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Title: Elements of Surgery
Author: Liston, Robert
Language: English
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Copyright Status: Not copyrighted in the United States. If you live elsewhere check the laws of your country before downloading this ebook. See comments about copyright issues at end of book.

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  ELEMENTS OF SURGERY:

  BY

  ROBERT LISTON,

  SURGEON TO THE NORTH-LONDON HOSPITAL, PROFESSOR Of CLINICAL SURGERY,
  ETC.,  ETC.,  ETC.


  FROM THE SECOND LONDON EDITION,

  WITH

  COPIOUS NOTES AND ADDITIONS,

  BY

  SAMUEL D. GROSS, M.D.,

  PROFESSOR OF SURGERY IN THE LOUISVILLE MEDICAL INSTITUTE, SURGEON
    TO THE LOUISVILLE MARINE HOSPITAL, ETC., ETC.


  Illustrated
  WITH NUMEROUS ENGRAVINGS.


  Philadelphia:

  ED. BARRINGTON & GEO. D. HASWELL.

  NEW YORK—J. & H.G. LANGLEY: CHARLESTON, S. C.—WM. H. BERRETT:
  RICHMOND, VA.—SMITH, DRINKER & MORRIS:
  LOUISVILLE, KY.—JAMES MAXWELL, JR.

  1842.


[Entered, according to Act of Congress, in the year 1842, by BARRINGTON
& HASWELL, in the Clerk’s office of the District Court for the Eastern
District of Pennsylvania.]


  TO

  WILLARD PARKER, M. D.,

  Professor of Surgery in the College of Physicians and Surgeons
    in the City of New York,

  THIS EDITION OF MR. LISTON’S WORK

  Is Inscribed,

  AS A TESTIMONIAL OF RESPECT

  FOR HIS UNTIRING ZEAL IN SURGICAL PURSUITS,

  AND OF ESTEEM FOR HIS PRIVATE VIRTUES,

  BY HIS FRIEND AND FORMER COLLEAGUE,

  THE EDITOR.



PREFACE

TO THE AMERICAN EDITION.


The character of Mr. Liston’s work is too well established to render it
necessary for me to say anything in commendation of it. As an outline
of surgical science, which is all that can be claimed for it, it is
unrivalled in the English language. Written in a bold and graphic
style, the distinguished author never hesitates to express his opinion,
frankly and fearlessly, of what his judgment and experience have led
him to disapprove. In this, as well as in some other particulars, he
reminds one forcibly of that great and eccentric surgeon, John Bell.
There is no cringing to this man or that, no doubtful or equivocal
sentiment, no attempt to theorise or speculate; on the contrary, he
comes right out, and clearly tells us what he means. His work, full
of vigour and freshness, contains more originality than any other
similar publication that has been issued for a long time from the
British press. The hand of a master is discernible in every page; and,
notwithstanding an occasional incongruity, or _outré_ expression, it is
impossible to read it without feeling that it is the production of a
great mind, thoroughly acquainted with the subject on which he treats.

Such a work is invaluable to the student; for, independently of
imparting sound surgical knowledge, it does more to form his judgment,
and to qualify him for the practical duties of his profession than all
the compilations in Christendom. Velpeau, with all his learning and all
his patience, has never furnished anything equal to it. His "_Medicine
Operatoire_" is nothing but a vast storehouse of research, to which
pompous doctors may resort for ancient lore, and prosing teachers for
materials for instruction. It details with endless minuteness the
operative methods of every surgeon, great or little, from the age of
Hippocrates to the present period, with their various modifications
and improvements, not forgetting the "appreciations" and labours of
the able professor himself. Such productions are well enough in their
way; they serve to give us an idea of the rise and progress of surgery,
and form good books of reference. Beyond this, however, they are of
comparatively little utility; the great mass of the profession is no
more benefited by them than if they had never been written; few read
them, and still fewer understand them. This attempt at erudition
pervades, if I mistake not, almost every recent publication on surgery
in the French language. Dupuytren is alone free from it. His writings
breathe throughout a different and more independent spirit: he speaks
like one accustomed to act and to think for himself; and the result
is, that he has accomplished more for French surgery than any other
Frenchman since the days of Ambrose Paré.

The first edition of the present Treatise was published at Edinburgh
in 1831, some time prior to the author’s removal to London. It was
originally comprised in three volumes. A second impression, of which
this is a reprint, appeared at London in 1840, in a revised and
improved form. The favourable reception which the publication has met
with in this country, and the desire I have felt to introduce it into
the school with which I am connected, as a text-book, have induced
me to prepare it for the American press with particular care. Among
the additions, properly so called, is an article on Strabismus, and
another on Club-foot; two subjects, the former of which was entirely
omitted in the English edition, and the latter discussed in a manner
altogether incommensurate with the existing state of our knowledge in
regard to it. The notes are designed to serve as further illustrations
of the text, or to supply deficiencies in relation to certain topics
which have been passed lightly over by the author. They might have
been extended to almost any number, and it would have afforded me no
ordinary gratification, had it been consistent with the views and
interests of my publishers, to present what might be considered as a
tolerably fair outline of American surgery. For such an object ample
materials are extant, highly valuable in themselves, and eminently
calculated, when they shall be properly embodied, to reflect credit
upon the talents, enterprise, and dexterity of our surgeons.

It need hardly be added, what is self-evident, that the editor of a
work is responsible to the public only so far as his own labours are
concerned. He adopts only in a general manner, without endorsing all,
the views and opinions of his author.

  S. D. GROSS.

  Louisville Medical Institute,
  May, 1842.



PREFACE.


The rapid advancement made in the pathology and treatment of surgical
diseases demands a perpetual revision and correction of the systematic
works devoted to this department of the healing art.

Accordingly, text books, various in merit and extent, have emanated
from the different schools. Several of these have, by successive
editions, kept pace with the science; whilst others have fallen into
disuse.

In this part of Britain, the systems of Latta, B. Bell, and Allan,
occupied the field; but it being now vacant, I venture to supply the
deficiency, by reducing the heads of my lectures into a compendium, or
guide, for those students who resort to this city.

It must appear superfluous to preface such a work by anatomical
descriptions, anatomy being now studied more generally, and with
greater zeal, than heretofore. Pathology also is more attended to,
and better understood. To which circumstances are to be ascribed the
improvements in surgical science, as well as in the art of operating.

The functions and structure of parts are more frequently preserved
uninjured—mutilation is more rarely required—and operations are
dispensed with. The wider the extension of pathology, the fewer the
operations will be—thus affording the best criterion of professional
attainment. Who will question, that there is more merit in saving one
limb by superior skill, than in lopping off a thousand with the utmost
dexterity?

To treat surgical diseases as they ought to be treated, the
practitioner must be thoroughly acquainted with the healthy and morbid
structure; he must also have a mind vigorous and firm from nature, well
instructed in the best precedents, and matured by observation.

Years are not the measure of experience. It does not follow, that the
older the surgeon is, the more experienced and trustworthy he must be.
The greatest number of well-assorted facts on a particular subject
constitutes experience, whether these facts have been culled in five
years or in fifty.

It is only from experience, directed and aided by previous study, that
accuracy of diagnosis and celerity of decision can be acquired. Besides
knowing in what manner to proceed, the surgeon must know well wherefore
he acts, and also the precise time at which he should interfere. With
knowledge and confidence derived from experience, he will perform such
operations as are indispensable for the removal of pain and deformity,
or for the preservation of life, with calmness and facility—with safety
to his patient, and satisfaction to those who assist in, or witness,
his proceedings.

Attention to the apparatus is necessary. It should be in good order,
simple, and ample. The young surgeon should note down, previously to
an operation, whatever, on reflection, can possibly be required. "For
in most capital operations, unforeseen circumstances will sometimes
occur, and must be attended to; and he who, without giving unnecessary
pain from delay, finishes what he has to do in the most perfect manner,
and that most likely to conduce to his patient’s safety, is the best
operator."

It is seldom necessary to employ much preliminary treatment. From the
usual preparative course of bleeding, purging, cooling diet, etc.,
patients about to undergo capital operations, as lithotomy, suffer more
than they can gain.

It is of the utmost importance to attend to the state of the patient’s
mind and feelings. He ought not to be kept in suspense, but encouraged
and assured; and his apprehensions must be allayed. If this cannot be
effected—if he is dejected and despondent—talks of the great risk,
and of the certainty of his dying, it is better that the operation be
abandoned, or at least delayed. If, on the contrary, he is confident
in the resources of his constitution, and in the ability of his
attendant, and looks forward to the advantage to be derived from his
own fortitude, then should there be no delay.

