>i[rLnei1 for some
^ weeka to ilie house by a sevei'e attack of coltc, ntteiided witli
j^^ conf'tijmtioii, at which lime I tihscrveJ a »!ijall, hiu'il tnmor —
»te[wler on jireflj^iire — in llie right Innibnr region- Two ycnre
Ifttcr, 111 Oetolicrr, he hiiJ a slvojuI nUikck, in nhich llm jijiin was
axi^nicijLting, sinil rotjuiroij the con^^tnnt inhdutiou ut' ether and
tiie use lit' ruiinles ti> rdievc hhii. At thin liunj, thpre was n
diffuse flvveiling in the right iliiui ftiid hnnbur I'egion*, rjiiife
hnrd, Bud yery^ tender. Uuder tlie ubc of leet^hes, and hy in-
ducing a sli^lit mercurial action on the F^y^Tem, he ^huvly re-
wtvered. Fearing some cjr^nnie aompliiint, not only fmni the
BvrcUin^, bul from his grejil fliiJiceiitibility lo cold ond disturbed
digeatieii, I advised him to rellnquif^h Luftiner<?i : at IcJist scj far
HA III allow him to hiive hj^ rnind [lerlet-tly free fr<i[n any cnre,
and tn give him an apiiorturity of itnyiui^ purticulitr jilicnliun
to [ilrt hcjdlh^ ThtM he did, and wns qiiile free from any trouble
until tlj(? firm) jituck, which came on nfter esjJOHiire to cohK inid
»onie irreirnUrity In dlel. Tlie |i)U[i, lor n diiy or Iwii. iLtiiciimird
merely tn a feeling of unearsitietts, bul ^rrsLilmilly becnme exees-
slve. A tumor could l>e dlsMuguiHliwI ut tlii^ period in tlie
riglit iliuc fus&a, nhout the sikc and It-n-^fh of ihe fiFrefinjrer: it
wn£ quite bunl, and t^ouUl l>e j^lino;:it seized ihrough the Inte^u-
menlfi. iind lifti^l u]i. The [iiiiu ami Icndemesa were ao ^reut
as to require the civcrpowt^nnir ii*c of 0|>iaie* adminislcretl hy
cnenin.
On the ihirtl Jay, there waft a slight evaenntiou from the bow-
els, hy nitatirt of Jtri enema; but t[;e patient shorlly after fell
iuLo a state of rolhijipc, juul died H.'vpn(y-four hoiir^ after ibe
violent BeiKori:'. For the last twenty-four houra, there was
the inu^l dir^tresaiu^ hie<;oijgh>
An e^tJiUL illation, nftcr death, revenled exteasive pertloueid
inllummatlou, Tliere was very great induration of the omen-
icKcnosre or sitrtiij.
Aed to be formed by au elevation of boaCf tthoai an inch
I, as if the tumur hud been forced out frijiii witliiii the cavity
he cmruim, i^Laliiufj the hone before it. Bj prcaamg rirtnly
jn Ihc upper part el" the tumor, irregular maaaes of bone could
distingitiflhecl ; some of iKem loose, otfaers forming hridjfca
dcr which thcr tluid coiitcutd of the (umor eouhl he forecfl with
gurgling sound. It was highly resonant on percuasioni Air
^K uld be rendilv forccxl into it frum the noetriJet and the teneion
^H kUs imparled to it remained for a long time ; owing, probably,
^H I the intcrpotiition of a pieee of loose tjesiie^ acting like n ^-cllve.
^H^iiriDg violent exercise also, the tumor generally became inflated.
^^ The diagnDsifl was a collection of pua» bcnenth the occipito-
^^rODtalid jnui<€lc, cotomuiticaling with the froctal ainusc^ ; but
^Brhether it onginatcil from periostitis, or from diaeaee of the
^^iploe, or from a tumor aming within the eronium, speared
luubtful.
OperattoUf Nov* SO^A. — The patient woa etherized, and an
icision made in the median line Inr^e enoui'h to lujmit the
igcr, A quantity of nir cscnpod; nnd tlie finger, which waa
icd into ihti wound, detcelcd the fuet that the bone wna cvcry-
rhere in a carious state. The incision waa then extended, and
'O^iseil at right angles hy another, so a* to expose a large {*ur-
Lce of the diecnscd bone. The whole external table of the
■ntal bone was mut^h thickened, and in proecsa of exfoliation.
probe paflAed reatlily into the frontal -situs, and from thence,
rith bomc man Jkgei [lent, into the left nostril. The patient, on
"vering from the ttfects of the ether, was able to force air
:cly throuj^h the wound. Blood cecaped alao into the nnsal
kvitJca. The apparent elevation of bone around the tumor was
lot owing to an expansion of the outer table of the skull, as at
Iriiit supposed, but to inflammatory action la the soft piirts ; a
dccc|}tioii einiilar lo tlidt which ia often found to follow blovva on
the head, ciiuaing nn ap^wamuec frequently imposeible lo diatin-
|Pgui»h from n depression of the bone. In the present coee, the
illusion was perfect. A compi>?ss wa.s applied betftttn the lipa
of the wound, which was left open lo favor the separnlion of the
lecroaed bone. The patient was immediately relieved from pain,
id the following night slept better than for six months before.
7S
his
uiecGiXAyEous cas&s-
i
'Hic fifth dnj after the operation, it woa found poeeible !«
some Urge plalea of bone, which ncfc eufticicnily iiiuiabit
taken awaj without violence. In the course of anoilier
the pnlicDt went home, oodrely fi-ec ironi piiiii, and m
health: it, waa thought unnecessary to dctiun hiui longer io
town, na the exPoiintion of the carioua bone would prulwblj it^
quire n long thiie for its completion.
A month or tix weeks Inter, Lc mnde « second visit to
when, after conEideriible manipulation, aDotlicr loug oni
piece of hone waA remoreil frtim near the cetiire of the os
The anntoniical appeamncc of this frn^ment Ic^ to rh*? aiwiw
tiun tliat it might be mnile itp cf both lahleu of ihe skulh Jt£
hod eyuiptoms followed ite removal, and the ^^uppiirAttois u^|
wound was much diminished by itn His health apponr^d to er
excellent.
«bljlt:
He again canie to Uoston, on account of a purulent coUkiIa
under the integuments of the torehend. Thib being rclieTnl tif
an incision, luo^e bone vv\is again rcmoved-
Since the obure record nRA made, I was consulted by himjA;
account of a renmrkablc de[>cbit in the cellular tlseue in ^|
of tlie upper extremities. There wa» a ^frent depreciation fl
health, and u dispositiuu to cerebral dislurbnnce.
Guthrie, in hi« v^luabk work, " Commeni.tries on the SuraciT
of ^Var." reiers to u tumor of thl» deseriplion, nnd in prtclHlr
the same situation as the one Jibove dewnbed, &» follovre:— ^
*' After a wouud of the frontnl aiaua has healed, ihe air bav IM
known to raiAO up tho intogaaioate of the foreliFai] lui^ ng vjuik
crGpilalLQg Bwcltiug, wl)ea<vi>r iLe pulient bJfjw his nose, so t!
eompre^A imd bftnila^e on the pjirt were required fur ita relief'
the^ cases ato very rare."
PJUV
I
Case CCUXLIX, — Poisoning by ^iiric A^citf.
Autopsy. — A negrcflfl, 34 years of a^, of abniidonoi] ci
ter, thinking ihnt f^hc wna three months pregnant, look
acid at IJ, I'.M., on the i3d of March , \^b\.\^ for the nurpo^
destroying her child. The quantity taken into her nioutii wis
reported to be Siij, hut mo?t of it was epit out> Alkali
mueilaginoua drinks were used ; but the burning in the
POIlOWDfG BT
LTC Aom,
579
ms intense througli the ni^ht, witTi re^t]eH?<ne«x fint) tieliriuin.
^he next morning »lie was brtm^lit from the jail, where the
wid waa taken, to the Iloepitol. Yellow i^EJiin^ were then ob-
[servcil upon the cluthinir, and the whole loE^iJe of the mouth
and fiiucee, ao ftti' aa could be ^ee^» wita of u di^p yeilow
color, the ton^^e looking ua If twvertHi with Tiidian iiipal ; the
^BreBpinLtion being jjiiinful, labored, and striduloua, ami speech
^fftlmo^t imiinj^Hible. Kxtremiciea cold, countenance of a leaden
^'liue ; pidae 120, and very small. Fur the first four or five
ditya after her admission, bIiq buffered from fioreuesA of the
mouLh und throsit, dyaphugta, thirst, and eollvation, with acme
vomiliri;;^: she also eonipliLined of lendernejrifl <if die alnloraen,
but nol particularly^ over the Htoniach, walklug with diilicultj,
and beut much forwoj^s ; bet tins was perhupe owing to ter
hLiVmg been thrown down und stamped upon, in an atTray, on
the daj^ on which the look the acid. After the first day or
twa, she WBtf much of the time up, and about the wai^; at
ihe end of a week, she was reported quite comfortable, and
b;iving oouie appctiLe ^ und, on the 14Lh of March, aa she
was doing well, siie was removed back ti] the jail, there never
^■luiving been auy fever, but ratlier a. state of dcpreasion. On
the morning of the ll3tb, she was attacked with cram^js in the
stomuch, Jind excessive pain and tendernes.-^, which were piirtially
I relieved by opiates; on tJie following morning, however, she
wai^ found deud in her cell, with a great quantity of blond in
tlie bed about her, wliich she bud apparently vomited.
On dissection, there was observed great rigidity ; upon the
middle of the tonj^ue a W^'e, yelhiwiah, smooUj pateh ; some
redness of cpifrloltis ; (eaophagiia healthy for the firtit two in-
chra, lait, below this, it was found exceedingly soft, of a greenish
yellow color internally, purple exteiTiuJly, and full of con^*
lated blood. The etuEunch was in a Bimilar, though much worse
^ shite; externally, it hud the same purple color, and waft univer-
satly adherent to the neighixiring pnrta by recent lymph, except
[It the left extreniitVi where there were old and close adhesions
to the spleen i internally, it was of a greenish yellow color, em-
phyacmaton,i, and so perfectly soUcned and friable that it could
not be jsepnrated froEn the surrounding parts without giving way
576 UIBGELLANEOUS GASES.
turn, with firm adliesiona, arising apparently from the previous
attAck, two years before. Some purulent matter eecnpei] tVum
the cavity of the pelvia. The appeadix Termiformid woa tounJ
gitngrenoua. And pcrforitted at both ends : in its central poni<iD
waH contained a maes of Indurated fecea, aa large na a prune-
stone- On section of thia aubatance, no nucleua could be dis-
covered.
It is well known, that amall shot, apple-Beeda, and taHqus
other foreign substances, lodging in the appendix vermiformi^i
will give rise to the a1>ove symptoms ; though, in post-mortem ei-
nmiiiationsof persons dying of other diseaees, these substances an
often found there, not having caused any disturbance during liie-
Case CCCXLVIII. — -^ecrosw of Bonet of Skull gitin^
rUe to a Tumor containing Air, (See Plate V-) — A man
from New Hampshire applied to me for advice on the 26th of No-
vember, 1S61. Four years before^ he had received a severe blow
on tlie forehead, from n heavy branch of a tree. Great swelling
ensued, which confined him to the house for a week or ten day^>
Tiic swelling ^adually subsidc^l, leaving a sensation of dull pain
in the part, neeompnnied, from time to time, by soreness umI
tumefaction. In July ^ 1861, while at work in the hny-field, lie
wad Heized uiih sevei'e Ijendache, and other symptoms indicative
of cei-ebriil disturbance. Soon nfter this attack, a tumor ajv
peijrcd ox'ci" tlie sent of the original injury, covering ncurly the
whole fori'hcad- After .i great deal of suffering, n discharge of
puA li>i>k ]ilace from the lefl nostril, and afforded him tempomrv
ivlicf. Sub?*e(|uentl_v, the lumnr became tense n^nin, and wns
opened with a huioet, wliich gsive vent to a small quanlitv oi
purulent mattor; a second oiienition rcsnhed, as he snye, in the
cseitpe iif Mood oztJy. His ^ufterings eoiitinueil to increase until
till' date of liirf vi.<it to rue. At this time they were wo excessive,
jiiid llu' (■o]j>tilutioniil j^viiiptiuns iif such a character, as ti) IcjuI
Iniii to tlie <*(in\ii'ti()ii tljjit hi^ ciise was altogether liopi'Ie.^i^i,
Tin; whdie fiiri'hojul was ocrujued by an elastic swcllinir, ''I
thi: sixe of h;ilf <jf u larj^^c oran^'o, [larlially divided in the ceiiiro
\tv a veilit'al dqire.'isiim- <'!iiisrd ii|i]>anMitly liy the tendon <»f tlif
uccijjilo-fruntalis mujsclc- Tlie marginal baae of the rumor
582 ifiBCELi.urEOus cases.
duemse is nio«t freqaently found ia penom wlioee oocnpation
produces m great Btnun on ihe joials, anch aa blaclciumthSf
I' fltone-cotterft ; «lao in wa^ierwomen, being Gansed by twudng
I cIoCheB. It occon in the uikle as well as in the wrist jointa.
I ^nie disease yields to treatment in about ten or fourteen days,
I as in the present case ; no pain or crepitation being perceptible
aft«r a fottnigbt.
Case OCCLII- — J^injki Orepttaiiott, of Tendons, — A
woman emplojed in wringing out clothes was eozed with a
i«Tere p«n in the back put of the arm, near the wnst, which
became swoUen. J saw her on the following day. A swell-
ing and redness then extended up the arm toward the elbow-*
joint, very paiuful to the touch, and on motion- On rotating
and flexing the hand and fore-arm, the fingers being on the
injured part, the peculiar sound alluded to was perc^ved. It
was perfectly dry crefutus, which at first nught be mistaken
for that of a fiw^ured bone by one who for the first time ob-
served it. In those cases where the accident had occurred to
I the long head of the Incepa, it had been mistaken fi>r a fracture
fi of Ae neck of the humerus.
J The symptoms lasted about fourteen days, and yielded to rest
m and antiphlogistic remedies,
I This affection I have not seen described in any of the Eng-
lish surgical worka: it has been treated of by Velpeau under
.■ the name of "Crepitation Douleureuae dea Tendons," and is a
I disease of some practical interest.
jl Partial Rupture of the Tendos of the Quadeiceps
Extensor Fehoris Muscle, — The complete rupture of this
muacle, or rather of its tendon, is at once so patent, frotn its
eymptome, that there is no mietoklng the nature of the treatment
' to be pursued, and a coae of It hna already been given above.
} Purtinl rupture, however, of this tendon near the patella is of^en
at firaC not marked by any Bymptoms whatever, or else by signs
so obscure as to make it very difHcult to determine the true
nature of the accident. Aa instances of this accident, I would
uiention the following cnscB : —
PAHTIAL RCTTDBE OF TENDON.
58a
I
Case CCCLIII- — A gcntlemim tibout 65 ycara of n^,
[of lurgc and powerful f'rcmc, npplicd to roc un the 2\)X\\ of
Kovcmbcr, l^Gl, on nccount of A lamenese of the right knee,
of which he gavG the fullawin^;^ account. Uelwcen one nnd two
yonra before, while kneeling on the ?nnd hy the seashore, he felt
a ButlJcn pibin shoot through hja knee. No symptoms of anj
coneeqnetiee followed until three months after, when he liegon
to be A little Inme. There wiis fiorencsB iibout the knee, some
ali|^ht ilifHcijity in extending the le^, and in goin*^ up fin<l down
iBtairfi. The limb wne rubbed in the ufiunl wny with limmenla,
Ac., but without marked etfeei, Ae time went on, neundgic
pnina tvere felt in diHerent partjj of the limb, both in the thigh
and leg, and the litnb beenme obvioualy more tinbby and emnller
thnn it^ fellow. On e^inmintn^ the knee, I at onee di^eovered,
just iihovc the pittelk, t\ di^tinet depreasion or ti^^ure, about nn
inch long» in the cxtcneor tendon, and penetrating, as it ap-
peared, through nbout hnlf ita eubalnnce. At (his puint, thet^
was a little rcflnei^a of the skin, and a puDinesa not to be dk^
tingui^hed above (he other knee. The mti^lca both of the
thigh and le^ were quite aotl, and measured one inch leaa in
circumference than its fellow. I advised the patient to wear a
leather Inecd stocking CAtending from the nnklc to tlie hip, and
fitted acciimtely to the limbi to use a cnne in walking, and to
fitand OS little i\& poj^^ible ; hIbo to employ bnthing and IViotlon:^,
In enee of nn iiggravation of tiie symptoms, I nUo otlvii^ed Ikiin
lo do what he now altogether refused, — to have a splint up-
plied, and to keep perfectly at rc&t. I was ;;lad to find after-
Wfli^da, that my diagnosis waa confirmed by Frofesaor Willord
Parker of New York, who hod previously eifimined the eofle,
Cape CCCLIV. — .Several years sinec. a young gentleman
was seen, in consnllrttion, by Dr. J. C Wnrrcn and myself, to-
gether «rjth the phy^ieinn of the patient, on account of un neci-
dent to the knee, which had uccnrrod siT months) or a veaf
Ix'fore. In making some violent etfort, n slight ernek was felt
in the neighborhood of chc Joint, followc<l by some lameness and
temlerness. At the time, nrxhing eould lie didtinguialied upon
examination. Vorioiis iijctbods of treatment were tried wilhuut
5H
AnSCELLAKEOrrS CABBB-
effect, nn<l tlie patient, becoming ^frfwlually liitner, was brouj
to Bofitim for advice. A very careful inspoction of ilie
uLiout i\k knee revedcd n «m;ill li^aure, wlacli was dUtiootlv
felt in tlie edge of the tenrlon nc;Lr the pnlfll^, qiiiiu slmrp, and
evideudy showing thut tlie tendmoiu fit^re^ h^ bceu rupturv"!
at tliDt point. The pnlieni wna advised to try perfect t**i tor
the ]irnl», to have n hiim-ApliMt applied, eontinuiii^ the Crcntiuent
for flt least lliroe nioiitha. ThU wns fuithfully done for betvree^
three and fuur months, and resulted Id n perfect cure. ^M
As I now Btute ihia cnse froin reoollociion, I am tinnbU to
give with Jiatinoitiesa dl the incidents in it ; but the t»ci of
rupture and the result of ihe creshtuicnt are undoubtccli
nilJKOPHOBIA.