A mild laxative may be given, when an empty state of the bowels is
desirable, or when they, by acting too soon afterwards, might put the
patient to inconvenience or pain, or interrupt the curative process.

Attention to after-treatment is of much greater importance. The
practitioner is not to rely on success, however well the manual part
has proceeded. He must consider his labour only begun, when the
operation has finished; the patient is yet to be conducted, by kindness
and judgment, through the process of cure.

It is thus only that difficult and unpromising cases can be brought to
a happy conclusion, and favour and lasting reputation gained.

In the present work an endeavour has been made, in the first place,
to lay down, correctly and concisely, the general principles which
ought to guide the practitioner in the management of constitutional
disturbance, however occasioned.

The observations introduced to illustrate the doctrines inculcated are
given as briefly as is consistent with an accurate detail of symptoms
and results. The descriptions of particular diseases have been sketched
and finished from nature; and, it is hoped, with such fidelity, that
their resemblance will be readily recognised.

To describe all the methods recommended and followed, in the different
surgical operations, would occupy more space than can be allotted in an
elementary work—would, without answering any good purpose, lead into
the wide range of the history and progress of surgery.

Such modes of operating are described as have been repeatedly and
successfully performed by the Author.

If by clear and simple description of the phenomena attendant on morbid
action, and of the changes which it produces,—if by plain rules for
the treatment of the diseases, and performing the operations for their
alleviation or cure,—he contribute to the progress of surgery, and the
consequent diminution of human misery, he will consider himself fully
rewarded for the time and the labour spent on this production.



CONTENTS.


PART FIRST.
                                                           Page

  INFLAMMATION                                               13
    Signs                                                    14
  Irritation                                                 20
  Termination of Inflammation                                25
      Adhesion                                               25
      Suppuration                                            29
      Mortification                                          43
  Erysipelas                                                 55
  Furunculus and Anthrax                                     62
  Inflammation of Mucous Membranes                           65
      Serous Membranes                                       66
      Joints                                                 67
  Hypertrophy and Atrophy of the Articular Cartilages,
    with Eburnation                                          75
  Scrofulous Disease of Joints                               77
  Neuralgic Affections of Joints                             78
  Growths from the Synovial Membrane and Loose Substances
    in Joints                                                79
  Affections of Bursæ                                        80
  Coxalgia                                                   81
  Alterations of Form in the Head of the Femur               86
  Inflammation and Diseases of Bone                          94
      Suppuration in Bone                                    96
      Caries                                                 96
      Necrosis                                              103
  Fragilitas Ossium                                         110
  Mollities Ossium, Rachitis, &c.                           110
  Arterial System, Affections                               116
  Aneurism                                                  118
      by Anastomosis                                        127
  Inflammation of Veins                                     130
  Tumours                                                   134
      Adipose                                               137
      Fibrous                                               138
      Encephaloid                                           139
      Melanoid                                              142
      Carcinomatous                                         142
  Fungus Hæmatodes                                          147
  Painful Tubercle                                          149
  Polypus                                                   150
  Encysted Tumours                                          151
  Tumours of Bones                                          153
        Osteosarcoma                                        154
        Spina Ventosa                                       157
      Aneurismal                                            158
      Osseous                                               158
      Hydatic                                               161
  Wounds                                                    164
  Tetanus                                                   183
  Ulcers                                                    186
  Hospital Gangrene                                         191
  Sloughing Phagædena                                       191
  Malignant Pustule                                         193
  Ulcers on the Genital Organs, with their Consequences     195
  Scalds and Burns                                          211


PART SECOND.

  Injuries of the Head                                      215
      Wounds of the Scalp                                   215
      Wounds of the Temporal Artery                         216
      Concussion                                            218
      Compression                                           226
      Fractures of the Cranial Bones                        227
      Wounds of the Brain                                   232
      Hernia Cerebri                                        233
      Perforation of the Cranium                            234
      Inflammation of the Scalp                             238
      Thickening of the Scalp                               239
      Tumours of the Scalp                                  243
  Diseases of the Eye and its Appendages                    245
      Inflammation and Abscess of the Lachrymal Passages    245
      Inflammation of the Lachrymal Sac                     246
      Fistula Lachrymalis                                   248
      Encanthis                                             252
      Encysted Tumours of the Eyelids                       253
      Closure of the Eyelids                                253
      Ectropion                                             254
      Entropion                                             255
      Trichiasis                                            255
      Pterygium                                             256
  Diseases of the Eyeball                                   257
      Ophthalmia                                            257
      Purulent Ophthalmia                                   260
      Staphyloma                                            261
      Inflammation of the Cornea                            261
      Pustular Ophthalmia                                   263
      Ulcers of the Cornea                                  263
      Leucoma                                               264
      Hernia of the Iris                                    264
      Albugo                                                264
      Nebula                                                264
      Ophthalmia Tarsi                                      265
      Staphyloma                                            266
      Hydrophthalmia                                        266
      Exophthalmia                                          266
      Internal Ophthalmia                                   272
      Iritis                                                272
      Hypopium                                              273
      Choroiditis                                           274
      Amaurosis                                             275
      Glaucoma                                              277
      Cataract                                              277
      Artificial Pupil                                      287
  Wounds of the Eyeball                                     288
  Orbital Inflammation                                      290
  Tumours in the Orbit                                      290
  Strabismus                                                292
  Nasal Polypi                                              301
      Malignant Polypi                                      303
  Nose, and Nasal Cavities, Inflammation, &c.               308
      Noli me tangere                                       310
      Ozœna                                                 310
  Rhinoplastic Operations                                   312
  Inflammation of the Antrum Maxillare                      317
  Lips, Ulcers                                              319
      Congenital Deficiencies                               322
  Palate, Congenital Deficiencies                           322
  Soft Palate, Tonsils, &c., Inflammation, &c.              326
  Tongue, Ulcers                                            331
      Inflammation                                          332
      Division of Frænum                                    334
  Salivary Ducts, Diseases                                  335
      Ranula                                                335
      Gums, Diseases                                        337
      Teeth, Diseases                                       338
        Extraction of                                       340
      Lower Jaw, Diseases                                   341
      Disarticulation                                       345
  Wounds of the Face and Neck                               347
  Larynx and Trachea, Diseases                              354
      Foreign bodies                                        363
      Tracheotomy                                           364
  Pharynx, Diseases                                         368
      Foreign bodies                                        371
  Œsophagotomy                                              372
  Ear, Diseases of                                          373
      Foreign bodies                                        375
      Polypus                                               375
  Deafness                                                  375
  Bronchocele                                               377
  Glandular Tumours in the Neck                             379
  Hydrocele of the Neck                                     381
  Distortion of the Neck                                    382
  Venesection in the Jugular Vein                           384
  Ligature of the Carotid Artery                            385
      Arteria Innominata                                    387
      Subclavian Artery                                     387
      Axillary Artery                                       392
      Brachial Artery                                       392
      Humeral Artery                                        394
  Wounds of the Palmar Arches                               395
  Paronychia or Whitlow                                     396
  Onychia                                                   399
  Collections in Thecæ                                      401
  Ganglia                                                   401
  Venesection, bend of the arm                              403
  Mamma, Diseases                                           405
    Encysted Tumours                                        406
  Affections of the Chest                                   409
      Hydrothorax                                           410
      Empyema                                               410
      Wounds                                                411
  Affections of the Abdomen                                 412
      Hernia                                                412
      Congenital Scrotal Hernia                             413
      Hernia Infantilis                                     414
          Inguinal                                          415
          Crural or Femoral                                 416
      Ascites                                               435
      Ovarian Dropsy                                        436
  Bruises of the Abdomen                                    438
  Lumbar Abscess                                            441
  Spina Bifida                                              444
  Affections of the Rectum and Neighbouring Parts           445
      Hemorrhoids or Piles                                  445
         Distinct Varieties                                 445
      Inflammation of the Rectum                            447
      Fistula                                               449
      Stricture                                             450
      Schirro-contracted Rectum                             452
      Prolapsus Ani                                         453
  Pruritus of the Rectum                                    460
  Neuralgia of the Rectum                                   460
  Affections of the Mucous Membranes of the Urinary
    and Genital Organs                                      461
      Gonorrhœa                                             462
      Hernia Humoralis                                      467
      Inflammation of the Bladder                           469
      Irritable Bladder                                     470
      Stricture of the Urethra                              470
      Fistula in Perineo                                    472
  Retention of Urine                                        478
  Incontinence of Urine                                     489
  Gonorrhœa Præputialis                                     490
  Phymosis                                                  491
  Paraphymosis                                              491
  Hypospadias and Epispadias                                495
  Chimney-sweeper’s Cancer                                  495
  Hydrocele                                                 496
  Cirsocele                                                 501
  Hæmatocele                                                503
  Sarcocele                                                 505
  Castration                                                507
  Calculus Vesicæ                                           508
      Lithotrity                                            517
      Lithotomy                                             519
  Calculus in the Female                                    530
  Gonorrhœa in Females                                      531
  Gonorrhœal Lichen                                         532
  Retention of Urine in Females                             533
  Vesico-vaginal Fistula                                    534
  Imperforate Vagina                                        535
  Contracted Vagina                                         535
  Inflammation of Vagina                                    536
  Polypus Vaginæ                                            537
  Diseases of the Uterus                                    538
  Ligature of the Common Iliac Artery                       539
                  Internal Iliac                            539
                  External Iliac                            540
                  Femoral                                   541
  Aneurismal Varix in the Thigh                             542
  House-Maid’s Knee                                         543
  Cartilaginous Bodies in the Knee-joint                    544
  Distortion of the Feet                                    545
      Varus                                                 547
      Valgus                                                548
      Pes Equinus                                           548
      Calcaneal                                             549
  Exostosis of Distal Phalanx                               551
  Fractures                                                 552
            of the Cranium and Face                         558
                   Spinal Column                            560
                   Thorax and Upper Extremity               564
                   Pelvis and Lower Extremity               574
  Disunited Fracture                                        586
  Dislocations                                              588
      Lower Jaw                                             591
      Upper Extremity                                       592
      Lower Extremity                                       600
  Sprain                                                    607
  Bruise                                                    610
  Amputation                                                612
  Excision of Portions of Diseased Bones                    632
  Excision of Joints                                        634