Cash CCCLV. — Hydropkohh. D^nth. — Tlie tbllowm^
account wnA principally written from data fumishetl by Dr. J-
Stejims, then hoiiae-surgeon to the Massachusetts General Hos-
pital, who tof>lc much irterest in investigating the fiitts of the
caae. The patient was u male rliild, hy name Patrick Murphy,
three years of age, living in BoHtun, and was brought itklo t^^
Hogpital on June 2^, 1)^59. ^^
Five weeks before, he was bitten by a dog six or ei^ht months
oM. The animal was not thought to be rabid by the bysiei
ers; altliougli, on the eoine day, he had "snapped ui
slightly bitten ** a man, as was tliouglit, from play^lneea,
litFle boy had a eniekcr in \\\a hand, which the dog ^tlc!tnpli^ to
fleiac, tnking into his mouth with it the whole of th<; right hnni
nnd inHicIing a wound on each ^ide of tlie wrist. The won
on liie anttsrior surf:icc, was frinn hulf to two-thirUs of un \i
ill length; that on tlie cj[tpo^itc side wna likij llie iiturk from
simple punciure. Tlie wounds were treated hy a siir^on, who
cauterized them nut long nfter the injury, ami oi-dereU a. poultu3^|
There was no further treatment used. They were verv s<»re. for
a time, pnrticiiUrly the one in front; but the ehiJd continued u
well as usual in his geneiiil lienlth, and nothing remarkable oc-
curred rill a week before his admission to tlie Hoi^pital.
At chijj time, the mother'ti ntteulion was drawn to tb
nuts
I
.1
HTTJEOPHOBIA,
565
^
by wlittt sbe cnllerl a " dulneas '' conaing over him, fiilloweil hy
& " aiHinea^ ami li^tles^nejia." Four days Ijcfm'e Wa enLru.n(;e to
tliti TLigpitLLl wii^ tire fir^t onset (jf the (iiiroxyaiiis, whkli wsvc
dcACribci) ua haviii*^ beca faults fonniJable : they were eapcmuUy
\iolciit when witter wna bruiight ueiir liiiii» oo that the nuitlier
was i>blige[l to give uji waabing^ the cliiM. He manifesteU a
desire t<i tttke fooil nnil drmk from hla mother, tliough, on atr
tempting til swallow, he wa^ quite unuble to eAtfCt It. For this
reuflon, he touk eciircely any DOurUhjDcat for four Jaya bcfor?
Le was brought into the Hospital- The pieceJing facts were
principally obtmnett from the parents of the cliilj.
On hi3 entnince uito tlie hou^e, he wria in a liiglily exciteJ
GoDditioii, torislng lijs ii^al, linJ tijrowlni^ about bis linibti in
every dlreiitioii. Hi? spit violently, or attempted to do eo, as
if bis mouth waa full of fenthers ; occasionally crying out or
snapping at those about him* saying that he vvlahed to bite
tbcm, and they nniet get out of hid way. Ilia eyea were very
bright, his faee pale, and there waa a Hvidity about the eyelids,
and generally over ihe whole surface, with a quivcnng of the
lipa JLud mUHck-a of ihc fuce, and eonataoC ti'enior of tlie whole
body. On tiikiiigp a doae of morphine, he was quictcil, and the
Tiurae prevniled on him to swallow some niilk from a mug.
Afler a time, he drank a whole mugful, itEid ate a duinll piece
cf ciikc. His manner of taking the milk was not as If he hud
any aversion to itt but from apparent consclousneas of the
cffbrr necessary to swallow, lie elutchcd violently nt the mug,
with eyeballs starting out, and the whole frame undergoing the
grealeai agitation. The effort of avvdlowing vvns attended with
Q sense o? suffocation* and the corners of the mouth were
fitnjngly rctmcteJ. He exhibited the same eymptomo on taking
cake; mid, from his great desire for both, jippcared to be suffer-
ing niueh from hunger. A viscid di*cljarge Uwk place from the
mouth* Tlie urine waa paased iii great abundance through
the al^ernoon and evening.
He gradually became quite calm, through tbe great attentions
of tile nurse, nbo seemed to inspire him with confidence, und
'ent to bed with him in her arms, in apite of the remonatrancea
of those about her. He talked ineesaoiitly and incoherently,
7*
586 UleCEUUANEOUS CASES.
though At timee he could be understood. He eeemcd to Appre-
ciate much the kiudncBB of the DurBe, find told her he should
bite her ; but, when she put out her arm to hini, he kiMed and
stroked it. He had several paroxysms af^er HIb entruKc,
with intervals of comparative quiet; the attacks being toAjd
short duratioUf lasting about five minutes each. He becanie
weaker as the night advanced, and, at half poet 3, a.m., died in
one of the convulsive attacks.
No examination of the body could be obtained.
Dr. Steams, at my request, visited ^e haiise at which ibe
child had resided, for the purpose of obtaining eome more ftctt
in regard to the case, but did not elicit any thing of importann
beyond the preceding. He saw the wife of the man who w
bitten on the same dny with the little boy : the bite n^as said to
be a very slight one, on the joint of one finger, and no blood
came from it. The man promised to be at the Hospital on tbe
following day for me to examine it, but, for some reason, ^
not appear. The dog was drowned, and Dr. Stew^is conU
get DO further history of it, A superstition existed with them,
— of which they informed him, — that, if the dog could imn
been killed by one of the family, the patient would have e»-
caped ; also, that, if the liver of the dog could have bsfn
applied to the wound, the effect would have been equnlEr
eflictcnt, which, of course, naturally implied the death of the
dog.
In connection with this case of hydrophobia, I would remark,
that, about fifteen or twenty years since, I proposed, at a meet-
ing of a society, for the purpose of obtaining information, the
question wliether any case of hydrophobia had ever occurred m
Boijton, or wliether tlicre was any tradition of one in the New-
England States ; but no answer was elicited in the affimai-
tive*
The first case reported in Boston appears to be that of Dr.
Coiiie, in October, 1848, which was followed, shortly afterwanl.
by that of Dr, Curtis, in LowcU, supposed to have been caused
by the same dog, wliich had escaped from Boston, and made li";
way to the latter city. This was followed by other cases lu
various directions, running through a course of two ur thnK
HYDROPHOBIA.
587
yeftrfl^ darmjj which time I saw, in Ronsultaiion in Brooklice, a
patient of Dr. Wild, and ihe co^e of a child brought into the
^HoepJtn] within twclvo hours after having been hiiten, where
the parts were freely oauleriaeJ a.t the tinio, and, within twenly-
^four hours from the time of the ixccideni, cut out by Dr. Cabot.
y This piitient returned hrjine vvidnTi t'jur weeks, ftpparenlly per-
fectly well; butf by the expimtiun of i;noth&r week, the digcAse
ap[>eanjd, and she waa returned to the HoapitniT with nil the
I Bympioms siniilnr to those detailed iibove.
^fe All the^ pniioEitA died, &ftor three or four dnys' illness; the
"atlnck corning on in nn average of about Sve weeks from the
[^receipt of the injury.
^P Ai^f that pedod, the contagion, if it may be so called, or
inoculation, seemed to have exhausted itself; and but few cases
were recorded until 1859, whi?ii rumors began to be heard of
its re-jiHppearance, I have constantly had persons call to eonanlt
me with very severe bites from dogs ; but, not finding from them
that the nnimnls had shown any signs of rabie*, I hare not
» thought it wari'iinlablo to apply so severe a remedy as cauteriza-
tion or excision to an accident bo common. When rabies is
actually present amon^: the canine race, I should feel mj-aeif
called upon to make a thorough nppliciition of the nitrate of
silver to the wound, as recooimeuded by Mr. Youatt, who oon-
siderod this remedy as almost infallible, if applied immediately ;
I' and who. from his linhllily to be bitteni alvvavs carried a piece
of cansLJC in hi4 pocket, and had many Times made use of it with
effect on his own person; or, if circumstaocea required, free
excision should be made of the injured part.
The following remarks of Mr. Yfmatt are of so much value,
that I have extracted them at soine lennth : —
^:
Tlie wound sliould he thumuglily waslied and ol^ianwd a* HOim bj^
piK^aiblt: a^W thti bite la inHii^ied : no auckirg of tlie part», an n ad-
vised bj many, for die purpose of eitraotiug the jxiiaon, aa iho proi-
Ittnoe of ft smnll abrasiun of Ihc llpi or interior of the mouth would,
mo^t osscirciUy, aitbject ibc y»arls to inoculalion. If the wounri be
Ira^j^J. Ihe eilge* mny be tnkoii off with a pair of pharp aciflaor* : the
wound mu»Jt tJi?n hti iUorou^Uiy caulerizvil with nitrate of silver (lunitr
eaasiic), being sure to intnxlnce the cauwiic into tJiB very deptb-* of The
[ :
588
mSCELZ^NZOUS CASES.
wounds io thut U will reach ever^ particle of pol<oo lint ere
iDBmuHltfd ilFPlf into Ibe flesh. If (he wound ja too smill id mk
the stick of chubIic, it uia^ be enlur^d bj tJie kntfe ^ lathif fit.
ever, not to carry llie jioiEon into ihe fre^L cut, which c«n Ix »«£'
wiping the knjfe al «uch incision. Should ihe iround LeiE>^:t:|
of Ibe \mhfit a InnJage maj be placed around it dun'ng ibe f^i
of (htpe rcni^dicH, the more effeclually to prevent ihe abMrpiii»J3|
veiDfi- Nitrate of silver is a mo^t powerful neulmltzer (I'inil
poisoup, and the affV-cled ports will soon come away wjili iht slnai ?1
droseingB bving rccestarj, except perhaps olive oil, if tkere ^'1
much inflaminntion of Ihe parity If the above plan be parnrt^
])alient need be under no apprebenaion aa to the result^ bvi biUj]
miad perTeclly eaaj on the poinL"
A questioD haa been freqtiently aaked, whether tbe« ^
toma might not be of a tetanic character, froui the irritttke"
the wound. There haa not been the slightest nppearai]ceolt>'
tnus, or locked-jnw, in any of the caaes I have aeen; lodn"
lapae of lime from the receipt of the wound hasbrtu^'
long to be attributed to such a cauae, the wounde btk
healed, and, for the most part, having abown little oigitt ^
irniation.
When writing this, I hod a cnae of triamua, or locked-nv.t
the Hospital, which, nlthongh not severe, affotxled an oppa-
tuiiily of conipat^ing this rare disease with hvdrophobia. 'i--
pationt was il wi^mnn, 45 vcara of age, in quite "tuxl he^ht.
upon uhom a lurgo pjiitik feli, producing a compound fracture,
and dij^Jof'atinn of the anktc-joint, I saw her nbout hnir ^
hour after flic receipt of the injury: the lower c.-^tremiiv '■■
the tibia pny\?<'(e<l through a hirgc wuund at the Bnkle-j":::^
the internal tuallcolus being broken off, and left in the u-ounu-
Thia 1 removed with a knife, r<o as to allow the dtj^looateil b(^^---
to l>e rost<»red to \U proper pbiec, uitli the iiopt-, in the iir>:
view of the ea;^", of saving the limb. On further oxanjinnti^m,
h<)\vevcr, wbeii cho rcr^toratiiui iif tJie bone nilowe*! •.►f a uv^t^
full invci^tigatii-n of tlie juinC, I found the injury of the lil-i^
to be cnmjfiicated witli a ctjiuniinnted fracture of the ti'jula souk'
piceoa of which lay loo,-^c in the jifint. Anolhi_'r fraolmo of tl t
tihuhi nUo exiatcilf abtJuC h:tlf-way up the limb. Aii)Liuiau<-j[^
HTDHOPHOBIA.
fjgO
of the leg was, therefore, reacrled to by tlie double llnp, just
obove iho upper frin^tiire, in wliut rippenred lo be sound j>nrt#-
Althtnifrh every thing Beemcd to be favomble for union by
tlie first intenfton, jet tbe u'inmd pnrtiidly siippnrntwi. nnd tooV
on SI sloughy n[>penriin<*e ; the viinl powers of rhe tissuea having
pi'ohiibly been injured by tlie blow^ Tillhou^h t\ns^ iil the tinie,
wxa not oppflrent. The pntient^ hoi,vever, complained of little
or no p^in, but seemed to be qnirc cnniforlTible nni] in gnod
spirits^ thongh witb little npiM-tiJe : sbe lind no levpr, and no
other s^mplom.q of const! till ion nt [rriFaltoii.
On June 30th, when I visits] lit'f ill tbe morning, shi? tohl
me that Uec jnwa were fltifif, nnd fihe euiild only open them
nbout n qnaner of nn inch, bv tnking hold of ihem with her
hnnds. She said tlint *he ha^l felt some soreness in her jaws for
nbout four days, huL Ijnd not thuuirbt it cf eii(!^cicnt iinpoil-
anee to mention. I euspecied the nature of tbe di^ea^e, and
roijuested Dr. Stearns to keep a close watdi upon her, nnd
inform me if any thing unit^unl OL"c*uri'cd : I also enwmraged
her to take a more Fitimulatlug diet. She herMilf Virus uot
advised of our suspicions.
[n the afternoon, ahe was^ j^uddenly taken wilh uligbt tetanic
ini!*, greut difficulty of breaihin^, and coldness of the ex-
tremities' stimnlants were administered, hot npplicntion^ ^nd
olher external remedies used ; and, when T saw lier abuut ll,
l\M,, she was iii a very comfor(at>le cundition. Her jnws^ at
this dine, had to be piied upen to ijitmduce any thing. I
ordered a drachm of tlie sululiou of Lhc sulphate of morphia
to be jidministereil every three or four hourf>, and ns tiiueh brandy
to be given as **he was disptisetl to rake.
She pa^swl a very <iuiet night under the treatniefit dlit^eied,
and, on tlie following day, prononni^ed herself inueb relievi^l :
the stump was su|>punLting fri.'cly, and gave her no pahi-
The mental condition of this patient and of the one with hy*
drophobin, ii will be pereeival, were strikingly diJTerenL The
ler was juTfet/lly calm tind coliectwtt the pulse not imich
!ted, being ralber below than abme tlie natural standard:
the latter scuu-deliiioue, agitated) anj violent; the pulse very
rapid. To a person who has seen the two diseaficf;, a nii^^tnkc in
the dl^ignoSLH id nut easy.
S90
1119CEI.I.ATrEOCa OASES.
EXTRACTION OF KEEDLBS.
Th,
.11<
'liicli hf
LteO
n<!eiiiea wiiicii nti\c penef
parte of the hmly ts nut un uniiiijioiluDt part of t^ursGTV. A*
a rule, it is better never to nltempt ah opertLCioD unices the
neoiUe can lie illstinctly fph. Even t]i<n, after the Aret irkdaiafl
if [t JH not immei]iMttly eipusttl, the traL-Ks of it are apt lO^i.
limt. and tlie aejiix^j tedious. Where the openition fails to i^^
close lit by tbc ap^jlJcnllon of a poullicc bringiug rhe wo^|
into n ^uppiiniling etale* the cjiscoloreil i^ee^lle, in ihe f^nrw
of a few (]:iv^. often nutkeK its a,p[FennLiice ; arul X i!o not ^
iDemLcr, in mv own pniclice, anj instojice of injtirv ta ^|
patient from dduy ULider tlic uhuve ci re uiu^ Cancel, %vherf*BS gmf
liu.rm tu;iv be di^ne by an unu^vailiti^jr ^carcli ainun^ delimte and
ftcnaitlve teiturea; fbr iikMance, the palm of the Laud, the ^^U
of the foot, I propose to give a few cases of (he results of
needles penetruling the koee-Joiut, a number i>f v^'^liicli lutv
come under my obaervatiun « theae bemgt on tlic wliole, thfl
most enilKirnissing of nnj of this class of cases that w« hfti
deal wilL^ and the kntfe-joiut bein^*^ more ex^xised than am
the jonits to tljis kind of injury. It will lie observeil, tliai
three out of tlie four cjises given below, the needle broke,
in the joint, after having been fixed in the bone.
Case CCCLVT, — -*Vee<^/f iivnctraling ihn TTrtee-jotnl^
Ilemauted Ji£€d hHwttii Coitdiflcjt, — Feb- l,t, 1K54, & ehiH
of scrofulous inibitf five or six years old. whih* kneclinj on
the iloor, Imd n needle larger than the onlinarv darnij»^*needU
penetrate, imd break off in the knee-joiilt. Being called to^|
tills child, hi conaultiitlon. I fifund thiit a small aperture cottIT
be dUlinguishcd below and to the inside of the [mtclln. The Itg
was flexed on the thigh, and Bxcd in that [lomtion so tliai it could
not be cxlendedn The needle seemed to have pencimCe<l b^
tween the condyles of the femur, lo have become IiAec] there,
and to be broken off in the joint, as nothing could be felt of
it externally. I advised tliat a dissection ehoidd be mnde aa
as the capsule, but to abstain from goin^ iurtlier unlesR
needle could then be detected.
BXTRACTTOW Or WTlKDIiEB,
5S1
This wj^s (lone, but nothing found- The question ihen arose,
whether the limh sHonld l)e left in The }>osilkin in wJilcli it was
fixed- 1 ndvif^ed Pirung flexion iind exieiieinn lo be made, bo
that, ID case the body were lodged m the way eupposed, it
might eilher Jje dislodged, or else plout^b up for itself ii cavity
in the cariilagc of the bend of ihc Tihia. By these meanuresi
the TDOtiona of the limb »erc restored. The cbiM wum tept
perfeeily qiiiel for n few weekn, tinril all itiflnniiTiutiJry eymptoma
hiid eiib^ided ; .il^er which, he wnlked alutit without ineon-
venience.
This pjLlient died uf phthisiH Home jeara after tht^ Occident ;
and. on exiiiiiination of ihe knee-juiiit, the following whs the
appennint-e : Tlie needle, nn had heeii RUppused, was finnly
lodged between the condyles of the femur. It wau eomewhiiE
corrirflcd ; niit]. fmrn the motions of the joint, it hml worn and
nrainUined for it»e]f ii passage, no as not to interfere with flex-
ion or extension. Tbe joint itself vras otherwise healthy.
Case CCCLVII. — A^^eille jiefitlratintf KuPt'-jolyU. Fnn-
goits Growth ^rom Wound. Hecotjfrrjf. — A child six years
old ran a needle into the knee-joint, In llie Hiiinmer of 18r>.3.
It was imunKiijitely withdmwn; and tbe child, not suffering
any pain, was allowed to use the limb. A few diiye nfter,
severe inflammaTion came on in tbe wound, and n fungus shot
out. At [his [jeriotl, 1 was called to see the patient. Tbe
joint wufl found to be in a \ery tender and iiiHained eonditiun.
On flexion, a quantity of pa» ran from tbe wound, wbiob was
Hurrtiundeil by n fnngua of the size of a fivr-cert piece. Entire
refit, with a tiplint. wan enjoined^ and the fungus wor touebed
with caitt^tic; criui^ing a.t eneh fipplication an inerense of in-
flammatory trouble. Afler four or five weeka of treatment,
the case finally fenninJiIcd ravi>rably. Tlie needle liad entered
just on ihe inner Hide nf the ligament of the patella.
Cask CCCLVIII, — .Vee^Z/e broken of tn Joint. Fixrd
in Jione^ Rtmmnd by OjR'.nrtion. — Tliiw instance was ob-
served in a cbilU of five years. Kneeling down on the floor in
front of a bureau^ to get sometlnng fponi underaeatb it, a needle.
592
HiSCEXLANEOUa CAflEfl.
which had been engaged in the carpet, ran into die jusltl
broke off- When aeen by mc with her physician. Dr. Mk
limb was painful on motion, eomewhat swollen, and ^^-^
unable to walk. By making strong fiexion, a hard 9a]ffLD
could be felt below the patella, on the inside of the joint, gi^z:
to the touch the sensation of aome larj^e bodj like a nul-
The patient being etherized, a disdection waa made dnx'
the akin and fat, until what appeared to be the capBuk ai^
joint was reached. Within this, the foreign Bubettoce t
felt, firmly embedded. The naila of the two forefiogtrtw'
pressed agaiost it on each side, causing it to pntject thmg^i
capsule, when it was seized by the forcepa. It was no«1ov
quite JifHcult to extract ; and this wna only done after a Tond
of efforts, and by working it laterally, thua disengaging ii tr
the bone. A aplint was directed, with applications of <i
water, and care in diet ; her physician promiaing to gire infon
tion if any symptoms requiring attention should present dx
selves.
The patient did well.
■
Case CCCLIX. — ^terf^e broJcen off in Knce-joiiUi
fixed in Bone, Extraction. In January, 1867, I yvt9<t
in the evcnin*^ to see a young lady, 15 years of age, who. iJ
himrs bcfine, while kneolmj; on the carpet \vitii a child in
annj<, felt ij^omotliing penetrate her knee. She imiiiedU
examined, and withdrew through her clothes two-thiixU ^
coininuii-sized nccille. She was able to walk up stairs, lin>
Bonienhat lame. When I ?aw her, with her phvsiciun.
detected a smull puncture, atiiTounded by an ecchviuo^U In
anil on the inner side of the |iatelia. On Ji careful cxaiiiina
willi tlic fin^jor, a liai'd snbstanee could be detected like the
tion of a needle, whirh varied its position acconlin" to
motions iA' the joint. It i:onld not, however, be made nr
nont. Tiie prohability wii?^, that it hjid penetrated the boiic.
ha<l hrokeji oti' in,^j[lu the joiiit. I determined Uy cut duw
far iis tiic i^a^isiilo, :in<l explore. This was done bv u \crv i
fill dir^seeliiiu, oecasion;*! |)au''erf beini; made to allow the b
ing to cease. TJie capsule, covci'td by a sli-'ht celluliir 1;
nfjuRiES OF tht; os coccraiB^
693
dnff nrrived at» the euJjstance, whJcli coulii ensilv be felt with
the limb extended befijre the incision, now ahnoat c^Nuplclely
(liflfippcnrcd* The limb wna tiicn forcibly bent, whcLi the needle
at once iraa felt predajnj^ again:^t the cnpAule* and apparently
fiscd in ihc under part t>t' the patella. The wound bciiiir bcld
widely open, ttnd every thin^ kept sleady, w'llb the hunillc of
the knife en one aide, and the nJiil of the tbnmb on the other,
the Dccdlc wns innde to prciject through the ciipsulc, and could
be seen through the areolar tiaaiie over il. A touch or two of
the knife vow expnseil it; andi being seijsed with the forccpsi
with a iittlc force it was disengaged from the bone. It vrna
about half an iueh long, nnd had already Ijeeomc blackened.
The wouud was nt once cloacJ by a suture nnd adhesive
plnatcr, nnd the IJmb confined in a atnught positton, in a aplint,
with an injunctioji not to Hex it for a week. 1 haw her on the
foJIiJwiug day ; and she was quite free from any pain, swelling,
oe aensibility of the joint, and hua aincc done well.
INJURIES OF THE 08 COCCTGIS,
htiTC met with quite a number of instances of thia kind,
where the lower part of the oj ci.'ceygis baa been injured ; all of
them oceurnn«r to females from aUpping while descending the
stnircaac, or dlepping suddenly out of dciuv9 on a etcp covered
with ice, nnd receiving various coneuagions in aliding from one
etair to another. The ecvere and l(>na:-coi]linued fiymploms
ariaiug from thia injury ore not ensily explained- Scarcely an
inatJinec can be Paid to have resulted in perlect recovery ; and
many of tliem have caused severe local eymptoma for some
months and even years afterwards. The ^ymptome do not acem
to he easily ONphuucd, either by supposing ihcm to be cauaed
by a concussion of the spinal marrow, or by n local Icaion of
the nerves of tbia pari: although the region la very fully auj>-
piicd by nervous filaments. They seem to reaenible more closely
thoac nciLte pnina which attend periosteal inBamniiition . The
eHbet of tbi^ iiijui-y I propose to illustrate by a number of
cases.
upper and lower extremitiGB.
The conetitutional aymptoms very grAdually si
pain ond inability to sit upon the part Justed nu
ftnd the BeneitivcnesB of it continued for teD yea
dent. At the lime, on eiammation, no fh
detected ; but, on account of the sensitireneas
touch, the iDTcetigation was necessarily supen
Case CCCLXI, — /n/ury of the Ooccyx. -
for some jcare, had been in delicate health,
was desceudiug the stairs, and went irom tLe tOE
Btriking auccessively the lower part of the bacl
She was taken up in an almost iusensiMe com
first shock of the accident subsided, the most viol
nervous ajinptoms supervened, attended vvith
the coccyx- The head was in a state of great
confusion, the hearing and eyesight exquisiteli
arms and legs spasmodically contracted.
Being out of town, this lady was attended by '
tiuguished physicians, who came to her Jrom a
coccyx being examined, a distinct displacement
was distinguished, and by proper manipulations
this condition she remained two or three mon
be removed to the city, and requiring constant
remedies to relieve pain and sustain life. SI
brought to Boston, and came under my car«.
When nhp fin*t nrrivfil. T mmlp nn PTnmmnttnn
DJJUIUrS OF TOE OS CX>00TOI5.
595
Buggcet, was unable to bcur jiay prcaaurc it^wn the injured
pnrt. Air-cuehiona, with nperturtis in them, hud been tried,
but without effect ; tJic mere tigUtcuing of the skin arornid pro-
ducing^ aufTcring not to be eupportcd. The pfiljout was now able
to wnlk about tlie room a littlo with support, and niter a timo
was takon down etaira in the arms of nttondante, put into the
carriage, an<J driver out, auppoi'ted in the horiEontal position.
Shu did not recover from tlie icnmcdintc clfecta Df tbc uceideut
for one or two ycara, (lud now, at the end of eight yoara, id not
ftbl© to ascend stairs without sufferins.
I
Case CCCLXIl- — Lijitry of tho Goccyx^ — An unmar-
ried femnle, dii ycflrs of age, waa brought into the MaasfLohu-
sctts Generul HoEpital in the spring of 1^5>(, having fallen
while goin;; down the eeliiir-atitirs, striking violently on the
coccyi, iind injuring one of tlie riba. She cornpluiiied very
little of the latter injury, although one of them aecraod to bo
fnetured, but made the most violent exclamntioni* in i-egard to
the suffering in the lower part of the njxcrum. There was an
innbility to move the lower extremities, but no want of acnat-
bilily Id them. No fracture or dispiaeement of the coccygeal
bonea could be detected. Leeches, tomeotations, the internal
adniinidtration of opEuuii were reaortcd to. The only relief,
however, which ahe obtained, waa from the local application of
laudanum, or poultices aprinkled ever with ten gmina of opium,
)l was two or three weeks before she began lo obtain decided
relief, and about six before she wob able to lenve the HoHpital,
Case CCCLXIIL — Fractur-c of the Cocctfx. — Whde
making a vLait at the Hoapitol with Dt. Cnbot, in February,
19^!:^ he pufnlpd out to me a padent he hod just suoccss-
fuliy treated for veaico- vaginal fistuk. I observed tliat she
aat leaning forward in a very awkward position, Dr. Cabot
eaid that the pofilion waa not owing to hor ptcaent difficulty,
but to an injury alio bad received aome years before in goin^
down the ceUar-stMira, when ahe alipped upon something left in
I the way. The consequence wna a fall, in which ahe struck
uu the lower part of the back- The coccyx was fractured and
596
KlfiCElXAXEOCS CASES.
dU[iliir^l, itnil remain^ su, um vrnji veri6od br flu
Tumle b^ hiinseir, At tb<? time, alie u*tti* cvnfiiKd Jtct^
wi^rlcH, vvifli v^ry seiere (^ymjittimv^ and IwhI ncvrr frwi^
«ulti:r lu tlii^ pfirt ui) la iJiut Lime.
Case CCCLXrV. — ^rjv^ff-^ Tr>jurtew t>/ ilu C««f
In Miircht 1859, I was va\W\\ lo a niftrried JaJy wtmU ■
tliD day bc-fore tin iho u^, striking licr l>ack. Pari trf ttc i
wn*! m'civcil ii[w>n tlie rocryx. The injury |>rwlo<t<l ctnwi^'
Up lnnion<T)iHj nml, fur Honi<.' daj-St nltiujst inaiiiliiv to W"!
buck or niiiku amy liiitral iikOtioLi8.
TliiH pnticnt iwi(?47 b(?fi>rc hiid d MmUnr injuri' : oscc. v^^i
ctilli], fixjiii i]i« (?nVct of wliidi nlio never rc'Ot»\ot«d; tt^'^
«c.H'nncl lime III H ml tilievn yenm nfrur, wlicii «lic wtu ondv'
C0TC ibr Uio asmc injury, at wliidi time &he wma confined IB hi'
}hh] for It nuuiber of JiLjAf requiiiuj^ llic pei^iatent uppJiAW^
Case CCCI^XV. — />y>m; «/ (Ar Off CfHJejyi*. — »«
1850, a young lady, 19 years of ugp, was btoiinbt to tw«
nn injury uf llie coccyx. Three y»^i<ra before, M'hilc sliJing*
the \cQ. filic ftli, and rec^ivod a severe blow oo the lower fi*
of rho a|>inid column. The |>!iiu nnd icmlernesA eonfitKHl btfi*
two or llircc Java, and slie wai^ luuihlG iirierwftrda to U'ftr li*
leafit pressure on the pan, wliUe iliere waa a constant fitt*
of nnpji^iness in it.
About a j'ear before, a swelling commenced there, and ^lo*h
increased till it became of the size of sl wnJnut, hut niili to
inflniumntory appearanws about it. This wns puncliircd m
Api'il, 18h5J*, by hor pliysii-inn; and, bs lie stated, ai. cuT^r mat-
ter diBcbiu'iri^! from it. After [hat, a scnma ffiiici conliniicJ 10
flow ; llie opening; remninin;:^ fistulotia, v/jtb an inffanicd elevaiiia
of nearly hjdf fin ineh aboxx the surrounding tissues. The fe
clinrge eanso^l oonbiJcrabJe irritation between the natea and in
the vicinity.
Having exj^mined the disease iritb n probe, and not discover-
ing nny eitrioua bone, 1 adv i&cd tJiat llio patient ^IkiuK] be cliitr-
ized on the foUo^ving diiy, and llie tumor freely iiiciaed, Thib
rEACTUEE OF BASK OF SKULL, 597
being done, and the cavity fully exposed by a free incision, a
finger wna introduced^ and the end of the coccyx felt, but not
denuded. The interior of the cavity, being now exposed to the
light, presented that white, ailvery, epithetinl aspect observed
in the aacs of some encysted tumors. The whole of this eac
was carefully dissected out, and the cavity stuffed with scraped
lint.
On the second day after the operation, a poultice was applied,
which freed the wound from the adherent lint. The wound was
afterwards dressed simply, and the patient allowed to get up
and move about. She recovered entirely.
Dr, SimpHon, of Edinburgh, has described thie afTection in
his u£ual clear manner; and, in eome obstinate cases, after
having tried all remedies in vain, proposed, and practised with
success, the girdling of the coccyx by subcutaneous section,
just above the diseased part, so as to cut off all nervous com-
munication with ]t<
FRACrrURB OF BASE OF 8KULL.
Case CCCLXYh — Fractnre of the Base of the SktdL
liecover^^ — A man was brought into the Hospital, June 2,
1866, in an apparently dying state, who, two dnys before, hod
fallen from an attic window, out of which he was leaning on
account, as he afterwards said, of an asthmatic affection. He
lost his balance, and fell twenty or thirty feet, striking on his
head. When I saw him, he was lying on his back In a par-
tially comatose state, and, when roused, answered reluctantly by
signs- His right eye was ecchymosed, pupil fully dilated, and
not at all stimulated by the light. He had had a bloody dis-
charge from both ears ; the marks of it on the right side still
remaining. His pulse was 120, soil, regular, and moderately
full.
An examination of the cranium being made, no fracture could
be detected. There was very great tenderness at the upper part
of the spine, where it joined the head. Contusions were found
over various parts of the body.
The patient remained in a very low condition for about foui^
598
mSCELI^NXOUS CA9ES>
tccn d&yi, and with M the symptoms of &««tiire oT ik
ihe ekiilL He waa then aitucked with a severe lEkitfami.'
none of tlie reTncdics used Bccmo<I to hnvc tiny dlectap^l
u'hile it rcduceJ \us strcnglh, ficomed to itnprote ba
gcnce. Under it, in tho ctjurse of ten cJava, the ccnbnl
toms dien[>|icnrcU ; nml lie bctr^Ti to recover the BonlAfl
tho ri;j;lit eye so oa to di^tingiiUh Jiglit from clArkn»,0A^|
tJiuee cuiild aee large objocts before him. After ammg«*l
very lowest slate of muscular debility, J»e began to leWntit'
wa.4 finnllr eent to one uf the public tnftituIioii« ; thcvjn^
caused by hU orin^inal injury beln^ i^ o ^''eAi loe^iaim itM
alter about four weeks of treatment.
Tliit? eitsc ie related ns one in which, from t}ie wnv the t<^
occurred, nnd the eub-^eftuent eymptoing, dcnih vra» ibongfe*
bo inevitable by aW the sur^oons who saw hito. The afdnei
Byiniiloma were apparently relieved by tho fiupcrvcntioD of ^
rhcea.
Case QQQLXyiL^Jicstt^ciMicnofa Tnunff Loil^nfl']
Lon<f iSnbm^rf*if*nn — There hna been con^iiclcmlile diffemmcif
opinion expressed aa to the length of time reqiiireil for dfl^,
to take plnee by drowning. Two or throe mtniitew' Mibmciw
is generally conaideicd siiffieient to deetroy life. Cases,
CTcr, have been adduced, of peraonfl who have been sia,
or even thirty inmutca under water, nnd yet have been
The foUowiiig case occurred tit the drendful accMciii at XorwalU
Conn., where, from the tmio of cars nmuiuf;- off the bridce inffl
the ehannci of the river, fixjin forty to fifty persons lost tbrii
tive«. In this eaee, nearly twenty minutea eliipj<ie<| before ii-
tempts at rcMJ^citation were coninicnecd : nnd, ut rhe V4?rv l»«-
eat computation, ten julnutes niut^l hiive parsed before the naticm
wiia taken from the water; i.e., time enough for ik bomt i^ uai
oiit into the middle of the slream, nn aperture to be em with w
a\e in the side of the car, her ruoilier to be remove^!, who hJiJ
lier hciid above water, and etill kept hold of the youn"- lady, wlw
was fixed in the ^eats beneath the water. Aitcr beinc* tukeo
frojn the ear^ die wn8 tr!ins]iorIed to tlie shore in a hoiti nnd
thence an eighth of a imle to the shed where 1 iirAt saw lier.
RESrsClTATlOJJ AFTER DEOWNIXO.
599
I
At this time, iJI the plivsicnl EppGnrnnceB of denth were
present. The body was cold, the njouth and nose covered with
froth, the face Bwollen nnd liviJ, ilie pulae could not he felt, and
respiration had entirely ceased. Af^cr cleurinrr nway the froth
fntm tlie mouih and nostrils. 1 h»d the body invei-ied^ so ns to
drnin the water as much ab po^^sible from the nii'-pnssagea. The
motionB of respiration were then imitated by raising and depress-
ing the ribs. At the same lime, the finn;£!r was passed down the
throat, am\ The epi^dottia lifted, to onfthJe the nir to enter the
coviry of the chest. By following up thia process, hided by
frictions over the whole hodv, T finally rliacoverrd pomc nelion in
the muscles of tliD throat ; and, on peraeverance, n slight gasp
at length showed that life woa not extiiict. Kcfpimtioti and
restoration of the pulse were not established lill after long per-
Biafpnne in flie process described- Meanwhile, hy sending to the
village, a blanket was obtained, in wliieh she wns wrapped, and
her wet clothes removed- Having procnrod s(jme brandy, her
mnuth vias stimulrtted with it; and subsequently n little was
poured dnwn tl»e tfiniat, when I thought the power of ewalluw-
ing was restored. Consrant and long-eontiuued action waa re-
quired^ before the circulation and respiration were regularly
performed. In about rwo hours, or m soon as I thought it
safe, she was wrapped up, and conveyed to (lie hoiiee of the
hospitable people in the vicinity, who did eo much on that dny
to succor the wounded. She shortly after became delirious, in
which condition she remained for a part of the dny. For a
week ehe was seriously ill ; but I saw her about a. month after-
wnrda completely recovered, and entirely unconscious of the
e\enCs whldi Imd transpired during that dreudful day.