ELEMENTS OF SURGERY.



PART FIRST.

OF INFLAMMATION.


There are few accidents or diseases, to which the human body is liable,
which are not preceded or followed by incited action, increased
circulation, and accumulation of blood in the capillary vessels of
the part affected; and these phenomena require to be very attentively
studied, and correctly understood, by all who propose practising the
healing art. As all the salutary as well as diseased processes which
occur in the human body are more or less attended or affected by this
action, and as its regulation forms a principal part of the duty of the
surgical practitioner, this work cannot be more properly commenced than
by treating of its nature, consequences, and management.

Inflammation may be defined to be, an unnatural or perverted action
of the capillary blood vessels of an organ or part of the body,
attended with redness, throbbing, swelling, pain, heat, and disorder of
function, as well as with more or less disturbance of the system.

Every part of the body is liable to inflammation; and some writers have
divided this action into different kinds, according to the particular
tissue which it chiefly involves. But it appears to be always of the
same character, though modified by various circumstances, such as the
tissue in which it occurs, the state of the constitution, the exciting
cause, and the intensity of the action.

The usual division of the subject, into _Acute_ and _Chronic_, is that
which it is here proposed to adopt. The term Chronic Inflammation is
more properly applicable to a consequence of the Acute: but it is at
the same time true, that morbid actions proceed more slowly in some
constitutions, and in some parts of the body, than in others; and that
changes of structure and morbid products, such as generally result from
inflammatory action, even occasionally occur, without the prominent
symptoms of inflammation being experienced by the patient or detected
by the practitioner.

The term _Morbid_ is used in contradistinction to what is called
_Healthy_ Inflammation; but inflammatory action is generally connected,
more or less, with a diseased or disordered state of some part of
the body. In many circumstances it is highly necessary that a certain
degree of incited action of the vessels should occur, and continue for
a certain time; as during the uniting of fractures, the adhesion of
wounds, and the healing of some sores—and thus far it is healthful:
when, however, the action becomes excessive, it must, for this
reason, be considered morbid, as it frustrates the natural reparative
process; if the action, in fact, proceeds farther than is necessary
for reparation, it becomes a disease, and leads to absorption or
destruction of parts. In animals possessing the greatest powers of
reparation, inflammation, it appears, does not take place at all, or is
very slight, and scarcely ever proceeds to suppuration.

_Redness_ is the first sign of inflammation to be considered; this is
observed, in the living body, on the surface, or at the extremities
of those canals which terminate externally. The inflamed conjunctiva
affords a conspicuous example of this appearance. In a subject that
has suffered from an internal inflammatory attack, a good opportunity
is frequently afforded of observing the enlarged and injected state
of the vessels on which the red colour depends. But inflammation may
have existed to a certain degree, and yet the parts may be pale, from
the capillaries having emptied themselves into the veins immediately
after the patient’s death. The paleness may be also in part caused by
the influx of the red globules being impeded immediately after death,
or when the patient is in articulo mortis, in consequence of the
contraction of the vessels, which is well known to occur at that period.

It has been said that redness is not essential to inflammation; for
serous vessels may be altered in size and function by this action,
and yet not be sufficiently dilated to receive the red globules of
the blood. And, again, that serous vessels may be enlarged so as to
admit the red globules; and a part that is colourless when in the
healthy state may, in consequence, assume a highly red hue when in an
inflamed condition. This may be observed in the cornea lucida, which,
when violently inflamed, is pervaded by numerous vessels, visible to
the naked eye, distended with red blood, ramifying over the whole of
it, and freely inosculating with each other. Some have even supposed
that these vessels are newly formed, in consequence of inflammatory
action. This opinion is, however, erroneous; as the vessels existed in
the cornea previously, and are only increased in size, so as to admit
of the accumulation of a sufficient number of red particles to render
the vessels visible. The speedy, and, in many cases, instantaneous,
appearance of red vessels where they could not previously be observed,
decidedly overturns the opinion that new vessels are in such a case
formed. New vessels are seldom formed, unless after a breach of
structure, or in cases where morbid deposits become vascular. There is
no proof of the existence of mere serous vessels in the human body,
as any one may ascertain who is accustomed to examine the capillaries
with a good microscope. Vessels which are so small as to admit only a
very few, say one, or at most two rows of globules, would, of course,
appear colourless, and these are what have been called serous vessels.
The globules of blood are so small as to be invisible to the naked eye;
and vessels carrying only one series of them would appear colourless.
No vessels belonging to the sanguiferous system have ever been observed
less in character than a blood globule; and this, so far as I have
been able to observe, is, as nearly as possible, 1/3000 part of an
inch. They appear to be flattened discs; and whether those of the human
body have a central nucleus or not, seems, as yet, very doubtful. The
globules are here shown upon a scale of 1/4000 part of an inch, linear,
and in different positions. They are represented, as seen in the
greater number of microscopes, having a central nucleus. Whether, in
the blood of mammiferous animals, or not, this is an optical deception,
is not very clearly made out; but in that of reptiles the nucleus is
easily demonstrable. The redness then is not from error loci, or in
consequence of red particles flowing where none flowed before, but from
the capillaries becoming distended and dilated with an unusual quantity
of blood, which is stagnated in the central part of the inflamed
neighbourhood, the inflammatory focus.

[Illustration]

_Throbbing_, to a greater or less degree, is always felt in an inflamed
part by the patient; and it is frequently so distinct as to be readily
perceived by an attentive examination. This arises, probably, from
the stagnation of blood in the vessels of the part over-excited, and
principally affected by the disease or injury, causing an increase in
the collateral circulation; and it is this rapidly increased action
around that gives rise to the signs and symptoms, and constitutes,
in point of fact, what is known and recognised as inflammation. The
sensation of throbbing is not, however, produced entirely by the action
of the capillary vessels, but in consequence, also, of the larger
trunks in the neighbourhood sympathising with these capillaries,
and so having their action increased also. The obstruction of the
capillaries in the early stage of inflammation must necessarily cause
a greater force of the heart to be expended on the trunks leading to
such capillaries; hence the greater impulse and velocity of blood in
the circumferential and patent vessels. In fact, when the inflammatory
action is extensive or severe, or when the part affected is of much
importance to life, the whole circulating system is disturbed, and thus
arises the sympathetic excitement of the constitution.

The incited action of those vessels in the more immediate vicinity of
the inflamed part is well marked in cases of Paronychia. There the
digital, the radial, and ulnar arteries, with their branches, beat more
violently than usual; and with much greater force, though not more
rapidly, than the vessels in other parts of the body.

_Swelling_ is caused by the enlarged and overloaded vessels relieving
themselves by effusion of part of their contents into the surrounding
cellular texture. The effusion varies in extent and consistence,
according to the degree of inflammatory action, and the species of
resistance offered; at first it is serous, then mixed with fibrin,
and consequently spontaneously coagulable. _Cæteris paribus_, the
greater the resistance, the less the effusion, and the more violent
the inflammatory action; the chance of its speedy and favourable
termination is also more diminished. Even the enlargement of the
blood-vessels produces a certain degree of intumescence previous
to effusion. The relief to the vessels by effusion giving rise to
swelling, when it occurs in loose cellular tissues, may be considered
as a beneficent provision of nature. But in vital organs it may be
productive of the most serious consequences; as in these, very slight
effusion will often endanger the structure of the organ, destroy its
functions, and not unfrequently be attended with fatal consequences.

The nature of the effused fluid varies according to the degree of
violence and advancement of the action, and is also modified by the
texture in which that action occurs. It may consist of serum, lymph,
blood, or pus. In inflammation, in short, exhalation, though at first
diminished, is soon much increased, whilst the powers of the absorbent
vessels are diminished, or at least do not maintain their usual
relation to those of the exhalants.

_Pain_ is the next symptom enumerated. Here the very common error of
supposing that where there is pain there must always be inflammation
may be noticed. Some diseases attended with the most acute pain, as Tic
Douloureux and Cramp, are generally unattended with inflammation. Many
chronic diseases, too, are accompanied with violent and long-continued
paroxysms of pain, without excited circulation of the part.

This erroneous opinion often gives rise to highly prejudicial
proceedings, as—the exhausting, by copious depletions, the vital powers
of patients, already enfeebled by continued disease or treatment—the
consequent aggravation of the urgent symptoms—and, the then only
termination of the disease and of the practice, death.

Again, it is true that we must bleed, in some cases, with the view
of preventing the occurrence of inflammation; yet the prophylactic
treatment may be carried too far, as in cases of violent injuries, or
after severe operations. In these instances, the immediate abstraction
of blood, so far from being beneficial, expedites the dissolution
of the patient, or at least greatly retards the cure. Pains arising
from local irritations are often treated in a similar way, whilst the
removal of the cause would be much more likely to restore the natural
action of the parts.

Though inflammation does not always accompany the sensation of pain,
yet the latter, in a greater or less degree, attends inflammatory
action; and, perhaps, it is fortunate that it does so. Because, were
it not for the occurrence of pain, the patient’s attention would not
be directed to the disease; he would continue to use the part as if
in health, and the affection would thus be much aggravated. Whereas,
according to the existing provision of nature, pain is felt at the
commencement of the action, the presence of which the patient is
thereby made aware of; and he is compelled to employ such measures
for its removal as reason naturally dictates, of which none is more
effectual than disusing the affected part. The nerves are thus the
safeguards of the various parts of the body in health—their nurses
in disease. A part deprived of sensation may be used, even to the
destruction of its texture, without producing any impression on the
sensorium, and consequently without the animal being conscious of it.

The presence of pain, as a symptom of inflammation, may be easily
explained. The connexion of the vascular with the nervous system
is very constant and intimate. Their ramifications accompany each
other, and are contained in the same cellular sheath; and without the
reciprocal influence of each, neither could perform its functions
perfectly. By injecting a limb soon after its separation from an
animal, and before its vital heat has departed, spasms of all muscles
are sometimes produced; showing the intimate connexion between these
two systems. This, however, is distinct from the contractions of the
muscular fibre produced by the application of stimuli. In the former
case, the contractions are universal, and induced through the medium of
the nerves. In the latter, the irritability of the fibre is excited.

When the circulation is excited, the nerves accompanying the affected
vessels are unusually compressed, and over-stimulated by the
circulating fluid, in which, probably, some change takes place, and in
this manner unnatural impressions are produced; the nerves themselves
are likewise the seat of disease, in consequence of the enlargement
of the minute capillaries which permeate them. Over-distension of the
coats of the vessels may also be supposed to give rise to painful
feelings, independently of any affection of the accompanying nervous
trunks.

The degree of pain is generally in proportion to the sensibility of
the part when in health; it also depends upon the distensibility
of the parts affected, and on the intensity of the inflammatory
action. When bones, tendons, &c., which in their uninflamed state are
nearly insensible, become inflamed, the pain and suffering are most
excruciating, owing to the resistance opposed to the dilatation of the
vessels, and the prevention of the effusion by which they naturally
relieve themselves.

The kind of pain also varies, in consequence of different modifications
in the action causing different impressions on the sensorium. Pain
is not always increased in proportion to the natural sensibility of
the part; for in some instances the sensibility is rendered much more
intense, while in others it is much obtunded.[1]

The last, and, according to some writers, the only unequivocal symptom
of inflammation, is _Heat_. In extravasation of blood into the cellular
texture, as under the conjunctiva, there is redness, swelling,
and occasionally pain; but at first, and unless the action of the
bloodvessels be excited, there will be neither heat nor throbbing.
In many internal inflammations heat is much complained of; and in
Enteritis it has been considered a pathognomonic symptom.[2]

The signs, symptoms, and consequences of inflammation—and amongst
others, heat—are modified by the distance of the affected part from the
centre of circulation. All actions, healthy as well as morbid, proceed
with more vigour in the superior extremities—in the head, the neck, and
the trunk, than in the more remote parts of the body; for to the former
the blood is transmitted more speedily, if not in greater quantity, and
is not so liable to be impeded in its return. Hence an arm may bear up
under a severe injury, which, to an inferior extremity, would prove
inevitable destruction. The heat, however, of an inflamed part, is
generally supposed to be much greater than it really is. The sensation
of heat is considerable to the patient, as well as to any observer,
whilst the absolute increase of temperature is very slight indeed.
It has been proved by the most decided experiments of Mr. Hunter, on
the mucous canals of animals, first when in health, and again after
violent inflammation had been excited, that little or no variation of
temperature can be observed. The elevation of temperature is probably
constant, though only amounting to a degree, or even less. As the blood
is the source of heat, wherever an increased quantity is circulated,
there should, to some extent, be increased heat.

The effects of an incited action of the vessels on the system at
large must now be adverted to; or, in other words, that general
disturbance in the system which attends inflammatory incitation, and
which occurs in a degree proportioned to the power of the exciting
cause, and the kind of texture primarily affected. The functions both
of the sanguiferous and nervous systems are deranged, producing a
state termed Symptomatic or Sympathetic Inflammatory Fever. From some
observations of my friend Mr. Gulliver, it is probable that this state
is frequently, if not generally, dependent on changes in the blood
consequent on inflammation. A sort of decomposition of part of the
fluid and vitiation of the remainder; the fibrin being separated and
effused into the injured part for the purposes of reparation, while the
blood globules are converted into pus in the capillaries, and mixed
with the circulating fluid. Thus the presence of pus in the blood may
become the proximate cause of fever; but if an outlet to the matter be
established, if it be discharged by the occurrence of suppuration in
a cavity or on a surface, the case is benefited and the constitution
relieved. This points to an important principle in practice. Nature
puts it in operation in small-pox, for example—how favourable it is for
the pustules to come out, and to what danger is not the patient exposed
if they are repelled.

During the paroxysm of inflammatory fever all the secretions and
excretions are diminished or suppressed; and hence the hot dry state
of the skin, the thirst with foul and dry tongue, the scanty and high
coloured urine, and the constipation of the bowels. This last symptom,
however, though it may arise partially from the diminished secretion
of mucus, yet is often dependent on disturbance of the functions of
the brain and nerves. The pulsations of the arteries become rapid and
strong, the sanguiferous system being unable to relieve itself by
effusion, in consequence of the obstruction of the exhalants.

If the extreme vessels are in any way obstructed, and the general
circulation in consequence much accelerated, the internal viscera
become oppressed, and are interrupted in their functions; and relief is
experienced only when relaxation occurs in the vessels upon the surface
of the body. Thus, in any violent and continued exertion, there is a
sense of oppression in the chest, and the functions of the encephalon
are somewhat disordered, but as soon as perspiration breaks out the
relief is instantaneous, and the animal can, without difficulty,
persevere in its exertions.

In inflammatory fever, the breathing is often difficult, and the
appetite declines; the patient is restless and watchful, and when he
does sleep, he is not thereby refreshed. In the more violent cases,
the sensorial functions are much disturbed; even delirium supervenes,
with violent muscular exertion and convulsions, and may be followed by
coma, should the local affection not subside. The delirium attendant
on violent diseases and accidents may often be considered a beneficent
effect of nature’s operations; for the patient, frequently losing all
consciousness of his situation, seems to be under the influence of the
most pleasing hallucinations, and is freed from the more lamentable
state of severe mental as well as bodily affliction.