Out of fifty person* drowned, ehe was the only one reeovered-
Tlie shed in which I waa, was filled ivith bodies taken from the
water; flnd» as they were brought in. 1 instructed and encour-
aged the bystanders to go through the same manoeuvres that I
was practising in the present case. Partly from want of
persistence iti them, but more probably from the attempts com-
ing loo late, nothing was effected. There were many dlstiu-
gni&hed physicians in the traiiii some of whom were destroyed
either by drowning, or from concn^sion received by the falling
600
Misccn,Axi:ocs CA^es.
carp; and t}io«e wbo e«capei1 wcro cn^n^f! in the tenvEfV
wnik, at a UiMancc, doing cdicient work iuii«>D£; the nimaiaL'
eotlin^ rr:ic[urc<l boneSi Miwmg up n'ounU^f ami giiitt; i^
l:li
Ci9E COCLXVTTI— /Wura^/ort of the CcUultrT^
— Thia diacaeo is a very common one ia tlic Fr^oth liuifh^l
«»{] n \t'ry filial one; more than two-thirds of rho««*»
auackcd \vith it dj^m^. By examinnciond Rftev doih. f^
lowisli or <jrooni*ili soro-albuminous fluid is fuund rfniol *
llio rt-HiilEtr iihi'iiibniu(^. Tlic rc^molc cnuec is uuixrUili. h^
b^en frequently itttnbuled to the imperfect filling of ibiM
\vitli :ilr 01 Lii^ili.
tn thi« ciMiniry aluI in En^lnocl tho affection ia a ¥0710
one, aad I hnvc floea but few cases of it. My fricDd. Tn^
Bor D. H- ^ti-irer, — wlioiie exjHiTii^nce on the euhjcct i* «*i
to t)];U of na one in New Kn^dnnd, nnd whwec viUuabfei^
r tnko this op[jortuiiity of eayin^, 1 huve availed n»j:«U«J*
many cnsus ru-lulcd in tlna ;vork, — infot-ms me that he itf^^
seldom met witli it in his pracUee. The foliowhig it a>
Btflin'W : —
In Kc'hnuiryT 1847, I was requested to see a dnhl bis »*
old, nnd i-ecoived the folJowlr^ history of it ; When a week*
it vviifi nct:iiionta.lly diaoovered llmt tlie cdliilar tiicniLraiie of ^
thiglks and Ici^a WAS as hfLrd as marble, and thnt this hud iti^
nlly extended up on the bi>dy ] tlie pnrt nt which the harriitf
IcrniiortCed beins; eo peHectly distinct that it couM be lunrl^
by a 3ine drawn in-onnd the body. I directed frictions to I*
made over the indur:tlcd part wilh wnrni sweet oil ; and, io tl*
event of lliid fu]Jin<^t the use, to a limited extent, and ^
proper preciiurioHS* of merourml oioiment.
Under this treatment, the hardness be^Q graduallv to be <IU-
pel led ; Jtod, at the end of eix weeks, it had fjiiiie diciappwired
from every part, with ihc exception of ft few luuip^ in l\^^^ pop.
liteol £pace.
Case CCCLXIX, — Ivoi'ij Penholder^ four incAcs ioiWi
removudji'om Bludd^i'^ — In February, 1844, 1 vi-a^ regnesitiJ
/^
TBT
601
ij a. phydr^liin to see n htty 14 yeara old, who, two days before,
whily eagti^d in pjuiising an ivury pen'hauJIe ititi> liis urtllira,
liJid it tilip fri>ui hib gHL^p, and rarrled liaok into the blndder.
ACter tlie accidentf his water dribbled uwuy fr[>[ii hnn, and wna
OccuaioDally lin^^ed w!tli bluod.
Wialiing Ui Lijnopjd thf. ?-M-.t ul' ita introduction, lie had made
&a incision into the periniPum with a penVnife, for tlie purpose
of cxtrntlLjig ki tliiriking he felt It at that point.
0^1 examination liy the rectunii the foreign body cotdd be
distin^tiishfd lying across the bkdder, one end of it just
en.i^agt'd in the neck of tliat organ, fram which it hnd been
prevented from entering entirely by the irritation eao^etl by it
producing a contractii^n of the cavity to half itH natural dize.
(Jooj>er's forceps, for extracting aniall calculi, were now in-
troduced into tfie urutlira ; and, on reaching the foreign body,
opened and manipulated, with the expectation [>f engaging it in
it^ gnhspi Afler dome inc^ffectual mnnosuvres, thb waa Unally
elFe^^ted; nml the jiefdmlder, whose farlber exireniity wjih lifted
up in the hhuMer, wuh sei^^eJ at an ohtuae angle. By a little
Iruction, and aidoil by the finger in the reelnm, it made a spring-
like motion on the forceps, and came into a etraigbt line with
It, ami was i\i[i^ withdrawn.
Alt the isyinplcma were at once relieved.
Dr. Paul F. Eve, in his collection of " Rcmiirltiiblc Cases in
fiurgei-y," has given a number of instance* in whii;h foreign
bodies have been removed from tJie bladder Ln this vray.
WRY NSOE.
Case CCCLXX, — Divhion nf ike Sterao-tmutoid Mun-
ch for Wrtf Neck, — I waa requested, in 1841, to *ee a boy
16 yearti old, afTeetetl with wry neck, and received the following
history of hia ca^e : — ■
B ^Vhen four years of age, hp fell from the top of a slain^ase
to ihe bollom- N^o wound wiia to be discovered on any prirt of
I the [xjdy : he complained, [lowever, of a pain in the le[\; side
of the neck- Shortly after the accident, it was found that the
fiead inclined to the left, iind that the musclea of that aide were
602 MiaCELLANEOUS GASSfi.
in an unnatural etnte of tenBiOD. This diatortion gradnally
creaeed, untU it attained the appearance which it presented
the time I saw him, twelve years afler the aoeident. At i
period} he was eufTering from frequent attacks of headache, ■
from an almost conaiant and severe pain id the leit eide of i
neok. lie was rather short for his age, and the distortion an]
much to diminish his natural height.
On viewing him in front, the following were the appeanuK
obeer^ed : let. The head was di-awn down to the left stA
the ear usually resting on the lefl shoulder, although he had t
power of raising it a little &om that position ; 2d, This incliD
tion was accompanied by a rotation of the head, 00 that the h
■ regarded the right shoulder.
■ I Observed from behind, there was a deep sulcus on the left ai
' I of the neck, with a corresponding projection on the right &A
J - made by the transverse processes of the cervical vertebne. .
, I , curve had taken place both in the cervical and in the lumbarpo
' \ tione of the spinal column. The leti shoulder was higher tLi
, ; the right. The left side of the chest waa projected, and tbei
i i was a considerable depression of the ribs on the opposite ad
On examination of the vertebne, proceeding upward, the spii
ous processes of the cervical portion could be diatiniruisheduiii
the third vertebra was arrived at: here the line of the coluro
was lost, being concealed under a lar^ mass of muscle; wil
great ci\ro, the spinous process of the second cervical vertehi
was discovered, having performed a rotation of nearly ll
quarter of a circle on its axis. The stern 0-1 nastoid muscle <
the left side, on being examined, was found to he very strong]
retracted, as well aa the deep-seated muscles of the neck' tt
sc^lent particularly could be made out in an unnatural stale *
rigidity. The former, however, appeared to be the cbii
obstacle to the endeavors for bringing the head to an upri^^
positron.
la addition ro tlicse changes, the face had undcrt^one a n
markahle altcrJition, worthy of notice. The whole left ^ide <.
the face was luorc or less atropliJeil, and each of its conjponen
parts was much smaller than tho^c of the other side ; the K'l
eye was much smaller than the right, which was raised uii aa
WRT
«0S
on a level liiglier cIhiti its fellcw ; and tills n|ipearance wna not
owin^ to the inrlined j^osidnn of tlie IilmJ alune, an was iiiore
ditftinutly verifi<?d when ibe ftice was brouglit intT> ita natural
poeltion afler the operation.
The henTlh of the putient was not good; and in udditJon to
the imiitificaciun of being aflli^^ted with so Bevert n deftinnit^. the
pnin at tlte eput where the curvature witn moat extreme waa at
tiiHes excessively aevere. He elejit usaally «n his ri^Lt eidc,
Boniethnes on his biick, but never by any chance on Lhe lefl
Bide*
It bavmi,^ heen aacei'tained^ so far aa was praeticuble, tliat the
chief ohsta.ele tu the realorjition of ihe head existeJ in the un-
naiiiral stale of the ftlerno-tnastoid iniiscle, it was determined
tu divide it at ita sternal insertion ; the retraction, according to
Gu^rin^ who U oonaidered the best aiilhnriiy on tins poiut of
Burgery, generally eiisling in tins portion of llie muscle.
Tlie operation w&a performed as follows : The head being
*iipp<frletl, and i:arried a little forward, so as Ui project- the
'inaade outward from the «ubjiiL*ent parts, tlje patient was
direcled to raiike strong efforts to exaggerate the exirttlnir rota-
tion, so HS to produce iia great a tension of the mtiscle as poe-
Bihle. A puncture waa now made with a lancet through the
«kin, about six lines above the ehtvielc, between the sLernid and
clavicular portions of the muscle. The narrow^ blunt-heailed
knife of Bouvier was next iiitrishieed, its flat *ide lowarde
the muscular fibre, curried behind tlie sternal head, its cilge
towards the muscle, and the section completed by a slight
sawing motion. The effects of this operarii>n were at once
manifested by a distinct crackling sound, by a separation of the
divided parts, and by the partial re8tJ>niliori of tiie head to its
natunil position, also by the [Xissibility of rotation in every
di^tection. The wound on the neck was covered wilb a piece of
court-plaslei-. a cap pliiced on the heud, to the bat*k of which,
op[ios]te tlie right mastoid process, a strap was attached, >md,
being drawn tigfit, was secured over the breast of the same
oide.
B On the fullownig day, he was quite comfortable : he had slept
Hwell, lying on his lefl side, which he had been nokble to do
tlie hend secured by a bapdage carried under
attached to the upper part of the board.
In the course of a fortnight, a very great itr
perceptible: the head, however^ had not yet reg.
position, but waa still incHned to the left. The
had united ; a firm and almost cartilaginoua e
apparent at the point of union. The clavicular
muscle had becotne much more prominent fiiuce
its sternal attachment, and felt rouud and con
an obvious obstacle to the adjustment of the
therefore thought advisable that the division of t
muscle should be effected; and, in order to *
advantage from it, the operation was perfornied i
manner : —
The head being supported and ^e muscle euffit
the body of the stemo-mastoid, just above its div
nal and clavicular heads, could be readily eeizei
thumb and forefinger, and completely isolated f
sealed parts* An appropnate knife was now can
muscle, until it could be felt by the finger unde
the opposite side; and, the patient being directet
muscle in strong contraction, the section was com
difiicuUy*
The second operation was not followed by any
the wound being quite healed at the end of fortj
and, by persisting in the treatment before directed
very shortly restored to its normal position. Xim
intT fflSCK,
carrying the head in an opjiosile direction. The face stiJl
lenU tha altcmti(»n nlrcady pointed out; viz., an alrophy of
^yje whole lii the nliccUd ^klc. The eye of ihc Left siJc ia Riuch
i^i^ee prominent, the lid more closed, and tho level of it lower
^ghao its fdlcw : the ivhole onacoua, rcJlulnr, nnd miLt^culnr system
l^pattakc in this Qktcratmni or WEUit of Uevolopmcnt,
1^ From bdiiml, the following chungee are visible: The dorsal
^ and lumbar cunuturci^ of the epinal column have dianppeiircd,
ami the fchoulders have regained their nutural elevation. The
depresflion of the ribti on one eide, nod ihc projection on the
Bother, are fnst di,^ appear Ln^^ The right half of the munclca of
Hfthe neck etill remain ^Tcntly developed above tliat of the other
^nidc, nnd a alii^ht curve atill cxiels in the cervical Tcrtcbnc-
. The health of the patient hrta ^atly improved ; and hid nppoar^
fc anco is en eomplctelv altered eincc the operation, that, his former
p trienda scarecly recognize him.
Cask CCCLXXI. — DivUio-n ofths Stern o-nmafo id Mhs^
th for Wrtf Keck- — The tbllowinv ciiae was operated upon
by IJr. John C, Warren, in the hrst part of June, 1>J41 ; —
The patient was a little girl, nine years of age. When about
four weeks old, the pai-enta observed that the niuric^lea on the
left eidc of the nci'k were in an extraordinary stale <ii" icnBiun :
it waa not, however, until the ago of four ycnra, that the hea<l
in to he distorted; ami IVoni that perioil the distortion bus
iually increaeeU, ho that the contraction become so great as
to bring the mastoid procGBs ncnrly in contact with the left
shoulder, accompanied by a atnmg rotation of the Itead to tbo
right. Tiiid distortion evidently hud a y;rt'iit effect on the health
of the child, who was pale, emftcijvled, and of n feeble consti-
tution. A double Inecml curvature of the epine esiatcd. thou<^b
not BO markdl u^ in the preceding ease.
Under tbedo eireiimstaneea, Dr. Warren determiucd to divide
the elemo-eleido-mnstoid muscle of the left side, whidi wna
fbujid to be (^tron^ly retraeledt and was evidt^ritly the chief
obstacle to the return of the head to the upright position.
The operation was performed in the following manner: The
bend being supported so as to give aufKeient projeclion and ten-
to make strong an<l constant eflbrts to rotate t\
also placed on flb inclined plane for three or fi
the head secured by a bandage carried unde
attached to the upper part of the board.
In the course of a fortnight, a very great ii
perceptible : the head, however, had not jet r«j
position, but was still inclined to the left. The
had united; a firm and almost cartilaginoua
apparent at the point of union. The claviciUaj
muscle had become much more prominent since
its sternal attachment^ and felt round and cot
an obvious obstacle to the adjustment of the
therefore thought advisable that the division of
muscle should be effected; and, iu order to
advantage from it, the operation was performed
manner : —
The head being supported and the muscle sufi
the body of the etemo^maatoid, just above ita di'
nal and clavicular heads, could be readily seize
thumb and forefinger, and completelj isolated
seated parts. An appropriate knife was novr caj
muscle, until it could be felt by the finger und
the opposite side ; and, the patient being direct*
muscle in strong contraction, the section was coi:
difficulty.
The second operation was not followed by anj
the wound being quite healed at the end of fort
WRY NECK,
605
hy carrymg the head in an opposite direction- The fitce etiH
prescnta the ulterfttion nlrenJy pointed out ; viz., an atrophy of
ihe whole of the iiffccted *^idc. The eye of the left side Le much
le^B prominent, the lid more cloaod, and the level ".if it lower
thn.li its fellow : the whole osscoub, cellulur^ and mu^culnr eyatem
pnrta](G in thia nlicratlon;, or wiint of dcveZopmont.
From behind, the following changee are vieihle: The doraal
and lumbnr curv:iturej? of the s[>mal coluoin have Jisiippenretl,
and the diouldera have re^ineJ their natural elevHtion. The
depreEfiion of the ribe on one side, and tho proJectiLiD on the
other^ are fast diaappcariag. The ritrhl half of the muddea of
the net:k still reiiioio ^roiitly Jeveluped above thsit of the utljer
gidfit ^nd n ftli^'ht curve atill exists in the cervical vcrtebrie.
The health of the patient has ^reailj improved ; and hia appear^
once h uo completely altered since the opemtlon, that hi& former
frienda scarcely recogniae him.
Case CCCLXXI. — i>i"iv"jjfjji of the St^rno-mastoid Mu^t-
ch frr TFi-y Neck. — The followinrr ease waa operated upon
by Dr, John C. Warren, in the first pnrt of June, iJ^il : —
The patient wiia a little prl, nbe yeara of a^re- When fibi>iit
four weeks old, the parenta obaen'ed that the nmselea un llie
left side of the neek were in an extraordinary state of tension :
it wafi aot, however, until the age of four years, that the head
began to be dij^torted : and from that period the distortion has
gradually increaseJ, so that the contraction became so great iia
to bring the mastoid process nearly in contact with the loft
shoulder, accompanied by a atronjj; rotation of the head lo the
right. Thia distoition evidently had a ^reat effect on the health
of the child, who wiu pale, emaciated, and of a feeble consii-
tuiion. A double lateral curvature of the spine exited, though
not ^o marked as in the preceding eiwe.
Under these clroumstances. Dr. Warren dciennined to divide
the fltcrno-eleitlo-mastoid niu^ele of tho loft side, which was
found to be strongly retracted, and was evidently the cliicf
obstacle to tlie return of the bend Xi> the upright poaition.
The ciM^ralion was performed in the following manner: T)te
head being supported fio jis to give sufficient projection and ten-
u
again entcrea ai ine same onDoe, carneU m front o
mastoid, and this head of the muscle divided in a f
Der.
The result of the operation was an imniediate altf
head to a more upright position. The wound he
days. The subsequent trealnienl waa the same ;
tailed in the preceding cnee.
The following Is the substance of a letter r^cei^
father two months nfter the operation : He stated t
perfect command of her head, and a power of rol
directions. Her head was so nearly straig-ht thai
would not notice any deformity. "From the dh
neck slopes to the right, which is apparent -wh
behind her- The short curve at the upper part of t
scarcely be perceived. The cavity on the ooe side, t
largement on the other, have returned to almost
shape. Her schoolmates are astonished when th
with her bead up, and Bay how toll she has groTra.
you will probably remember, was appareatly very i
now a very long neck for a child of her age. She o
inclined plane four horn's each day/*
Remarks. — In reviewing these cases, we shaJI fi
lowing circumstances worthy of netice : In the first
anatomical changes produced by the contraction of
are very interesting, as bearing on many cases of
besides that now under consideration. The \eh haJf <
as has been already stated, had become more or leas
tramiinicated t
T^ioes a rotntion on its axis, so as to brinp; Jt into the huri-
ontftl <iii-ection ; the ej-ea, as H. truorin rcmiirka, being pluccU
n relation to each otlier, as it were, on a staircnee, from
^vhencc eon did enable trouMe in vision ia produced an tbc firat
Jjudtmont of the head, Tiic alteration in tlic apinal eoluma ia
interesting* In ordor to abvtJite the inclinati[)n of the
kd to the left, whieb brinfra it without the nxia of tbc body,
inclination takes place of the ecrvic?ul on the doreul region,
>f the dorsiil on the Jumbar, and of the Inrabar on iho eacral,
'he deprceaion cf the ribs on the one aide, and their projec-
tion on the other, nutiirally follow from iUs pcr^JsCcnce of the
mrvaturc In the ^spinal eolumii.