Writers on Inflammation have expatiated at great length on
_Sympathies_; and these have been divided into, 1st, The Partial—the
Remote, the Continuous, and the Contiguous;—Remote, when parts
sympathise, though situated at a considerable distance from each
other;—Contiguous, when the sympathetic action seems to be produced, in
separate parts, merely from juxtaposition;—Continuous, when the action
extends in parts which are of similar texture, and conjoined with that
which is primarily affected.—2d, Universal, where the whole system
suffers along with parts of it. For instance, the whole system is often
disturbed by a deranged state of the alimentary canal, and, conversely,
the bowels, or the skin, the brain, the osseous or any other of the
textures, may suffer from a general disorder.

The system sympathises much more with some parts than with others;
and we accordingly find that disorder in one part will give rise to
alarming constitutional excitement, whilst in another, a much greater
derangement in function and structure will apparently be almost
entirely disregarded by the constitution.

_Irritation_ is an effect of sympathy, and differs from inflammation,
inasmuch as the functions of the nervous system, and not those of the
sanguiferous, are disturbed;—the latter frequently supervenes on the
former. Irritation is local, or constitutional. As examples of the
strictly local species, may be mentioned that peculiar and dreadfully
annoying sensation produced in the alveoli by the presence of a
diseased tooth, or the irritation caused by ascarides in the rectum, or
by stone in the bladder.

But, from this action being dependent on the nervous agency, irritation
is frequently produced in a part remote from the source of the action.
Thus, if an irritating cause of any kind be applied to the origin
of a nerve, the effects of the irritation may be evinced in a part
supplied by its extreme branches; while, if the cause is applied
to the termination of a nerve, a similar action is produced at its
commencement, and in parts supplied by nerves from the same origin.
Thus, disease of the hip-joint causes pain in the knee, whilst
dentition in children not unfrequently produces fatal effusion at the
base of the brain; and again, irritation at the neck of the bladder
frequently gives rise to pain in the feet.

Local impressions, injuries, or irritations, though apparently of
little importance, frequently produce irritation which affects the
whole system, and is therefore termed _constitutional_. Syncope
sometimes follows the passing of a bougie along the urethra. We meet
with too many instances of constitutional irritation following severe
injuries or operations, especially if attended with much hemorrhage.
In general, there is considerable prostration of strength; the patient
is anxious and restless; his sleep is disturbed; the pulse is weak and
fluttering, occasionally intermittent; the tongue is white and loaded;
the appetite is gone; the stomach rejects the little food which the
patient is able to take; he is startled and annoyed by the slightest
external impression. At this period of the disorder, rigors generally
occur, and are followed by a sense of heat, and by perspiration; then
the above symptoms gradually decrease, and the patient recovers; but in
certain instances his breathing becomes quick and somewhat oppressed,
attended with a peculiar spasmodic elevation of the nostrils; all the
secretions are diminished, the intellectual functions become impaired,
and there are occasional convulsive twitchings; coma supervenes,
preceded by a low muttering delirium, and followed by death.

This action, as well as every other, is much modified by the importance
of the part which is the source of the action, and by the constitution
of the patient. It is more severe in children than in adults. The
affection will be more fully detailed, when treating of local injuries,
and the management of patients after severe operations.

The _Causes_ of Inflammation come next to be considered; and first, of
the proximate cause or theory. The different states of the Vessels, in
their healthy and in their incited condition, have given rise to much
discussion. In the first place, considerable difference of opinion
exists as to the relative share which the heart, the larger arteries,
and the capillaries, have in propelling the circulating fluid in a
state of health. Some physiologists are inclined to attribute the
principal power to the heart, the blood being propelled and returned,
according to them, almost entirely by the vis a tergo; while they
suppose that the arteries possess merely a degree of elasticity or
tonicity. Considering the arteries as elastic tubes, performing an
indispensable part in the propulsion of the blood, we will now briefly
consider their state in inflammation.

Passing over the different theories of error loci, spasm, &c., which
have at various times been entertained, let us first examine the
condition of the capillary vessels, for these are primarily and
principally concerned. In inflammation, the balance of the circulation
is destroyed, but a diversity of opinion has existed as to the precise
nature of the change which occurs. It has been supposed, and perhaps
correctly, that the circulation is, in the first instance, much
accelerated in the capillary vessels of an inflamed part; but it has
been satisfactorily proved by experiment, that, after inflammation
is fairly established, the blood circulates more slowly than in the
healthy state of the vessels. There appears, in fact, to be, as
insisted upon by some writers on the subject, a state of excitement,
then of collapse, followed, if the life of the part is not destroyed,
by reaction. When a part is stimulated, the circulation is accelerated,
and a greater quantity of blood is transmitted by its vessels: if
the excitement is speedily removed, they recover themselves, though
perhaps a little dilated, and no inflammation ensues. If, for instance,
a foreign body of any kind gets entangled betwixt the upper eyelid
and the bulb of the eye, and it is permitted to remain a few moments
only, redness of the whole surface of the conjunctiva takes place,
but it is transitory, and disappears entirely some short time after
the extraction of the foreign body. If, however, it is permitted to
continue longer in contact with this sensible surface, the membrane
reddens more and more, and becomes thickened. Violent pain, with
discharge of tears, and alteration of the secretion from the mucous
surface, take place, ophthalmia is, in fact, established. If the
exciting cause is applied for a sufficient length of time, the extreme
vessels lose their contractility, they are weakened, become dilated,
and the contained blood circulates slowly. When inflammation is fairly
established in a part, the capillaries become considerably dilated,
and the blood is often completely stagnated in the inflammatory point.
In the circumference of this focus, it is accelerated as formerly
noticed: the blood is probably stagnated for two or three days in the
capillaries and in the contiguous cellular tissue, when the action
is at all violent. It, however, begins to move again; it loses its
colouring matter, while stagnated; the fibrin is assimilated to the
neighbouring parts, or rather effused, so as to cause the thickening,
and the blood globules have possibly undergone a change, and been
converted into those of pus. If the disease be of a limited extent,
and without breach of surface, they are carried into the circulation
very gradually, and in such small numbers as not to produce injury
to the health; otherwise the contamination of the blood by a large
quantity of pus causes inflammatory fever. It is probable that the
permanent dilatation occurs in consequence of the larger vessels in the
immediate vicinity being incited, and propelling more blood into the
minute capillaries than they can readily return into the corresponding
veins; and in consequence of so great a degree of distension being
produced, the vessels are incapable of again speedily contracting;
the blood, also, from being stagnant, becomes of a darker colour. The
larger trunks propelling blood into the distended and comparatively
inert capillaries, which are incapable of transmitting into the veins
the same quantity of fluid which they receive, will cause the throbbing
or pulsating sensation. The blood circulating in the parts around is
sometimes apparently changed in quality; it is redder, flocculi appear
floating in it, and the globules disappear. These last may have been
broken down, or partial decomposition may have taken place from a loss
of vital power in the vessels themselves.

The blood globules are, perhaps, merely compressed; for whenever motion
is produced in the fluid, they speedily reappear. Fresh globules
also find their way into the affected capillaries from neighbouring
vessels. The alteration in the component parts of the blood has been
supposed to depend upon the previous state of the inflamed vessels
in which it is contained: it is said soon to reassume its natural
appearance, when brought into a healthy vessel, and reference is made
to experiments on the web of the frog’s foot. When once altered, it
is, however, questionable if the blood ever reassumes its natural
appearance; of course the blood which takes the place of that which
was stagnated in the capillaries will be natural. If there have been
extensive inflammation, and therefore much altered blood, one of two
things will happen, viz., inflammatory fever and its consequences, or
the discharge of the offending matter (the altered blood) as pus. We
may also conclude that the blood of an inflamed part undergoes chemical
changes; for when the part becomes gangrenous, the blood then loses its
red colour, and assumes a yellowish-brown hue, from the absorption of
its colouring matter, which necessarily implies an alteration in its
chemical constitution. It seems not unlikely, that the change which is
early observed in the appearance of the blood of an inflamed part is
the commencement of a chemical process, which, if the vessels do not
regain their contractile power, terminates in the total destruction of
the ordinary properties of that fluid. It is probable that the more
modern speculators in medical science have paid too little attention
to the state of the fluids, and to the fact that, when diseased
action occurs in a part, its secretions and supplying fluid are very
considerably changed.