There are few opcrntions that have been more benefited by
le eBtabllehinent of the principle of subcutaneous ineUiona
ban that for wry neck. The operation prcviout:iy emploved by
Ijstiaguiabed fiurgeotie eonsiaEed in tirst itiakin*r a tran3ver9e in-
ihtoTi ihrT-JUgh tbc ekin, so aa lo expose the fibre of the stcmo-
[tnaetoid : the muede was then carefully JiHflecled, layer b^"
lyer, until the whole was divided- The rceiilts of this method
retc often very eevcre: there was great intlrtninmtiou, and eitp-
mi-ation, frequently fuUowed by infiltration of pne into the
[ftuterior mcdiu&Iinum, ^ometimed eauHJng ihe dontli of llie pa-
ieati Tbc contraetJon, aleo, of the cicatrix trom so severe a
^Ivonnd. often eounteracted the benefit derived from the division
Lof the mUBcle.
To Mi Gu^frioi of Fnriaf wo are chiefly indebted for the ex-
position of the pathology, physiology, nud tlie surgical treat-
nient of wry ucck» \[p Gui^rin has endeavored to establiah
the following propositions : —
l8t. That what has been calleil the etemo-cloirlo-mafltoid
jiiusetc constitutes, in fact, two diatinct musclea, — the stcrno-
ntattoid and the eJeido-mti^toid*
2d, The stern o-miwtuid and the cleido-maatoid are poBBesscd
of different functions : tbc lirst is a Hi'xor and rotator of the
hcnd, the otbcr muscle i^ oefcntially a muscle of ret^piration.
3d, In wry neek, which has i\i\ia far been attributed to the
flhaptening of the aterno-mftstoid, the aternal muscle ia primi-
tively alone affected.
i
608
MISCELLANEOUS C^Afl&8.
1
MJ
4lh, That, iti the trentraent of chronic vrty neck, ovring u
the aht>rCening oi' the flterno-mAatuid, the section of ihc Hin^
portiuu nlone eufKcee to deatroj the e^cntial cauae of d»
dcforraitj.
The praoticol intercoce to be drawn from them appears m lifc
fourth proposition ; vis., diat m the mnjorit_v of cases, ihc ^teni4-
mrtatoid is priuiiirily aiiectod, imd thia done requires ao opcrv
tioD. Where the jiffectioa hoa k^tcJ for a length of time. a£ in
llic tvro i;naoi< slated nbovc, the clcido-mfLst<>id almoj5t di
parbikea in the dtf^caaed action ; and jilthough, by ii Jong
ence in the use of mechiinical means, thla tnny be f vmetj
overcome, yet the cure i» undoubtedly much fn^niiiitcd hy
division. M. Gljl'hq hns drawn a dislinetion, vrortiiy of jioUk
betwe&o what litr calls die retraction und the contt^actioM of
muecle. Tlie formefi he hoa cndeavarod to show, only I^kei
pUce afler a loug per^i^teccc of didcai^c, und con^i^^Fs in a f hroiM
degeaeratiou of the miidc'lo, and nlwuyt] retjuirci^ f^ur^ie;^ inO^I
ferencfi ; whercoa the latter, which occurs in ncutc vrrj neck.
is a simple lemporary ahorteniiig of the inuecuhir fibres, &nch
occurs in cominijii mu^etilar notion, and i:^ aJ%vn_vd ome
to the nae of locid remodics, more porticnlnrJy the appliot
of the tiirtOT'Cmctic oiotmcnli
The fuUowing ifl the most approved manner of perfurniiiig
operfttion : The head of the jiaticot, being firmly euppijru
carried H. little forward oiid strongly routtf^, 30 oa to p
tl)c muadc outward tVuni the euhjaeent piirte, and make it
tense fts possible A fold of dkiu over the lquscIc bein^
a puncture ia made with a lancet from four to six lined aboi«
the clavicle, and betwcfu the insertions of the two lienija of itie
muscle. The narrow, blunC-hendcd knife of Bouvicr ia nov»' in^
troduced, and carried with its flat side between tlie muscle and
the akin^ The hold on the gkin may nuvf be relaxed, the
of the knife upphed to thi^ muscle, nnU the division cJTuc
Tins ia usually announced by it crackling aound, itnd bv
pai'tinl adjustment of the head. In^lcnd ol' posj^in^ the
in front of the muscle, it may be (.virricd bohind it; but in
case it ii:' well tiiat the knife dhuulil hitvc a dilTcrcct ahape;
the former a concave, and in the latter a convex, edg« ia
JU-4
CroyOBSTTAL FtT8H>N OF FINOER8.
609
ureJ. If It hKouM iiuAv Ije dt^tcrmincJ to divide ttic c1aviculn,r
lead (»r the muscle, tlic knire may be Introduced Into llifr snme
lorifice ill the akin, Cj\rriei.l h^ckwArd^ and t^ic divi^iod uin^le !ia
the jtrecc^llng case; the acotion of tlie muscle from without
iitwunl htin*; here alwu^H to be jir^errcd, aa mure aafe uud
;eH*> of cxeeuticm*
\Vlien the projeelion *j( the muscle from the p^trta beneath i*
[•ufficient to remove them fmni tlio diin^er of Jicing puuctured,
land it lias been deU-rmmed t^ divide the hitAy uH tbc muscle,
|thc mcthjd iiia^ be ndojited which wa?i practised lji tlic former
of the two ciiaes which have been relnlcd. The botlv of tlie
muscle jn.*t before its division Ijein;^ seized between the finj^'crs,
%o lliEit thcde jtre luado to meet belilml it and nscertnin ihjtl no
abstflcle intervenee, n narrow-bkdcd knife is curried benendi,
UDiil the point is detected under the skin on the opposite aide;
luid the division is then to be mndo from vrithin L>ut^'brd.
In dividing the interiiul head of the muAcIe, we have occasion-
filly henenlh the skin the nnterior jugnW vein, aa it passes
ifici'usa the neck to enter the subclavlnn. This, hDwever, id
liljr avoiiieii h_v making ihc incision aufBciently near the
clavicle- The carotid nnd internal jugular are protected by
die etemo-hyoid j^nd tiei'no'tljyrold musclea, and could not be
reached but ljy the [mint of the knife carelci^sly introduced, In
Hdividing the clcido-miLstoiil, the cxiemal jugular, which lies
between the bolder of the ninsele and the skin, may he wounded :
tfaia ia avoided by raising the skin and passing.' the knife with '\Xs
cutting ei]*>;e jterpendiculMrly to the muscle; the vein hein^ lelY
between die back of the inatruiiient and the ekin. In dividing
—^ llic body of the muscle, ihc external jugular is the prineipal
^ Toaael to be avoided, and with auftieicnt circ can be easily left
on the outside of the puncture neccfisary for iDtroducing the
knife employeil In tlie operation-
COSOENTTAL FUSION OP PUJOERfl-
Case CCCLXXIL — Cot^tnilal Fusion of the Middle
Fiiiff^rs of both Hands. Operation, Cure. — I am led to
record the following case, from tlie difficulty experienced, when
77
ft 4
'I
filO
snsccLL-umoua ca^iba.
it wftJi firat brouj:lit t" my noltcCi. of |>rociirin;! auir pnrte
inFurrtiiitbn on tho aiibjcct from the our^jcnJ wprlu fewn>
rL*fiTiT<l tit ns im'lniritv. I wiia rc'yiin?3tc<l% in OdobcTi li'Hs
BCD n <:Uiltl, who lui^ Ijcimi l^trn it few cjiivra lictoro, nirb u eO-
mntc union uf tltc midJIc and nn^ iin^ers (>f cJtch haml. Ik
4<)iiM was n ^(jrv Rnc <jiic« »mt iiihcr\t't8C perfect; its pmk
rcinnriii^bJy linnd^^oiito nnd vt'll-forincJ* Tli<^y were exERW^
imxioLts llint ^>mc opci^atioD ^lioulc] be ditnc tu brin^ tbc fi>|ff
iiiti.» n ni^tcrul comljijun. On a cnrcfaJ intf|teclii>D. i IM
tlio iiU\tv of thiii;;s (18 fdllovvfl ; —
The 0(iiLjL>mLil iiiiifcr of cndk 1mm] liAtl but a euigl« >u^
I»o6icion tobroHk up intn two. K<i liattire «r dcprc^it>l O^
he Uictiti^uj^lioil iiimkiii;; llic Jjstmcfiim lictwocii ihc Iwob^
ns nviy bo ubsorvcU in wliat ht ciillixl tt-cbbctl fiti^rcr^. 7^
fin^'cr wne euscc[>lifilc of Hcxion ami csctcn^iuti ; but no i];'^
nnoo r>r ^epunLtc joints ouitUl be oh^ervo^l, or tfCtrATiiie ^1
Btruttui'ci in fnct, tbera whs ii|n»iM-e[itly but <»nc finger in (J*
uf twOi 1 tiLcrofoLC ndn^cU lluit the o)>t;rniiuu aljould \ft^
Iftvt-tl, to nfford fiiitficicnt lime fiir tlie ik'VL'lojujicnt of i\t*:^
crctit urgnna ; tlikt tljc coiijulncd Itn^'oru ^itutiltl be neizeiL ii'
mode to wurk ialGmlly ono upan tho other, ao na to dou^
if ]n»Sflib!cT the uniting lucdiuni bctwtcti tbc tvro.
The jjrccciling pJiin was nUvptLHl ; iitiU, al ibc enil of «s
montlis, the bony etructtirc, joints, and otbcr textures, wea
autficiontly devclofK^l to sbow the elements of two Gn^era iiiik
niaaa, nnd WJUrant the ntlcmpt nt an operntjon %vith n rt^awn^
cbnncc of tepn ruling tbtiUi, without cutting iiit\> ibu Joiiil:'. icJ
producing &titihc&a or ancUylo&La. The operation wua ibiis pt-r-
formed s —
The fbild being ctlicrized, tho ends of tbc fingers, where d«
bony dtructure j^ecnieJ to be united, wore acpnrntcil u^i to ihi^ fir*t
joint, by ihc t^Litting plicra, A carofiil dj^soclion then spiuiratrJ
ihcfingcra, forluiiatcly without entering the jointiii, except [lo^
eibly the laat joint of one finder on one hnnd, wJudi ini<r]i; have
been opcnol ; but thii^ wn^ doubtful, nnd not at all indicncod by
the anbsL?qiicnt progvo^a of the case- Tiic disi^cction n-;is nuTiH
r;ithcr further towmd^ ihc hand than the uutural diviaiou. in
arlv down tu the first or Icmifklc ji>int, in <
^ifor It ccitnin nnioimt <if fldticoiuu or coiitpiiuiion, whieli iL wrw
fet#thou<{lit nif nrt or lubor- wouM l)o iiblo to prevent- It wna then
n,.ntti'iu|>tej, nt flie nnifle Jind a»lt*d of the fin-^er, to brinjf the
^tflkin ot^ iIk- Imck »nil iiiilni of tho h^Tid tn ccxitncC by meiirid of
fiulure^, Tiiis wns ctt'octcdj but with grcot atrjiiit of thciiito^-
JDts, on nccount of the thickness of the parts. A lon^ piece
>f ndhc^ivc }>l£ister waa pisiced between tho two fin^oi"^, ntid
mdo to eserl ns grcut n [ircfl:*ure ns poadibic on tho iin^le of
ic wound. Thiif wiie roplieeil from time to IJme« the uao of it
'bciiijr mniutuiiied lhr(>ri;;hrjiit the vvhtile trciitmcnt.
It will be imnef^es^nry tu ^\j iiiLo nil the n^iiiuLin:< of tlie aub-
jquciit mnjMgcEiiont of the ciuCi It piMvcit pcilcjtlv eucccss'
Ful, mid left llic diild with two wcll-fLinneJ tin^r^, jind the
sntirc iwQ of the joinia. The inula, which lind been dividL-d, in
Lho 00111*80 of Olio or two mouths wcro otivero<l on tlich' cut
[aiirriioca by tiew skin ntid Hcah, jxiviii^ them quite n njiim'iil
ftppcnmncc. The *Mr/itrit, wfiirh cJtteinlL'd frnm the nrirlc uf
tlic firk;rQra upwnnk on cwh sjdi-, hjul n rcndency to t^ontmur,
|«nd eiirvu tho Bn^cr^ in^ninU; nnd thi^, n^thov thnn the di^po-
^aition of the fin^^or^ to n^snUi unite, wns the pHnd[>]d ptunt
iwhidi requiri'd nttctttiun tinvnitU ihc end fit' the trctitmetir. It
\yirae lhoii<;ht u^de.'^s, Jit tl»o curly njre of tho pnliont, 1o ritlempt
Any iiicehanicnl mL'rine to obvintv thia eorLlrnclioti, whieh wna
Itonnteriictcil by iho constunl nltcnMnn of the mother* in BonkinLf,
«nd fui'cibly bending tboni otit. Tho resnJt of the itporatioii
wae, in pJnM of a. very grcftt dcfbrmily, tn rcijtore the hntid to
n useful comlnion, nnd to nn rtppcnmnee which would patiB
wiflmul reinni'k,
I hrtve cfteii operated to remove Biipcrnmncrary finger* nnd
froni inftmLd« and invnriiihly with rrood rctttihs. Houie-
■e two tiu^ei'j} or toes nrc pWcd on the fitme juinl, eaeh bnv-
in*( itfl peetdinr fncet in the joint. When the patient iu very
youn^T' »uid the additional excresoenec on tlie outside of tJio
fin^'or or toe, I hnve not seen any intlommntion of the joint
euDiic from removing it. At n kter period, when ibe joint la
Rioro fully or^ani^ed, it nppenr« be^-^t to eut oH' ibc hend of
lb« bouv jufit bhort of tlie jumt, whieh, il' neatiy JonCf ahovra
^a
HISCEtXAS&OUS CA8EB.
but little aflcrwardfi. I have lately opcraloii on tiie
coeo: A little girl, eight years of «i?Ci bad two tcrmiBal
on ihc ]a£t joint of lh^ ibiLtiib, with two nails ; t\\f tw^Hm
B[irin^i]g from one joint. By difFectin^ up the ekin, 1 mW]
tlic outor one, with pnrt of tlie b^ee, mtbout ictcrr«nit*<^l
the joint; aod the deformity remoining after tbc openttioa»i|
very sliglil.
I hnve twice eeeu perftone with & eioglc enonaous fn^,'
Bppearing ns if viewed tlirotij^b n injigfnifying glasf<- The *A]
lowin-j remarkable exuberance o{ growtli and dcfomiiiT jf di
ioQi U the only one of the kind that I huve met niib : —
Case CCChXXUl. — ^faf/or^7lat^on ofJ^oot.—Xw
fiboiit 30 yoiu'e of n^e, nppli«il to me for an injury of herhif
which, ahe anid, waa n remiirknbla odg, boin^ congenitjJlf'
formctl ; and ihia I found to bo thcooee. The foo4t as firial
grnaX toe, on the inside, wns nutuml; and, on tfic outer aqc^
were two natural toes- Springing from between theic «■
wh(it nppeored to be another fteahy foot, terminated br tW
rudiments of toes buried in the end of it. On a cnrvful MW-
pulation, ihe oaaeovis p^irt of it wils found to be cct uj pcecii *i
two lar3;e bonCH, apparently the metatureai ; there was no pn«a
of flexion in this pnrt of the foot. On the dorenl u&pect. acdi
the junction of this foot with the other, was w-jiai appcarel »
be a gniiglionie swelling, wliich was quite tender, anJ Wd
been caused by n strain. This yielded to trcAitnent in a irect
or two, Tiie leD*^tb of the foot was thirteen inches.
I lately measured the foot of a man six feet fijx Inchea hish,
at the Hospital, and it was found to be n little less tlian twdrt
inches in Jengtb.
Mr. Annndale has recently written uu interestinrr book on
"Deformities of the Fingers and Toes,'' in whieL are caxa
sometvbat eimiUr to those given above.
chapteh xtv:
AN-£ST1JETICS.
:e cliFin^ mndc m the praciioo of ^iirgcrv hy ihe dWoverv of
Ltlte anitalhoric power of crher cnn scnrcely !x> iip|irm!Hefl hj
I0A« who huve come on the Miiji:^ aince the introduction qT this
igent. It wns in ihe city of liostim, n little more tlinn tAvcniy
'ear* sinec, that tlip full rnluo of this discovery wrt« first di?-
tlPOD-itrnted and piibli«h<?<i ; anJ it ]<» truly rcmarkatiJe, that,
Lt the preaenl day, artificial anawtliesin ia best attiiined by svil-
Iphitric clher, tis&l in suUstanlially the same numn^i' 0.4 whf^n it
^ivas first Tried in sur^ictd ojierationft at tin? Mus^acliusett* Get»-
rul IW|»itnl. Wiule chloroform la nekao^vleil^r^J to be ikn-
pemua, and while the fjreign medical jnumalu conmin frer^iient
notices of Uantb from ibc use of this po^oni anient, it is a strikiDg
ifiiet, that, out of iha hundreds of l[kousuii<k of cusee of etheri-
[ffaiiun, the fiwt umlnu^iteil ca*e of detith from its nciioji i» yet to
be recordwl, Ii la not pretended by this staieinent to abjure the
nae uf chluroform, which, in anme cases^ ia certainlv preferable
to any known aitaesthetic ; being far more f?onccntrnted in fortn,
morp ngreeable* and more ncrive in administration, than any of
the ninny snl)<4titufE^ which have been pinpnsicd for it- On the
baitlt-fitkl, en]>eoitdly, its grearer poriabiliiy in likely nlnaya to
secure (lie preference far ft over «afor bnt more bulky aun^
the ties.
Tlie flrst and perhaps the moat important application of ether
is in prmliicinir nnconscLmi.^ncas of piin ; and it is for lhi?4 boon
that ihi? pailent will ever be cbicSy lliantrul. To the fliirjjeon,
aIj»o, the Ti on -in diction of pn.in is often a mniter of the greatest
moment ; for he eaii now undertake a long anU tediours dJHM^ction,
or u delieaCti explorution of an acutely inflamed cuvity, undi^-
614
torbed bf tbe InToluiitary moreiDMit* of die potittit. llMpCH
to ftboUah pain has also nuiterulJy enlarged the domaia of ope
tive siirgeiy, not only by ^mtwUliifty ^^^ dreed of eoma
operadom, and allowing of diur miwe frequeoit pcrforiBM
but alao bj admitdng iato the liat of juetifiiU>le operatiaiM m>
whose severi^ would othorwite, in moet oaooa, IbrbHl mta. i
thought of attempting. ,
The other great ^tplioation of edur ia mar^ery depeade v|
ilB pow^F of ralaxlDg the T<4imtU7 ainflolea by InAt^i^r^ « ga
<^ the brain aiiah>goiu to ooioa* la die de^ toleep of ooo^
etherization, the manipuladon and fedoedoai of liaemeB i
difllooationt, the diagnosia and traatment of eaeli^^oett, te :
duotion of atraagulated hernia, Ac.* are immrniiulj fagjlrtift
The question of iu OM in oertain tpecial departnenCa of m
gesry wiU be nodced ebewbere.
Thi« it not the plaoa to dwell on the Ter^ inqwrlant oMi
ether in midwifery, and in painfnl or oonTnlaiTo medteal diasM
bnt of its inostimable valoe in the alleviation of maSUmg d«
the last iDomente of life, I cannot omit thSa peaiing afftffm.
Having been oonveraaiit with the prindpal fiieta rehtag
the introduction of the inhalation of ether for amttieal **fiiHT***
from the bcgioning, it may not be considered inappropriate
give, in this place, n alight sketch of ita early hlstoiy, mi
especially aa, aince the introduction of chloroform^ and
almost complete adoption abroad, the oH^d of etherijotti
seems in danger of beiug lost sight of. The ikcta, eo fn u
am acquiiinted with them, are briefly as follows : —
In the autumn of 1846, Dr. W. T. G- Morton, & dentist
Boston, a person of great ingenuity, padence, uid pertiiwcj
of purpose, called on me several times to show eome of I
inventions. At that time, I introduced him to Dr. Jt^ I
Warren. Shortly nfter this, in October, I learned from D
Warren, that Dr. Morton had visited him, and informed bi
that he was in possession of, or had discovered, n means of pr
ven(in<r pain, which lie had proved in dental opemtionSf ii
wished Dr. Wnrren to give him an opportunity of tryin<r it
a surgical operation. After some questions on the subject,
regard to its action, arfd the safety of it. Dr. Warren promisi
AN-^EflTHETIOfl.
615
thtit he would dn sn. On the Titcsilfiv fullowin^, Oct* 13tli,
nfler tlie aur^'iciil mit nt the HoyfjitJi], n patii^nt was brauj^ht
iTitiJ the umphitlicntre fbr 0|>emtioni Thia being the first op-
Hurtunily wliicli \md occurred eiiica Dr, AVurrcii'a proiniso to
Dhp Morton, Dr, AVurrcn said to usi "I now remember thnt I
hare ntiLdc n promise to Dt^. Marton to give hliu an oppurtunity
to try A new remedy fiir preventing psiin in euigioal opernliona,"
nnd ti^k\id tlic piiticnt if be elioutd like to ]ihvq tbc opoi^tion
done witEuiut soiToringp He nnturally nnswered in the nfliniiR-
tivo, Tho operation wna thereloro deferred until Friday, Oct-
I6lh» wlien tbe ether vrns fidmini&tere<l by Dr. ilorlon with bia
nppuratua, and tho operation jjerformc*! by Dr. Wnvren. It
conaiatetl in the i-oraovfll of a vnsculnr tumor of tho neck, which
occupied five minute^, Durlcig a purl of Lhc time, the putietit
ebowcd some tnnrka af seiuibility ; but fsubs-cqueiilly nun] ihnt he
bnd no pain, uhhou^b he was awiire lhn.t tbe operation was prL>-
cccding. On the following day, » womun requiring the removnl
of rn adipoac tumor from tlic nrm wns rendci'ed inecortiblc by
Other, given by Dr. Mtnlun ; nnd Dr, Wsirrcn reqiieatL^d Dr.
Haywniil, who was proBont, to porform tlio operation. This
wjia Eucc^eefful ; the ether bein^ continued thruuph the whole
nperjition, wliiuh was n ^liurt one, and the palient being entirely
in&cn^iblo.
A few days nftcrwnrda, Dr, ^A'arren informed mo that fie li»d
learned from Dr, Charles T, Jaekson that he had suggtiattd
the lite *jf eilier to Dw Morton*
The aucoe^B of this proecas in the prevention of pain was now
fpiitc establiahed. ltd u?e^ liortever, wne siiapendcd for a time,
for rcneons which Dr. Wiuren lisis already given in Wis tirat
paper oa ether; and the expenmcnta were not ogaJn resumed
until Nov. 7th, when Dr- >Iorton declared hi.'^ wilhngnesa to
state the nature of the agent employed. Two imporUiit opera-
tions were now dune ^iiceessrully nt the Mas.'iaehuaetis General
IIo7^[>ilal under its uj^eney : one, an anipulxttion of the thigli,
by Dr- Ilaywaitl; the other, n very dtt^c^ult and bloody opera-
tion, — -reinoTul of a portion oT the upper juw in a woman ^ — hy
Dr, Wnii^en. On the enme day, I operated on nn infant f^ir
liure-lip \ but, a^ we had tliuei far hud little experience in the use
616 ANESTHETICS.
of ether^ it wns not thought prudent to employ it with f^ jnet:
a child. With ti more full cxperteace* however, 1 havt ^i
given it, in thid opcnitlon, at the earliest ^g^^ of lif^^ '^^
between eix and eight houra after birth.
On Nuv. 12tli» I performed the firat successful optn&c
under ether wliich was done in private practice, on a ncz
woman, for a tumor of the itrm. The ether wms ftdminkiaa
for three minutes, when the patient became unconscious. Tk^
enition then proceeded, the inlialacion beiagf conliaued. Tk
patient was bo entirely tranqnilf that Dr. «T. C. Warren,!^
wns standing by her side, was not aware ihat the operaiion H
commenced until it was nearly completed. Nov. £lft, 1^
another operation in private practice, at ivliich many of the pifr
fcssion were preacnti — the retnoval of a. formidable tumoia
the thigh, wluch is thus described by Dr. J, C. Warren: —
I '^The patient lying upon a bed^ the vapor was admialsUftd ^
j Dr, Morton, in tha presence of Drs. C. T. Jackson, Kejwl^
[ ! J. V- C. Smiib, Flagg, Gould, Shurlleff, Lawreoce, Pursona, Brigs-
( nod otliers. After he liad breathed the vapor for three miaaip-
', j hla head fi:!I, aud ho ceased to respire it ; but, presently awaking, ^
• J inhuiatioQ wn^ renewed until he again appeared iniieasible' Tbr
I ■ operation wjis limn oonimGnead. At the first stroke of the koiff.tf
! dafipcil Ilia liand on the wouml ; but 1 tminedlHteTv s<?ized ami heM '-'i
diintig the rctnmnJer of iht' opcralionj ihougU not wEthoui >nine Ji^-
cuUy^ ill c'tJiis<.'c|m!iiL'i! of JiL^ 3(ru^n[k'a. The opcmtiun wixs iximpW-
in two or llnuG tiuuiHe:^, iieuJ lliu p^uienl remaiucil if iiieUv ou \m biif^.
wiiU hi-t ej'ua fh)9cil. On exainiuaiion, (he pupiJs wurc foumi to w
ililati?d ; ilic pul^-c whs not inxtermlly iifFcrltit. Afrer hv [mtl Ui^
nbout Hvo tniijiiica, 1 ichim'iI biin hy (lii^ in<|uiry, ' How do vuu an
lo-Uiiy?' ill vvhii'h lie ropli^^U, * Vury well. I iliank yon/ 1 iheii iistcl
what he Imd boon iloin;^- Jli: ^aid he Iiclicvcd he had hceu dronmic?:
he iJroamcd rlint hi: wjn rit liuine, and making ftomr exainiiuiiion iiii'
his bii>iiK'-M. ' Dii vnii t't'cl iiiiy pEvin ?' — * No/ — * How U rh.ni timiT
of yourjs ? ' Tliu puiionl rJii<oiJ lihnself in bed. lo^ikoil iil |ji,i tlii"!i
for a iimTi]L'ii[» and Mud, * II is gone, and i'ln ghid ol' tt/ I liun
iiiqiiir*'d if hu hud fell any pain duriug ihe opcrafion, to xvJiidi lie
replied iti The ne;^iilive. IJe soon recovereil hU njitural sl.ile, expe-
nuucetl no iiieiniveinenec from ihe iuludalioti, xvus rem,irkiiblv fri'O
from |i;iiti» and in three d,iy,i wnui home inio llie couiiirv."
617
Tile preccilirg oj>eraKons \H the Ilaspifftl were folluwed by &
iri«(y pertWiued tliery by ll:e oilier siajrcona of llic Institution,
Drs. iS. D. TowiiaeuO, S, Parkiuau, IL J< Bigelow, atid
lyaelf.
Tilt life uf etliei' iii *urgirftl 6perfttii>na bcinj^- Banclloned by
jtbt: i[fdical Bounl of the Ilosplrd, the Consultin^j lionixl, and
fthe Bliaix] of Truflteefi, — the last composed, as it alwitys is, of
llstinguisheU nnd [inidiiaent men of IJostoD, Imving in charge
linportuiit irusle,* — was. after some little reaialancc* gradually
adopted throughout this counCry, oiid nt once iiiiide use of by
Itirgcona in Eurojie,
About u year after the diacovery of the flna^sthetic pover of
'her, chK>rof(inu was iiitioduced, and, from its fascinating
[LULlltiee, seemed likely to displace ether, wLidi had the dii^ad-
[Vanlnge of being disn^Tceiible to the emell and t;vite, and ob-
jeeliunable under certain ciix;umatftnces, from ita inflammability.
Vary ADon, however, fatal accidents began to be c&uaed by
[diloroforrn ; many of them occurring where it was given for
linor 0[j6niti<jn8. The proportiou of deathfl had continued up
the present timet ^i^d may be estimated at about one a munth
For the lafit twenty yeara ; wliitb ratio seenia scarcely reduced by
le uae of any care or ingenuity.
Dr. Jolia Ci Warren and myaelf introduced into practice,
^and Uflcd for about five years, concentrated chloric ether, pre-
* OrriCKHS QF raB UA^HAcnDBstra GEVkajhL HoiSriTALr IBJt, — WiLlliin
[Ap[iJe[t)i[. Prcfjrffjir; Tlicoriore Lyman, Vtoo-Praidtiit ; Henrj AmJrews, TVboj-
■; Marcui Morton, Jr,, Srtrrtnry.
Trm^fTi- — Cli4rIo# Amory, William T. Andrew*, Xjilhnniel I. Bowdilfh,
M. Dexter, Raliert Hooper, Tiiomu LiLmt>, Fmndi C^ LgirelL, JuIlji A,
r^vrell. ll^nry B. Ruytra, J- TIjuium SLG^ttismi, J. Wile/ Eduianib, EJward
Boatd of CvturtirnTi'Tt. ^ Jamm J*eluori, M,D. ; John Jaffnotj M,D.; George
:, ShAlliiclt, M.D. ; Edward BerDoHn, M.]>.
(tfFh'Rj Phgiickim.—Ju-iih mgelim. M.D.; Etiuch Hale. M.D.: John B, S,
rukion, M,U-; Honr.v I, Ba*dii4.>li. M.D.; John U- Fitber, M-U-; OUver W.
[oLmtfl. M,D,
Viiit\rii/ Suyiffuna- — Juhii C» Warren, M D, ; Geur^ naywird, M-D-^ Sulomon
». TortnBond, M.D,; J. Muon WiureBf M.D-; Siiiiiwl l*irkiH*n. M.U,; llenr/
r.Bigelotf, M.I).
Of riJb MtLs&M AsvLCWr — Luther V- Bell, M-D>, Plijeiciaii ukd Skiper-
618 ANAESTHETICS,
p&red by dietillntioTi nfler a process recomroendpil by Dr. I
Hayes. It had tlie advantage of being very a^n^eiUe \.
taflte, not mH&mmablef easily manag^abJe, eafe, and a ^\i:
stitute for chloroform. Its liability- to aduIteraciaD. lo^^
accidents which subsequently occurred, probably from thiical
after ita use became extensive through the countrrjed*"]
abandon the responubility of recommendiug it, and u mz]
to the uae of sulphuric ether.
Ether was first adminiatered by an apparatus. The o^'^i
this was inconvenient, especially with children, and led w
administer it on a eimple sponge, which immediatelT loat ^
plikce of the apparatus everywhere. The sponge fint nxAi^
j the Hospital is still preserved there.
I In the course of twenty years, as already stated, not t si?
[ death can be fairly attributed to the use of sulphuric cthw. Si
1 the Massachusetts General Hospital alone, it has been cid|^
^ ^ over twenty thousand times, without a single unfavorable orr^
rcnoe. In some cases, particularly iq young pcF^oid v^
females, I have seen disagreeable and troublesome lymputf
occur from prolonged etherization. From the great tHqueo^
' of tlie use of artificial teeth, the followiu^ not unusual sra-
dent may be mentioned* In one instance, after operating upn
; a lady, under other, for a tumor of the thigh, 1 found her a
an M[)[i:iR'iilly (lying state; respiration liavinn^ aJuiOft c^^^''-
:ind ibe jmlse bein;j; ju?^l perceptible. Passing my fiiij^cr J-^
tl^o throat, in i>ixler to admit a current of air to the larvni.
1 dij*covcrod an cntiic upper set of artificial teeth oloriclv tVW
down on the glottis, TJieso Ixfing withdniwn, it waa onlv ain'-
ft long [>crsistcncc in the use of the usual remedies empluvcl i"
rei^i^vcr a person from <lrijwning» that the re^^ular course >^
respiratiiin and cii'culation was restored. She then bttMin^
vldloiitly ilelii-ioiia for a time, but recovered woli. J have un-.v
or twirc, 111 ibe Cfnirse of clbiTization, found ;iriifiiial loitb
loo.*e in tlie moiilli ; ami now gfufrally inspect it i>rov]ou?lv.
wlieii 1 liEive r»us|iici<ins of their presence.
Patients riulyocted to lung operations — sucli a^ diffiouh
ve^ico-vaginal listnla in wtnuen, and ax.-'G^ requiring I'Onneii)
Jicetioii in iucu — sliimld be iilloweJ, from tiim? i,j liun' i^.
ANESTHETICS.
619
partly ircovcr from the ctlier, and get a supp]y of fresh atraoj'-
pheric lur into the lungs, Othcrwiee. from the pr>silioii of the
patient, wliich incerfcreH with llie abdominal respiration, and
fi*om the pj'stein bceoming completely BiituruteU with llic onica-
Ihetie ngent, I Iijlvo seen an unplcnauul and prolongcii deprea-
eion occur a number of times, cftuein^ eo:iaiderttble aiixiotj-.
For amiy uee, ohloroform will umloubtcilly take tJiC place of
ler. FriHii tho prejudice in luvor of rtlior ia tlii:^ countrv, it
thought that, diirin;; the Jatc war, it miijht be eubetitutcd
tor cblorolbrni. This, in priwticc, hoe been found not to be the
case; the greater portability of the iiitter outweighing its dna-
gcre. In fact, to a eur*^con on the field of battle, it would
probably have been found nocc^aiir)'' lo huve abstained from the
use of nmeithetica, if But^h a bulky and explosive article aa other
hud required tmnsporttttion.
Tlie I'uUowiug is the rcgtilt of the use of aniEiSthotiufi in thti
'ftrmy, aa given ia Circalar No- tl : —
** There have been t-onstulted, in regnrd |o the emjiloymeof of flnsea-
'tholirj, ihti rqiorttt of 23,200 surgical o|n!raTiii[is perfunnfd mi tkfl
F^ficld or ta genemi hoapilnls. Chlaroform wn^ ueml in sixty per eout
of these Dpi.-rai[one, ulhur ia Ihirty par <^um ; jiud, iu tcu per eent of
the cases, a miKtiira nf Ih^ iwn was administered. At the general
,l]Oftpii»ls, ih& greater sufeiy oPeilier, a« au ann^adieiic^ was conimouly
CifQCfldcd. Il vriM nflua i^EnploycrU aiktl do fatal licoidi^nt from ltd usq
has been reporlH<L Iti iIiq lii'lcl oporaiionB, chlorolonu was almost
excUiBtvelj uHed. The returns ladieate that it waa adrntuLmt^reil ia
not le^!] thnu ui^hEy tbouttand cases. Tu fte^eii jastancca, fuful r«Hulta
bare bcF:a oj^criHctl, wilh apparent (airueas, to its [iao."
In Hix of theae fatal cases, the operations were triiliQg; and
|in one oaly was it adminiatercd for a capital opem^oii.
In civil practice, ether will pmbably, from Its greater safety,
;nidnaUy take the place of chloroform ; und this is iilrc'^y bciiiig
jdoDe in Aome of the great cities and hoepitala abroad- Fr<H
fcssur P*;tret|uin. CA-ehJef sur^^eon of the Hotel Dieu, of Lyonrt,
Laa recently preacnteU to the French Acadeiny of Stiieocea on
article etyled, ** CltmciU Studies on the Injurious Effects of Chlo-
iioforui on the Best Coijatitutiona and all AgX'a, and on the
Necessity of aubstitutiag for it Rectified Ether."