But the blood in inflammation also undergoes a change, observable
after its removal from the circulation, and especially when the system
sympathises with the part affected. The blood, it is generally believed
and stated, does not coagulate so quickly as in the natural state,
or else, it is said, the red globules, being increased in specific
gravity, fall rapidly to the lower part of the containing vessel, so
that a yellowish crust appears on the surface of the crassamentum
or clot; and this appearance is termed the inflammatory or buffy
coat. The blood extracted from the veins of a patient labouring
under inflammatory fever often appears to coagulate very quickly;
but it contains an unusual proportion of fibrin. In certain states
of inflammation, this crust is also much contracted, so that its
marginal circumference is at a considerable distance from the sides
of the containing vessel; its margins also are elevated and inverted;
its upper surface is smooth, whilst the under adheres firmly to the
coagulum; and in this state the blood is said to be cupped, as well
as buffed. The appearance of the buffy coat is not peculiar to the
inflammatory state, but is apparently dependent on hurried circulation,
however occasioned. It frequently presents itself in blood removed
from the circulation during pregnancy, and in several other conditions
of the system, apparently altogether unconnected with inflammatory
excitement. In these circumstances, however, the contracted or cupped
appearance of the coagulum is hardly ever observed. An ignorance
of the above fact leads to dangerous practice, inasmuch as certain
practitioners will bleed, and continue to bleed, for very equivocal
inflammatory symptoms, conceiving themselves fully warranted in so
doing by the presence of the buffy coat. This coat is often not so
apparent in the blood first drawn as in that afterwards abstracted.

In inflammation, as was formerly remarked, a greater quantity of blood
not only flows into the capillary vessels, but it also escapes from
them, or is extravasated. This may occur with or without rupture of the
vessels, and to a greater or less extent, according to the violence of
the action, and the texture of the part.

When local inflammatory action exists to a considerable degree, the
general circulation is more or less disturbed. The heart, and the
larger vessels supplying the capillaries, which are more immediately
concerned in the local action, subsequently sympathise with the part
affected, and, acting with greater vigour than usual, propel the blood
into the extreme branches; so that the inflammatory excitement may be
said to be gradually communicated by the continuous sympathy, till the
whole sanguiferous system becomes subject to its influence. The degree
of this general excitement depends greatly on the texture and function
of the part primarily affected.

The term _Passive_ Inflammation has been applied to that state in which
the larger vessels are not excited, or have ceased to sympathise with
the capillary branches. The term _Chronic_ Inflammation is properly
limited to the consequence of the acute inflammatory action, the part
remaining turgid and swollen, the vessels over-distended with dark
blood, but with little or no pain, and without heat or throbbing.
_Congestion_ is also employed to denote fulness of the vessels,
large as well as small, when no sign of excited circulation, or of
decided inflammatory action, has occurred. It is most frequently
used, however, when describing the condition of an internal organ. An
over-distention of a particular set of vessels may certainly exist
(as a consequence of inflammation, or altogether unconnected with
it), unattended with inflammatory action. These two states ought to
be carefully distinguished from a similar condition of the vessels,
attended with inflammation; for practice, which would be beneficial
in the one case, is highly prejudicial in the other, and lamentable
examples of the non-attention to this distinction are every day
observed.

It may here be mentioned, that some have denied the existence of
vitality in the blood; and to some minds it may, perhaps, be difficult
to conceive how a fluid should be possessed of this principle. But
no one can either doubt or deny that the blood, in its distribution,
in its manner of receiving increase, in the secretions furnished by
it, and in its various morbid changes, is governed by certain laws
and principles which cannot be explained by those of chemistry or
mechanics, but must belong to some other power. It is allowed, and has
been promulgated by all authors, that the blood is one of the most
active agents in the animal economy—in repairing waste, in affording
peculiar fluids necessary in that economy, in supplying organs with
materials for carrying on their functions, &c.; and yet all this,
according to some, is accomplished by a dead animal fluid; no one
can plausibly object to the laws by which the blood is governed
being referred to the power of life, and to their being called Vital
Principles.

Certain circumstances give rise to inflammation, and have been called
its _Exciting_ or _Immediate Causes_. Among the external applications
producing inflammation, stimulants bear a conspicuous part; the
effects of which, in causing this action, are well shown by many
experiments that have been performed on the lower animals: by the
application of ammonia, spirits of wine, or common salt, for example,
to the diaphanous web of a frog’s foot. As stimulants usually causing
inflammatory action, by their being applied to the surface of the body,
may be enumerated acids, alkalies, certain salts, animal substances,
such as cantharides, the juices of many plants, many poisons, an
excessive degree of heat, &c. Any solid substance, though by no means
acrimonious in its quality, may act as an exciting cause, as by
pressure or friction.

Wounds also, especially when of considerable size, and occurring whilst
the constitution is in an unhealthy condition, give rise to local, and
occasionally general, inflammatory action.

This action is besides frequently produced by injury from an obtuse
body causing a bruise or fracture; by the lodgement of extraneous
substances, or of decayed portions of the system,—such as portions of
bones, tendons, &c.; or by irritating matter generated in the system
itself,—by concretions, tumours, vitiated secretions, &c.

One of the most frequent causes of inflammation is cold; the action of
which, however, cannot always be readily explained. In some instances,
it appears to act directly on a part, as in inflammation of the mucous
membrane lining the organs of respiration: in others, its action is
indirect, probably by disturbing the equality of the circulation, the
inflammation occurs in a part distant from the surface the temperature
of which had been diminished. In the great majority of instances in
which inflammation has occurred, in consequence of very intense cold,
it is produced by the sudden application of heat whilst the temperature
of the part is greatly below the natural standard, as will afterwards
be more particularly illustrated. But the inflammatory action may be
produced, even though no heat be afterwards applied directly to the
part, by its vessels being too rapidly brought into a degree of action
similar to that of the surrounding parts which are in their natural
condition. Sudden and general diminution of temperature seems to act
as an exciting cause, by producing an instantaneous suppression of
the transpiration. Another exciting cause of the inflammation, is
the retention of the secreted fluids, causing unnatural distension
of canals or cavities, and is exemplified by cystitis occurring in
consequence of retention of urine. Certain states of the constitution
are justly supposed to excite inflammation, in particular textures.
Other exciting causes of inflammation might be enumerated, but these
will be more naturally explained, and more fully considered, whilst
treating of inflammation of the various tissues and organs. Their
effects are various and diversified, according to the intensity of the
cause, the structure, function, and sympathies of the part affected,
and the state of the system. And it is also to be remembered, that not
unfrequently inflammatory action appears, whilst we can assign no cause
for its production.

Inflammation is said to terminate in _Resolution_, _Suppuration_, and
_Mortification_. The application of the word termination, however,
is injudicious; for in general the inflammatory action, though much
abated, is not extinguished by the occurrence of suppuration or
mortification, but often continues in the surrounding parts with
unabated intensity; and not unfrequently several of the terminations
occur combined with each other.

_Adhesion_ has also been mentioned as a termination of inflammation,
but perhaps improperly; for, although in certain parts of the body,
as in the serous cavities, adhesion is produced in consequence of
inflammatory action, and during its progress, still the process of
adhesion is altogether independent of this action in other textures,
such as the cellular. In the uniting of a flesh wound, a certain
degree of incited action of the blood vessels is necessary for the
accomplishment of the adhesive process; but should that incited action
reach the inflammatory pitch, the union by the first intention is
interrupted, and the wound must heal by granulation with suppuration.
The process of adhesion will be more properly attended to when treating
of wounds.

The various terminations of inflammation are salutary or destructive,
according to circumstances; but resolution is, in general, the one most
to be desired; complete resolution, however, perhaps seldom occurs;
after the inflammatory action has attained a certain point, this cannot
be expected to happen.

Resolution takes place in consequence of the reëstablishment of the
circulation in the capillaries, in which the blood had stagnated;
hence the diminution of the increased action in the larger vessels—the
effused fibrin, at the same time, if there was much swelling, is
partly absorbed. The circulation in the part becomes again natural, and
the circulating fluid also resuming its healthy properties, the redness
and sensation of throbbing cease. In consequence of the bloodvessels
regaining their contractility, the nervous system is no longer
preternaturally stimulated, and thus the increased sensibility is
done away with. In short, when inflammation terminates in resolution,
the part is left in the same state in which it was previous to the
supervention of the attack. It is not an instantaneous process, but
gradual in its completion.

Again, it not unfrequently happens, when inflammation has occurred in
the surface, and continued for a short period, that it spontaneously
disappears, and does not again return; the action is said to terminate
in _Delitescence_, and of course this is always a favourable
occurrence. But if the inflammation, after having suddenly disappeared,
attacks another part at a distance from that first affected, the change
is termed _Metastasis_. If the inflammation leaves an internal viscus,
and appears on the surface of the body, the circumstance is favourable;
but if it leaves the latter to attack the former, the result is highly
dangerous.