620 ANESTHETICS.
Jt wUl he obserred, that the eupporten of chlnnte
much atreu on the method of its Mlraimstnuon h t
etniment, or otherwise, in order to measure the quu%r
find proper admuture with fttmospheric &ir, fromi^Kt
dangerous conaequencea- No fear or precoudon of ^
ia to be apprehended or required in the use of etber^ Ic
the more liberally it i* poured on the Bponge or towel ui^'^
more rapid and perfect i» the etherization, — the i
stage of excitement bein^ avoided, — and the quicker tbe
exi>el8 it from the ayatem after the operation. In chilAwn
reatst violently, one or two screams ao efiectualty enptr?
lun^ of atmoapheric air, which is at once replaced bj ibeii
of ether, that inaensibillty is almost immediate.
Previous to a surgical operatioot — which, it mavbei
t fluid, id always best done in the morning, unless forced otben
\ hy circuma1ance«, — the patient should take no aolid foodM
^ avoiding the occurrence of vomiting, which not only^ejw
him, hut much embarrasses the proceedings of the opermom
After the operation, it is best to leave the patient to nt
gradually, and perhaps to sleep off the effects of etherin
; rather than to rouse him suddenly, and subject him to a
I . ment, nausea, or headache.
; A caution may be given in regard to the inflammabil
I ether, during the night, where artiHcial light is necessarv (c
' performance of opemtionB, and in obstetric ca^^es. In on
stmici!, ^vhiie oporating at the Hospttiil nt iiiirht on a miit
tin^^or, tlic lamp being thrc^ feet distant^ and n sponirc i
over tlie piiticnt*d mouth, the air in the vicinity became ftatii
witJi the ether, ifriiited, slotting fire to the spon"-*?, bed-cl
ami even face of the patient. The flames were tbrtunate
this ease, extinguished without any injury to the patient, bi
without oausiug grCnit friglit to those in the neighborin-- bed;
nn">tlier instance, ibe same accident took pince from the
ducliou of a re<l-liiit iron into tlic mouth of ;i patioiit. fnim i
the nj«mge coutaiuin;^ ether had just been withdrawn,
flames wore furtiuiately at once extinguished with wuter i
was immeiliately at hand. These accidents imed onlv
mentioned to he avuided.
ANiC&TBETICS.
621
The importance of havia^ tlie ciher properly prepared and
thoroughly x^'fislietJ, so an to tree it from alcohol and otlier
irritating aubstnuces, should be carefully lonked to, Otliervri^,
the action of it ia disagrccahle nt the time, hi^'hly irritatin;;! unil
lie eub.nequent unpleasant effect* more protected. Tliis wua a
fact cfti-fy puiiited out to mc by Dr- ChaHea T. Jaiikdon.
Tlie nnjLv*t]ielic nclion of cold, developed by n refrigeratin*
mixture of ice aiid eall, as ftuggealed by Mr. Arnotl, may be .id-
vAtita^:eouflly aubfltituted jbr ethcriEation in uijiiiy casea of slii^ht
opcrntlond confined to the skia and ^ubeutnncuus tisauc3. The
operation nniat be performed quickly* as the parta thaw with
great rapidity as soon aa tlie warm bloDd bcglna to flow from
the divided vca^cid. h For opcmtionfl rc^xuiring nice diaaection,
the method is inappliciible, owin^ to the ri^^dity of the frozen
purtfl. There ore many eaues, however, eepwially [ninor opvra-
tiona, which present themaelvea at the house of the Burgeon,
whieh scarcely authorize the distarbance of ihe systeni or delay
which the administration of ether would reniJirc. For tbeac,
loc^al anroathesiA ia of gi'eat vahie.
In 1^52, 1 operated, at the Maaeachusetts General Hospital
and elsewhere, with Mr. Arnotl's freezing mixture of pounded
ice and salt ; aod^ from that time to the present, have frequently
need it, OA have mitDy other eurgeood in thia vicinity, both for
removing small tumors, and making inciaLonj iu ijiflauied tissues.
It IS beat applied by placing the mixture In small bags orgause>
Rnd having a number ready to be applied succeasively, rather
than to depend on a single one; the freezing process, hy tliis
meaijt, being more rapidly produced^ Irately, a nmch more
convenient method of effecEiLng complete local insensibility has
been deinonstrated by Dr» Richardson, of London, by tht^ in-
vention of an apparatus for the riij^id evaporation of ether,
applied to the diseaseil part. This has been improved on by
Pr, H. J, Bigelow, by substituting^ an agent which he has
named rhigoiene. which produces a much more rapid reduction
of temperature than nny other substance hitherto employed. A
temperature of — 1G° of Fahrenheit can be arrived at in one
minute with this «ub&tzince.
^2W A>'.EdTHETfC3,
Oac of the objections which, it was thott^t, wikM
tli« tree uBe at rhi^lcne was itm inBatntnable natun,al4
ilun^r of expJoaiou in warm weatlier ; ita boiliug poinl ^
70'. J have kopt it dm-iii[; the Bummer, u&ed it in nttcii
and hnve thus far expericTieeil no accident , nor bcaj^ if
o^wurring. I huve tried it iq oases of caucer of tiie tj,'
aind nose J and, with proper manag^uicnt, and enffiooi
for its Buc'fpflsive npplicntioTi, it ini^ht be emplovcd in li
icov&l of large tumora involTing superficial texturee.
The nitrt>u8-oxide gas is qow bein^ very cxtenHyelv it
tho dentists of this city ; iie inhalation being much &»
by recently irnfjrovcd valvidjir wpparatua, which allows
constant supply of the pna unmixed ivith tJic pulmow
hahitioUH. Thus fiir, I am not fiwarc of any fatal reouLt
ilw use. It ie very pleasant to ichale, an J tbe recoverr fi
effects is usually iraniotliate* It le very doubttal, howeT<
it will be adopted for aoy of the greater operations in soi
i/^^
INDEX.
HII
li/
INDEX.
Abi)oiD«n, Chaplvr V.
,, (jannhot Woand of^ Ml.
Sttb*n»S7(>. fi7l,
Abiance of V«j:ini ^nd Ulflmi, £0S, SOB,
Adipota Tumor of Huid, Ml-
f, Tuman of ^ptmijitlc C(>rd,34e'
Air-puSHKu, Porfiign BodLei tD, M.
AldBTi, Dr.,S4fi.
AllKrtozi. Ur.,333.
AmpuUtlon of Arm. 3S«, 390, 141.
orbiirhlblgK^Ol-
„ Hip-joini. 4Uf,107.
„ or Le^, Bei. 3B9, 304, SBfi.
„ Shoulder-iairt^ aST^flfi,
^ of ThJeh, SOAh 897, «00, bK,
6», A3A, £37, MA.
AiApDtfttLonif 864.
„ Tabid of, 409.
Amoanat, H.. 197, 304.
AnmLhuii, LocaI, 031.
Aiieilhetla, Cbaptar XIV.
AiiuidilB, Mr,, nil.
AnenrLiin by Anutomoils, 443, 4A1. IST^
„ or Abdominal Aorta, 437,
„ of ropbtenl Artery, 438.
.. of SnbolBViM ArtfliT, 436. 437,
430,
„ r»r Tborulo AotIji, 404-
„ VftrjccH, or II«nd iknd Ann,
4fll.
AnaDTi»n«l Tnmon and Llgitura of Ar-
IvtIh, 434.
A nut, ChapUr VL
Artlfldal,lfl8. 18ft, 176, 177.
Fluareof, IBfi-ISu.
KUtulaof, 191.
ImpFrforatF, 196, 196, 199, 301, 303.
Prokpua of. 194.
Apii«ndix VQTmironiaU, Guifcnnfl of, ftT6.
Arm, Tumor of, 619-
AniDtt, Mr.. 460, 631.
Artariflfl Hud Vakni, Chiptar IX,
Artflrj, Vertebral, Wound of, AfiB.
ATflrj, Mr, 139.
AxiLla, Tamor of, 61S.
RteoD, Dr. John, 313, 31 1.
Ball, Dr., 5^3.
f Burnea. Sqiy*"-**™""' U. S. A., 643-
\ Bartlett, Dr, Jo«JBh,48S.
btnon^B CIpfitKtioD^ 417, 430.
BoanmODt, Ur., 3SS.
Bvll, Honjiunln, 167.
„ John, 441, 443.
B«nDBC,Dr,T6.
Lteniutt, J. tiafbaa, Dr., 480-
B4rard, H^, 4ba,
Blgalow, Dn Henry J., 4e«, «17, 031.
Bladder, Stone in, 304-336.
„ Wonndof, 341.
Olaka, Dr. J. Q., 163.
BodBufaamer, Dr. Willlani,V)1.
Bond, I>r. H^rr, 831.
BowdLEcb, Dr. B. I., 147, 149, 161.
Boter, M.,383-
braln, Concutslon of. 16.
Breut, C«nc«r of, fi13, £14, 616, 617-
„ Chroolo IiLflaiDmatioii of, 611-
„ CvtlSo Tumor of, 609.
„ KrecUlfl Tumor of, 610.
„ Male, Tumor of, 618.
Brijj^CB, Dr., 41, 497, fil6.
Droadbflnt, Dr., 488,
Bmnchaa, Foreign Bodl«a In, 97, 100, 103,
104.
BrovD, Dr., 109, 178.
Brown, Dr. Buckmlniler, 164, 393, 434,
460, 67S-
DjTant,Mr..330,l48.
Back, Dr., «3S-
BDiutHd, I>r-, 889.
Cabot, Dr. Samual, 108, S64, 868, 404, 633,
6*7, C96.
CbIcuIub, Cntifl 0<ldv, 113, 314.
„ Oxarat* of Lima, 307, 300, 316,
330,333.
„ Renal, In Kaqulfl, B04.
„ Sallvarr,94.
^ Triple t^hoaphate. 318, 331.
Vealcal, in Female, SOB.
CancoT, ICpilhallal, 47, 481,
„ of Bmit, 481, 433, 613, 614, 616,
617'
„ of Kar, 69.
„ at Kj«. 66, 66.
„ of Ganltali, 344.
^ of Lip, 49.
70
1 1 1
^^^^^^^D^^^^^^^^^^^^^irn>EX. ^M
Cunc^ffr uT Kc4i;, &9,
DifllocAlioQ of Feinar kukvn*, i^H
^^1
„ vf fnroTia, 4&n, iO], 4as,
of F*iDDrfatioF<nBBVK,H
^^^
,. of HnctiiD>, 243.
^^1
„ of Tc*npie, «a.
s«4, sr». aTK ■
^^1
,. of Ton-iilB luiil Tbrnac, 12D.
f>^ l-'emiir domniBfl^m ^|
H 1
f, J'lLlilf of Ufierafiona far, S^fl.
^^1 1 ■
(JvKffniuft Tiunors of Jaw, SO.
Swkec, sei. ■
^H ^ 1
CvMid^ LJgAUn of If^ «30,
„ of ShouMfT btcknrii. ? ■
1 1''
Guroiidi, LigaiiiT« of both, t4«.
Cufti uf Tnpbmiuif fur £p1jei>dv, ThUv
„ ttf ShoitJdAT fvwifdi^ C H
SAA, iwt, m
HP r '
of, 15.
Hi 1
Ce}liiJRr Tl&9a4, IndumtloD of, QDU.
Hi I '
1 Ccrvin IHaH, LlypDrircrphr of, fl&4» 3^9.
4t*l-
Hn 1 '
DJfl]oeaLJ«pi, S4fa.
1 1
,, TBbl? of, m.
rt Btonrtoiit Tuiflor of, VJ&.
^^1
Chnt, tiunihnt WniirtJ □!, bi>6, EtflO.
iJopuytren, U.. 75, 71, iSij, Ifij, l"*.«
3±fr.22Z, 332. 4fiS.
^^1
„ Slali i[f. &70. C7r
^H
„ ibo, Cli(ip(i-TlV,
D^flt, Dr. Etm, 3ia, 405. *«,
^^1
Cheevor, Dr. V. W., ^03, 601.
^1 1 1 '
CliLorJa Kther, «17. Oli^-
E_
H u 1
Chiofrifbfm. 613. «IT» fllS,
III
CtccTtlur Nu. CL, S43, fiflS, 918.
Ear, EpiihelinT Cjincfir oC, S0.
CivinlL'.W,, 301,212.
Clarli, Dr. Henry G-, ^an, IflBj ftfiT, B7n,
„ Fibrout Tamoi of, fi».
„ th*, ,ift.
^H
Coftl?, Dr., 6N.
ELb^m', Lhtent] DJAJacnUnn of, Ml
^^H
Coecyn, Tujnries fif, E&3-5»a.
Ellis, Dr CftJvia, n, 306, 314, 404. 4JI,
^^1
ColliFi, Mr-, l^U, lAl, IftJV.
ftlifl. rj^4, e£<i.
^H
ConcuBftioif of xUe Drain, 1^
Enclii'iidrvniH of Fin^rer, StO.
^^1
CongGDJIaL I'^ii^ion of t'iiigen, 60^.
Eiifysled Tumor of Todrtnt W,».
Epllupflj, TrapQ*niiigfar, ..
^H
Cooper, Mr. flriDpliy, ffJU.
^^1
t, Sir Aatlov, 2')*^ &S4, A3S, S£4,
Epitlielial Cuaoer, 47,481.
^^1
1 S5H. a^b. ?T^, t49.
H
i Cord, Tumors (jf Spcramiic, i*9,
^ Cft^lello, llr., 48 T.
It M Of NaM>, &1.
*T 1- of Vulva, iTa.
Epn^K, 7r>.
1
Cfiiilwn, Mr., lafl.
Cos. Dr,, aOC>
EiecLih or Vascular Tomor nl.
CTitfhptoti, Sir Phi^i[], IAS,
1 CtudIuui, KrBctiir«ii ul, l.
„ Tumor of Br^^at, a|r>.
^^M
» t» of ChMk. &84.
^^M
„ Wound of, 6, Jj56^
«i 1. <jf Eur, 46j.
1
■■ « of Face uttl Seek. M*'
>i " oF I4snd And Arm. 4SI.
1 Crouri, ]c>e.
n 11 of HtfBd. 4oK
^B 1 a
OniihihiiTib,ltir., iHR.
pp pi of Keioc, -fcaij.
H f
Curliiijj, A[r., 2&^.
,, Of 3ilnuth, 4^9.
H \
Cpttis, l>r,, £6fl.
ti <^ <^f ^cjiip, tia.
H 1 k
CnvJflr, Ur., Surgfoti (!. S. A,, 644,
Cyfllio Tumor of HrcjiAt, 608.
F.TiL'h*«i. Mr.. 7.% 223, aie, i«.
H U
Ellior, flia, GI4, 010,617.
^H fi '^
„ of Jaw. 7a,
p Finl Opomtipi, under, *ia.
Exalalon of l^;»<emfit Candvl« of Ho
^^1 li
„ ^ rkf TiLln, A32.
^H '1
., «i v*«in*f ara.
meruH, 410.
^^1
■
,, (»r JninU, 400.
^1
T*.
af JoJatu, T*hle of, 423.
" 420**^°'"'" ***■ **** *'*■ "'
n of BhouIder-jfiin(» 417 45H
^H
Da-min, Ur. H. F., tOl.
^^1
Paviiipon, Dr, H, K., 110,
EiLiuclion of Keadleq^ 690-
Hi '
TJpi|»'rk, Bfl.
EnlrpiUlliftS tho, Chspier VlII,
Deptc^i'ion of Sktkll, T-E>, n.
Eye, Cancflrcf, G5,
H' '
Dflhniili, M,. J!24.
,. „ of, MelnnotJc. fie.
■ '
Def liLiiun uf SH|<tuni Nabi, 03-
,. Ihi", ifi.
■
Ditkf^ou, Dr. R. K-.VO, Hi",
EycUd, BesEamtion of Lawer 4^
^H
lllPtfenbncli, I«, lU, '^1', 121), 134.
■
H'
J)iKiUil Kcivfl, KxlIbIutl uf, 47{>.
F,
„ „ Nouralffiu of, 1?6, 476, 477-
j ilialDmlion cf l>rttli 1 filRlifl, w^.
H
Fnre md K"cdr, fiU-J.
* „ of KIbow, Lalcrnl, 353.
„ and Orbit, Tumur of, 4BW.
^^^^^
„ of Ktnmr, D'lrsal, 3Cl-3fi6.
,, il'jni ii|wi. i»l.
hbl
Sef^TM.
„ EhCf C^JL^|tl3^ U,
L F »
^p ^^^f
^VMDar, DUIouIlom or, 3«3. M4-*H%
Ofmd, Dr. Juhq, If fl. ^^|
V2>iVu«i>n>SirWl]lXBmH d». 130. U)<
Dr. S, A.. 3^2. ^^^^M
^■u*]bru4a Tiimur "f K«t, 6bd
Gnnci. Wound of, fii>&» ^^^^H
^K^ TiiciKirn Eir Jaw, M.
Grob, rnif'pafi>ir,T3, 9^.97. i7\ Ut^ ^^^^H
^1. „ T-JniH.r <jr Tbigb, &3tf, b^h
GitArlu, M., noa. UD4, aoT. OOA- ^^^^H
^■wi, Mr,
^^I^War^ tnclturidrnmn oA MQ.
^^^M
^^^^bn, CoEi/^tiiiink Fmk>u ofi I^OC.
Oalbrlt, Mr., &4a, «eD, ATS. ^^^H
^^^mSue af AiiiiA,
^^^^^^H
^^^, of Pulnm. i:iO,
^^^1
B PJMBlain Ann. lil^.
m „ UreChnil. frflm Waimd, 2S6.
Hemntopf t«, u^ ^^^^^^|
• „ Vc^CD-mHiJH W4, 343,
naljfhEtm, 4E>1, ^^^^H
* n p vKvi" J, asa-au8.
^^^^1
* FlnTiikiiu OiieniD^ cuiiUtDiuf ttklr. tv3.
HninliToii. I'TuHwur. H19- ^^^^^|
' iwa.
^^^^H
• Fl-ffR. Dr., 323, al«-
H>iix', Ur, A A. 6lf. ^^^^H
V yglti. Or, 36",
Rjivwiint. hr. ^^oi'i^i-, IM, OlA, ^^H
; Kfrii, MiiircriniLtiDn <ir, 011L
Kcj^ii. frilDnllol \Vl>UIii] 'jf, <*, A4S, &au. ^^^^1
ForaLgn Ei<j<1tf!« in Arr-pM4fi{iefl, OA.