_Treatment._—In the treatment of inflammation, with a view of procuring
resolution, our attention must be first directed to the exciting cause:
it is, if possible, to be discovered, and removed. Thus, foreign bodies
are to be extracted—fractures reduced—strictures divided—unnatural
accumulations of fluid withdrawn, &c. In many cases, if the exciting
cause is removed, nothing more is required; the inflammation speedily
subsides. If the cause cannot be removed, or if, after its removal, the
inflammation proceeds unabated, the arterial action must be reduced
by general and local abstraction of blood. By general depletion, the
action of the whole sanguiferous system is diminished, as well as of
those vessels more immediately engaged in the morbid action; but the
affected capillaries are still dilated, and less capable than the
larger trunks of effective contraction to propel their contents; and
are therefore only sufficiently depleted by the local abstraction of
blood, by leeches,[3] cupping, punctures, or incisions.[4] Blood may
be drawn either from arteries or from veins. In Arteriotomy, the blood
is discharged more rapidly, and its flow is of longer continuance,
than from a vein, so that the system may thereby be almost completely
deprived of its circulating fluid; and perhaps a more speedy impression
may be made on the inflammatory action. One objection to venesection
is, that after frequent and copious venous hemorrhage, the internal
vessels become gorged with blood, and a disposition to apoplexy is
induced.

But bleeding is not to be had recourse to without due consideration of
the age, strength, constitution, and idiosyncrasy of the patient; if
employed, it must be modified according to these; and it has already
been mentioned, that depletion is not always to be persevered in on
account of the presence of the buffy coat.[5]

Bleeding is materially assisted in reducing the activity of the
circulation, by the employment of saline purgatives, along with
nauseating doses of antimony. Diaphoretics are of essential service
in promoting the action of the exhalants, and thereby relieving
the affected capillaries. The exhibition of opium is frequently
advantageous, more especially after depletion, in allaying the painful
sensations when severe, and averting reaction, and also in procuring
refreshing sleep, when the patient is anxious and restless. Digitalis
has been administered, with the view of reducing the arterial action;
but it has been fully established, that this medicine acts at first
as a direct stimulant, and that it is only after its use has been
continued for some time that its effects become sedative.

The local applications to an inflamed part are sometimes made hot,
sometimes cold. The latter will perhaps be at first the more grateful
to the sensations of the patient. They are, however, with greater
propriety employed before inflammatory action is fairly established,
and they act by constringing the superficial vessels with which
those more deeply seated sympathise to a certain extent; but warm
fomentations are more pleasant and useful when inflammation has really
taken place; they relieve the pain more effectually, and at the same
time promote the cutaneous transpiration; they relax the surface
moreover, effusion is thus encouraged, the deeper vessels are so far
relieved of their load, and the pressure upon, and stimulation of,
the nerves are thus diminished. After the violence of the symptoms
has abated somewhat, the vessels still, however, being loaded with
blood, the inflammation in fact having become chronic, stimulants
may with propriety be applied directly to the affected parts; these
are employed, perhaps, with greatest advantage immediately after the
bloodvessels are unloaded by leeching, scarification, or punctures;
this practice is borne out by the result of experiment and observation.
It is seen, that after the vessels have become dilated, and the
blood has stagnated in them through the infliction of injury, or the
application of some stimulating substance, that the employment of
another and different stimulus immediately causes the contraction of
the capillaries, and the renewal of active circulation.

During an inflammatory attack, the patient should be allowed very
little food, and what he does receive must contain little nutriment in
proportion to its bulk. But in many cases it is unnecessary to enjoin
such abstinence, as the patient has no appetite, and refuses food.

In inflammation of deeply-seated parts, such as the apparatus of some
articulations, it is a frequent mode of assisting the completion
of resolution to excite inflammatory action in an external, and
consequently less vital and important part. This is accomplished by the
application of stimuli, caustics, cautery, setons, &c.

It appears that the stimulating substance produces an incited action
of the bloodvessels, or a revulsion, according to the older authors,
in the part to which it is applied; and that, consequently, the
neighbouring arterial trunks, in order to sustain that incited action,
supply the part with a larger proportion of their contents than it
usually receives; and the necessary consequence of the stimulated part
receiving an additional supply of blood is, that the part originally
inflamed receives less. The effect, indeed, seems analogous to that
of topical bleeding, with this difference—that it is more permanent.
Besides, it determines suppuration on the surface, and so renders it
less necessary for the vessels to produce pus in a worse situation—the
deeper seated parts.

But it must be borne in mind, that this method is not to be resorted to
in the commencement, or during the active state, of the inflammatory
action, but only when that action has begun to decline, otherwise the
disease may be much aggravated, instead of being relieved.

If, notwithstanding all the means employed to procure resolution,
the inflammatory action continues unabated, the result next to be
desired and accelerated is Suppuration; and with this view, it becomes
necessary to change the treatment, both local and general.

Above all, disuse and a proper position of the affected part must not
be neglected. Unless absolute repose is strictly enjoined and attended
to, and the return of blood from the inflamed tissues is favoured,
very great difficulty will, in the majority of cases, be experienced
in removing any of the signs or symptoms of inflammatory action, even
by the most energetic means, general or local. This will be more fully
insisted upon in the progress of the work.


OF SUPPURATION AS A CONSEQUENCE OF INFLAMMATORY ACTION.

It has already been stated, that the blood is stagnated in the
capillaries occupying the centre of the inflamed part, as well as
extravasated in the contiguous cellular tissue. Pus has long been
considered as a secretion; but, from the time of Mr. Hunter downwards,
a great similarity between the globules of pus and those of blood
has been recognised: the former, however, are spherical, larger, and
rougher on the surface, and are not so regular in size as those of
blood; their diameter is between 1/2000 and 1/3000 of an inch, although
some of the globules may be occasionally seen a little larger or
smaller than these measurements. Smaller particles are also detected,
the molecules of the pus globules, each of which contains two or
three. These molecules are insoluble in acids, soluble in caustic
alkalis, and can be freed from the fibrous capsule in which they are
contained, and of which the pus globule is composed, when treated
with acetic acid. The appearance of the pus globules and molecules
is here shown upon a scale, the squares of which are 1/4000 of an
inch. These small particles were pointed out to me by my friend, Mr.
Gulliver, nearly two years ago, as constituting an important element
in suppuration. It results from his observations that the entire pus
globule is composed in its central part of these minute molecules,
the diameter of which is from 1/10666 to 1/8000 of an inch, cemented
together, as it were, by a superficial deposit of matter possessing
all the properties of coagulated lymph. And these minute nuclei
constitute a proximate animal principle, possessing such well marked
characters as to justify us in regarding them as peculiar in their
nature, and essential to the composition of the pus globule. Thus
they resist putrefaction with remarkable pertinacity, are very dense,
and spherical in form, and are insoluble in some acids which act with
facility on albumen, fibrin, or the blood-corpuscle. They are easily
seen by treating a little recent pus with sulphurous acid, which so
acts on the pus-globule as to render the nuclei distinctly visible
through its fibrinous capsule; by sulphuric acid the external part of
the pus-globule is quickly dissolved, and the nuclei, somewhat shrunk,
are seen in considerable numbers floating separately about the field
of vision. The instrument used by Mr. Gulliver in these observations
was a compound achromatic microscope, with a deep object glass, having
one-eighth of an inch focal length.

[Illustration]

In many constitutions, the slightest incited action of the vessels
is followed by the formation of pus, and the appearance of a depôt
of purulent matter is often the first indication that such action
has existed; but in the majority of instances, the deposition of
pus is preceded by the usual characters of well-marked inflammatory
action. Suppuration occasionally occurs without previous solution of
continuity; for pus is frequently contained in the serous and mucous
cavities, when no breach of continuity can be discovered, at least
we find a fluid not distinguishable from purulent matter; it may be
a vitiated secretion, but still it presents the usual characters of
pus. But it occurs, generally, when there has been a previous læsion
of structure, and in this case its progress is most distinctly marked.
In exposed cellular texture, for example, particles of blood are
effused; the serum is afterwards absorbed, and the lymph remains;
this latter gives transmission to minute vessels which deposit the
purulent fluid, whilst others secrete particles of organised matter
to form granulations, in order to repair the loss of substance. This
process is often unattended with any great degree of constitutional
disturbance, because the fibrin effused sets a bound to the pus, and
is the provision against its being mixed in large quantities with the
blood. In healthy suppuration, the separation of fibrin and pus from
the blood in this way seems to have direct relation to each other;
and in unhealthy inflammation, when this does not take place, the
consequences are mixture of pus with the blood as formerly noticed. In
the latter form of suppuration the fibrin, instead of being assimilated
to the contiguous mass, is mixed with the pus; hence the proneness
to putrefaction of such discharge, and its disposition to coagulate
spontaneously when evacuated. This kind of suppuration, being matured
generally without thickening of parts, has been sometimes pointed out
as suppuration independently of previous inflammatory action.