„ h 111 {£^<ifiUH^iii. 112.
„ Body iD Vaglao, SfO.
nafnorrlinija, l&«-ta«, ^^^^^1
Foi. Dr.. ayi).
Mri, ^^^^^1
4, J, L.. r:^urA;i-oii U. 9- 'Strj, 6U, &».
HennapliroHliKni 010, ^^^^^^|
l^rjicrirre ni Arai.33l,
ina. ^^^^H
„ of Arm [idLtAilrif; T>L«|ocatlaii of
RiihcAl of, I'li'laH, ^^^^^1
Klbtw, tlU3,
„ df Hn» nT Mkoll, fl, 4, &aT,
n of CliTrclfl, BiO.
H?vwo(i4l. (>r. C- T., 41. ^^^^H
„ vt L'lT-cvx, ^liG.
Hip iinEt ^pirnil L>iiMiAAO>, f»T3. ^^^^^H
t, or CoDilvtA Of MitmrrQt. »31,
Kirvjoii}!, Am pill nil (III ai- 4'y£.4ti7. ^^^^^H
memft, Bin.
UudKfa, l^r R. M-, 31B. -1411. 40a. ^^^^|
„ of F«murH3:JS.ai4,fl4i,»:c,&iD.
Hnrik r>n the Fhf^p, ^^^^^^M
„ of tDre^arm^ fUl-
^^^^^^M
„ af llTimprw dniiDilw!, 32S.
Hiiuiok, llr, A. ^.. ^^^^H
» nf Mnlir D^ii?. ^20,
liiELiicr. ^1.. ;?4, ^iiiv, avB, ^^^^H
„ af Arnlftr |toa« utul Sun, Mmil-
EluiiL«nii» AiiiiiuiniiDn a^ &f^ 31H>, 4^, ^^^^H
btflocnrinn of, Hn4, Ififf-UA. ^^H
litv, !i'i7.
„ of Ni.T;k <kf [he ynmar, MO-343,
flir>, 8411-
,. of Neoli or tha Femnr, irith In-
onimdof, til. 433. ^H
virrAlon uf FiiDl, J142.
FrauluFfl of. Oitl, £fla. ^^1
of EpIphyslB of tloMd ^^H
af, aaan ^^^H
„ of PMflllH, ail, 88a-3»S.
,, of Pelu1t,D30,
., of Radius Jlal. SSDh
,. of Shirll, ^. A. yj.r^bs.
nf Qminltor], S3U. ^^^^^H
„ of ^|kiMF.324.
HuUiljln*ou, Mr-, 4», CS, aro* ^^^^|
„ of Supcrof Mftlillufy Boriat,
By A roe«lo, ^ 1 ^^^^H
SiT.
or the ^^^^H
Fnuturu, aiB-
Hriropbobio, Cfi4, ^^^^^H
,, of Cmninni, I-
tlypOTtroph; of CBr*U Uleri, 304, »S. ^^^^H
7uiif^id TannH- of Fonhtad. lau.
[line ^^^^1
G.
' 'tbai^hp oT App'udU Vttmtfarmiit f»'J^'
imrt^rlbrntc AnaBUnd kcctucn, W\. ^^^^^H
«*y- r.lr. <i- W.. m. ***
GflbttjU OrKiii's Cwicar of^ 3tA.
Dr. tir, ^^^^M
liidurAloi Tnniur uf renin. 24J^^4t]. ^^^^^^H
1 6eiiJLd-uriuii(7 Or|nuit, Cbtpler VI[,
InduTiUon r>r Celhjlhr Tihub. AOO. ^^^^H
1 Fonalo, lU.
Injurtu Hud Dlmuu o( iterrt^. Otup, X. ^^M
r „ H i. UnlOiSM.
of Ot Cnccy^i. GOS-tM. ^H
H«nsoal, Bfl.
of t>i* Scalp, Ifi. ^^H
GIIjIhh Mr-, lin.
^^^H
OlUira, Dr- C, B., 64&h
^M
titlmiin. Or-, hi.
Oordnn. Dr, ClLiirk*, Atf.
Jm:k»q, )>r, C T-, OIK. ^]^ rial. ^H
Gi>uIh|, llr. A. A.h33', «t<l-
l>r- Jkitio. ISI. INu, ^H
Pr- John b. 3., tUtf. aui, d]£, ^H
<jriBf«, ]«> fi0H 126.
- Gndtjt Dr,, STa.
aoSi&aa. ^^^H
628 INDEX.
Jav, CfttiflaroDA Tnmon c^, S<M4'
„ C^Ue TDmort of, 73-^^
„ Fibroui I'uiDon of, 84-
„ Myelord Tumorfl of,fl*-m
„ Nacnuii of, »&-n.
„ EomovAl of Lower, flO, 70^ "», M.
^ „ Df Upper, flr, 81, M, 84-
„ Trephining Lower. 472, 474,
Jnw-bOLifl, Tumora nf, 04-
Jointfl, ExiiIaIdd of, 4M.
JoDva, Dr., 4fll.
K.
Keep, Dr. K. C-, SQ-
Edm itnd Llbow Joint, GoiuboC Wound
of, 6W-
Kn«e- joint, Excisi<Hi of, 414. ttlMir, 430,
433,
„ M Nevuft of, 440.
,. „ Ncvdie paDstr»riDgr AftO~6n.
LHbiLL,M., 18,18-
h^my, M., M8.
LArynfrilrB. Tnich«otoiny in, 100.
LjkTjnK, Korfiiga Bodv fn, 10&.
LatiA, 107.
Uwrencfl, WHliun, Hr,, IM-
., WilhuD R., Dr., 00,414.
Lebf n, U-, 4H-
L<^, AmpjtatJOD of. 391, aflA^
„ Re-^iaputAiion of, aaa, AM.
„ Wound of, &i&, S4e.
LeuEsocylhEmlft, 4Ttt,fiO].
Lip, Cancer of, 4fi.
„ Ctncert or, Tflbltt of, £1.
„ Upper Chuncrfi of, 61.
Ll»fntnc, M.,31, S&l, SH4,
Litton, Mr-, U, 1 07, 880.
Ulhotomy, 204, ft 18-330-
Lilhotrlj. 304, 207-31 S.
LocB.1 Ansi^iheaiA, 021.
LoThmji, Dr. J. K,, 41iij. 428.
LuiLgB, Wound or, &U0, Gi}4.
M.
MHlfonnntJon nt K<>ol, 'i\2.
MHl]-ni>fiie, M , 832, 348, 319, 3^, 853, 3AB.
Mardi, Ki^f, 73-
Mjirrih, llr-, 3UB.
Metanu^it of Y^ye, 56.
,^ of B'jiroiiJ, 4B1.
Martier, Tkf,, 223.
MeyiT, 4t'v'i-
Mii'i"T, Iir- FrAiici«, 145, U.ft, 808-
ML^celliiiieciti^ (.'fl-c-, Clinprer MM,
Mi>]|4 \'eiiBrift, TiiTiLor of, '£'''j.
MiTphiH, lEvpchjeTEnic U^Q m Npiii'algLA,
4(i7, 4fiM, 4n, A71.
Mcirl'iii, llr. W. T G., iB7, SOil» fili-Olii.
Mii-:ii!v, iVfjlr, 40i-.
Mj^eloiil FuniOTs of Jkw, ^4,
N,
Kn>viis nver Knee-joiiir, 4ljO,
Neck, tncjsled TJiyroid Tiimui- of, 506.
N«ck, avdrocele of, Wi.
t, T&jToid Tnnaor of, 607.
,t Tumor of, 49S, Mr
„ the. Chapter IIL
„ Would of, G44, 658.
NecroAlfl of Jaw, SS-
„ of bkulJ, 670.
Needle penetfjirmg Knee-joiot, i»>-j«t
NeedJes, KxtmcCHja of, b>0,
NeTTBt ExcUion of Digitml, *n
„ Soivtic Wonnd JmplicEiiE^Vv
Harres- Ipjuriev mid l^ir nam vL lq>
ter X,
HearBlgU, Dlglta], 470-477-
,, FftclH], 4TS, 474.
„ TmuEnatic, of Arm, 44^, 1^
Nitnc Acid, Poi»oninjc bx, £78.
Nitrout-oxida Gafl^ QftX.
Nozrifi, I>r., 439,
Now, DaTiKiion of Stptnm of, 41, 6*-
,f l^pLchelrnJ GAnceroC, fi^
o.
OooLuion of Va^nB, 3T8, UO, TH. i-'-
3S7, a8S.
.» of Utemn. 191, m.
(Emphflgaa, Foreii^ii Bodiet in. in, iV^-
„ Strictana of, 114-116.
„ Tamorn in, 116-
Offlurt of Miua. General tfowital m
McLeui Avjldii], 1840, on.
OliTflr.Dr. M. K., m, ii7_ U9,in,tr..
Opaniuoa, Barton >. 417, 430.
„ PiincoAsi's, 184.
.. Pirop>fl''», SOI.
,. Svme'a, A»],
^.,"^ Wiiiier>, 1*7.
OrblT, Tnmorof. 6T_
Orgnni, Geiiilo-uriimn-, Ohaptu-VIL
" i> .T Fflrnale. lu-
ll ,p MaLe, 304.
Oli», f: A., Surpeon U, S. V., 543.
OvariuiL>nJ%, JOO, 3<ia.
P.
Ppe*, Dr. C- C, 134.
I^BH^'l, Mr-, 47, la. 2T0, 466, &3*.
Palme. Kis*urot.f ^oft atid Huni. iifi,lV
140.
Pnncon^ir, Prnf., 164,
Knrncniresin Thonicip, 146,
Pjirker, Dr, WlHar^, 13^ ^53
l^nrltmnn, Dr. Georce i'-'7.
„ Dr. Samuef, 164, 487, 617.
Pnrotid Kej^jLtn, Tumnr?i of 4^5
„ Tumor of, J8y, 490-4*13, 49o, 4'^:
Scirrhous 4^0.
Parsimi, I>r.,fi|fl. '
Pinchn Dr., ins.
pjii'-llH, Kmriurp of, .T22 33'*-_3^:t
Peirsoii, Dr, A. L,, 143.
Pelvi*, KrrtcTiire of, 33£t,
„ WliiiihI t>f, ."pfil. .'S07.
Pen^lnitii,£ WRmiiU'* of Chesi ni.d Aid
PpohotderrPmoved from Hlndder 600
Pens', iiidumted Tumor of. 3i6.
^^^^^^^^^^^F ^^^^P ^^^^1
^BR, Wdufid Qf, Kt,
Shurllcff, Dr-, ^^^^^1
^Vpflfiiirk'UEiL, IfupEqn af, 7fit*. 3M, Vtil.
*«1inp«Dri, Dr , 301, Slfl, S9T. ^^H
^P«iinoii] S«L^DD. U1V-2B1, 144-^0, 23»,
Sims, Dr^ 303. ^^H
* flirt.
Sktillk FrftcluTfl ufp 3. ^^^^^^H
*■- Pmi#|alD. FTOf.. aifl.
») Rvt of. ^^^^H
' 4 rhtmfuii. ^AO,
Slmle, I>r. D. !>,. «t, U«, 1W. ^^^^H
a. Phyiick. Dr., ITB, S:a.
Smith, l>r., Sii. ^^^M
^ PlTnp:>lT'»i Openlinn. 3l5[i, ^fi2.
tn^.i.v.c.,ni*i. ^^M
^ pFklwmDH Ut NiLiic Acid.ATB.
Smvly^, Dr., ISU ^^H
Zi PnMiwk, Mr-, 130, 131,
Hoii'h^rhielle, lir .60. ^^H
ai PutjpLtiijf ItHcruQi, l»fi, IH.
SpBnutLrc GoM, 'TuaiDrii Df.HS. ^^^H
t „ of lir^rii^p aTJ-i'ri.
Slbiili:^', Mr,, 73, S'f). ^^^^^H
14 Prlully, Ur.. ^I'i.
^^^^^^H
Pra]m]4e M Apil-, iH,
^[i»iie III DlHdiliir (oira Cnlculut], 104. ^^^^^H
( Pmrtilo, DLiviiHci uf, 210.
^ Putniim, Dr. Cturlei Q., S19.
SlTJCtUTfl of lE^HOftTlMKUA, 114. ^^H
□r L'ratJini, Fcrii*«Hl Section for, ^^^|
„ of Urotlim, with ItoEbnltoii, ;|u, ^^H
Suticlnvinn Aneuritm, All, 43T, 43V. ^^^|
R.
RnJluH, Pnti'lUTH oT, £121, 330.
Swan, ^^^1
Riiyor, M,, BO,
Swinbume. Dr^saa^ ^^H
Ku^finipurHTJon ct Ld(£, BV>X, nU4.
S/mo, Ur-, 30d, 3aD,Sh6^4UQ,46fl,4f<3. ^^H
Bvatuiu nnil Anu>, Impvroralfi. UOi
„ Ciiiireruf, 243-
^1
„ Polvjiuricf. IVfi, l;w.
^^^^1
lUcarront L^nh>Iid Tutitdr, 11^7.
Table of AmjiutPLiDn>,40D, ^^^^^|
Ramnvii] of Tfn^iU. ilW, rJI. 133,
Cjmcer^nf ^^^^^^H
„ at Lower Jhw, Q!r. 04« 70, 7^, 91.
|lMi>CHlJ01<f, 4M, ^^^^^H
„ of UpporJa*,*?, 81.«l,M.
cF lUiguiotiB iff .Milt", 43B- ^^^^^^H
Krntl CmIcliIu* In Fornilft, 3(H.
cf OpaTHliuntlikr Uinpcr, MIA. ^^^^^^H
„ or Oiitmlkn* fat E}iiluppy. IQ. ^^^^^^|
RvmnttDn flf EvHllil. OpBTatium for, i%
THlinDoliuft, tH. ^^H
U.
0[ifnUon by. HtUud Af, 8o, __^^M
RffiiiPcilaTinii Fiffor brDwninift f>nH,
^^^H
KfXHf'Nirl Tcirklf, 1^,7-
^^^^H
KertiulUs D^ t<lwnrii, AT, hi, «|(t.
TKylcir. 3dt,. ^^^^^H
Bhl«Dl4ri«, C31, I3fl.
TBiiilDit, PArtlAl Ruriture ef Oii»JrioBn. ^^H
llhlhO|ilBiitid Upentknna, ]a.
Bttt. iJia. ^^^M
Bbiuoplul/, latliiiD, lU, lia.
HLiiiLurD nr QDBiLrlct|jA. 146. ^^^^^^M
„ THlioofiLiiiii, K, M.
Tendarir Pninfut Cr^pLfalion of, fifiU-A^il. ^^^^^^H
TllchiirdMii. Dr.Cai.
Teiiilcte, KfftalnM, ^^^^^H
Rjchi<niml. BL, Mft,
Thigti, AinpiiiHiiiiEi of, fl^d. ^^^H
Rii^eri, u.. sre.
„ Uiiilocntiou uT. 3^3, Ki. ^^^H
Rntlvnt UiGor. 4}i. Cfl,
Pm^iure cf.az^. d:4. ^^H
Rous, U., Lsfl, 13Q, tnfl.
(jbiijihol Wuund a(, 640, &04, G8T, ^^H
KupEunof Pertiiiriim, ^J>M, 3flfl, Wl.
ThOTncic Aiirlii. Anflnniim n(, 4S4. ^^^|
V ,, uf Teiidnn of i^umLricapi Pflmu-
I'laaniDls Pirvcan[ni#, HQ, ^^^^M
■ ri», U^B-
Thi-oa,t.CAD€trtif,lW, ^^H
■ „ Ponl*!, of Tsnrtrpn nr (jLiiulTlecni
Tlvtanmnn. 4n<. ^^H
Toutue, Cmicn' of. tM^ ^^^H
■
Wound cf, &A3. ^^H
' S.
ToDfElA, CruicOT of, lU, ^^H
Sitlltirr Ctleiilbi. M.
Etomovnl nf. 119. ^^H
SaTimlm Mii*ljIf, Tornvr of, <i
ToHn^fln^^lJj. S- D-,A7, 944, «fT, ^^H
Sn-y? '. I>f, A. A,69&,
Tn-'rhi.'ta, Fr^rekfru Do-lv in, 104. ^^^|
Sriilp. Itjiiiiuor, Ifi.
TnrliNininy. l<l^ lire. ^^H
SiiljwprJI, :<n.
TrnriF^HuHiuQ «/ Oi^itii*, J^, ^^^H
Srlrrhou* Tuinur qT PHrafId, 41'0.
Traphiqing for Kjilkptj, 7'\&. ^^^H
fi«C!li>in, PrnriHl, 3:;i>-3ni. 3;t4-3aA. SSfl.
for N^nL^lD. 471, 474. ^^H
«a.
Tnbrrcif, rulnrul CvtontonA. AAA. ^^^H
Baplun Nutl, n^TtKlinn of, 03, flR-
Tdqidt, AriiyiOB^, of llmmi^ £31. ^^^^^|
ShHlluak. Dr. *i. C, Un.
^^^^M
Slmw, Dr. », S,<W, W7.
QonlJiinins Aiv. ^^^^^^|
_ fifamlAai, DlikHwCkoii* nf, ua. :E£4, ^60-
K aaa, mo, ^n\.
„ DrTtL*;^,;^^. ^^^^M
■ „ joint, Ampuudan ■». «8T-3«0.
■ . „ EialiJanof, 411,
of Vafrhn.ars. ^^^^^H
EiLCifpbHlold.cf Tlilgb, KIA. ^^^^H
;■ !
' I
ERRATA.
Pap 4e,1lii* a,|Dr"plftla.^'
.> M,
. lw(.
M W.
. ^^
1 w»
18,
, 8»> .
10.
. Ba» ,
IS,
, 10I> .
1£.
. 3H4, .
IT,
<^ ■urDitdnrDataDiit'^
t;, „ "iiiibU/'
•' OtjHtlOb."
'' pubrt."
' i
'I
r I
J . . I
IJVNE MEDfr*!- LIBRARY
ia avoid fine, thi* book should be retKm*d on
or Irelorc Ibc date tatr fUiti^icd below
"'N* :2't iii