After purulent matter has begun to accumulate under the surface, the
pressure thereby occasioned produces condensation of the neighbouring
cellular tissue, which, along with the previously effused lymph,
forms the parietes of the abscess; and in proportion as the matter
accumulates, the cavity enlarges by the successive processes of
ulceration of portions of its parietes, by continued effusion of lymph,
and by farther condensation of the surrounding parts. Thinning of the
parietes takes place by ulcerative absorption, particularly towards
the surface—or, if that be difficult, towards a mucous outlet—as is
exemplified by the bursting into the bowels or bronchiæ of abscess of
the liver.

But in some instances, when no lymph is previously effused, and no
cyst is formed, the matter is not confined, but pervades the cellular
substance extensively, and is generally followed by more or less
sloughing of that tissue, and by great constitutional disturbance. This
most frequently occurs in patients of a debilitated habit, in whom
the incited action has been so slight as not to cause the effusion of
lymph, by which nature usually sets bounds to the suppurating process.

M. Gendrin advanced the opinion that pus was nothing but transformed
blood; but his experiments on frogs are at least doubtful, since Mr.
Gulliver, on repeating them, could not by any means induce the process
of suppuration in these animals. It has been rendered probable by
this gentleman’s observations that suppuration is a sort of proximate
analysis of the blood, the fibrin being added to the contiguous
parts, as in causing them to swell, forming the cysts of abscesses;
the blood globules altered into pus being discharged as useless and
excrementitious matter.

Pure pus is heavier than water, of a yellowish-white colour,
somewhat of the consistence of cream. It is very little inclined to
putrefaction, less so, perhaps, than any animal fluid not oily. It
is composed of globules, and a clear transparent fluid, coagulable,
it has been said, by the muriate of ammonia. When a solution of this
salt produces any change, it is by rendering the pus more ropy; not
coagulation, but a sort of gelatinisation follows. It is said also to
be sweet and “mawkish to the taste.”

In unhealthy pus, such as already noticed, or in vitiated
muco-puriform secretion, the colour and consistence are different, and
flakes, resembling portions of lymph, are seen floating in it: they
consist of fibrin thrown off with the pus, instead of being used for
reparation and bounding the extent of the abscess; and by this latter
circumstance such fluid is distinguished from the pure or laudable pus.
In purulent matter also, especially that of an unhealthy character,
the existence of a quantity of sulphureted hydrogen is indicated by
the blackening of silver probes, and of various substances applied to
the sore. It is necessary to bear in mind, that a matter resembling
pus in many particulars, but in reality differing essentially from it,
has generally been regarded as true purulent fluid; for it results,
from some observations of Mr. Gulliver, that the pulpy matter, so
frequently found in the substance of fibrinous clots of the heart and
veins, is simply fibrin which has coagulated and passed into the state
of softening, which he regards as a very frequent elementary disease.
The subject is one of great interest, because it is connected with the
theory of suppuration, and tends to modify materially our views on the
pathology of the veins.

The symptoms attendant on suppuration vary much according to the
nature of the parts involved. In general, it is accompanied with the
subsidence of acute pain and fever; but, in unyielding textures, the
increase of swelling, by the formation of purulent matter, is often
attended with an aggravation of the symptoms, and with an increase
of danger to the structures affected. The pain which accompanies
suppuration is dull, and attended with a sensation of fulness and
throbbing, and an increase of the tumour; ultimately the parietes
of the abscess become absorbed, and the collection, being more
superficial, the most careless observer must be convinced of its
existence, by the less equivocal signs of fluctuation and pointing.
In general, especially when the abscess is deeply seated, a greater
or less degree of œdema surrounds it, producing a soft pitting
tumour; but not unfrequently, when the degree of excitement is more
intense, lymph, instead of serum, is effused, rendering the part more
hard and resisting: in such cases it may be difficult to discover
the existence of purulent matter, and the tactus eruditus, as it is
called, will be found of material service; for, though pus is neither
acrid nor corroding, still, if allowed to remain for any long period,
much mischief may be caused—the bones may become diseased—muscles
and tendons may slough—and the matter may discharge itself, by means
of ulceration, into certain cavities and canals, and produce very
serious consequences. Of the bad effects produced by the pressure and
irritation of extensive and undisturbed collections of purulent matter,
every practitioner must have seen numerous examples. Still, through
prejudice, erroneously conceived opinions, or servile imitation, the
greatest dread seems, with many, to exist of the practice of giving a
free exit to the contents of such depôts.

The symptoms and sensible signs of suppuration are usually preceded
by shivering, recurring at intervals, and commonly terminating in
profuse perspiration. But this is by no means an unequivocal sign of
the occurrence of suppuration; and this process very often takes place
without any feeling of rigor.

The older authors supposed that pus was derived from the solids—or that
it was formed by the melting of dead animal matter—or that it was the
result of putrefaction; in accordance with which latter opinion, the
term pus was given to the fluid; but such opinions have long since
been justly exploded. Pus is generally supposed to be separated from
the blood by the secreting power of the bloodvessels of an exposed
and inflamed part, in consequence of their having assumed a new
mode of action. The secretion from exposed surfaces is not at first
purulent, but is transparent, serous in fact, and is somewhat of a
gelatinous appearance; and it is only, it is said, after exposure to
the atmosphere for some time, and when drying, that it presents the
appearance of globules. Pus is often formed where the secreting surface
has not been exposed to the air; on opening an abscess, the parietes
of which had been previously entire and not much attenuated, purulent
matter of the usual properties is discharged. It has been asserted
that pus globules may be formed independently of any vital action; and
that, if the serous fluid be removed immediately after its secretion
by a granular surface, and kept in a temperature similar to that of
the inflamed part, and be at the same time freely exposed to the air,
globules will appear in as short a period as when the secretion is
allowed to remain in contact with the sore. Some have also supposed
that the mere admission of air into the cellular substance causes
suppuration; but this is far from being correct. In chronic purulent
depôts, however, the admission of air, by favouring putrefaction
probably, often produces most serious results; other causes are
generally in operation at the same time, as will be afterwards more
fully explained.

Pus was formerly regarded as irritating and corroding, and was
therefore carefully removed from every granulating sore; but purulent
matter, though it may prove a source of irritation to the neighbouring
parts, does not disturb the surface which secretes it, but, on the
contrary, protects the tender granulations, and acts as a temporary
cuticle. A crust is formed by the evaporation of the thinner part of
the fluid; and we frequently see small sores healing rapidly when thus
protected. In some instances, we adopt the hint given to us by nature,
and produce a scab by the application of powders, lunar caustic, &c.

The discharge does not always consist of laudable purulent matter.
Pus formed in the diseased part itself has particular characters,
according to the tissue involved; thin and greyish in bones, opaque and
caseiform in cellular tissue, flocculent in serous, and greenish and
thready in mucous membranes; it is said to be reddish in the liver, and
yellowish-grey in muscles. Its sensible properties are various, often
very offensive when proceeding from a cavity containing decayed bones,
and it degenerates in consequence of disturbance of the constitution,
or of the part affected. It is also frequently suppressed, in
consequence of over-action in the vessels of the part, or from debility,
partial or general.

Suppression of a purulent discharge is to be regarded as an untoward
symptom, fraught with considerable danger, being generally followed by
the most violent constitutional disturbance. Certain cases would seem
to warrant the belief that a species of metastasis occurs; that the
matter is absorbed, and again deposited in some other part, perhaps
of the utmost importance in the animal economy. The danger arising,
when the pus is not separated from the blood, has already been adverted
to. No wonder, if from any cause it does not escape by its accustomed
channel, that an effort should be made to deposit it somewhere else,
for the temporary relief of the system. The most vascular parts are
commonly chosen, as the lungs, spleen, and liver. In the cavities
of joints, also, matter is often found in great quantities. This is
sometimes indicated by the occurrence of tenderness and swelling for
only a short period previously; but, in other cases, its presence
has never been suspected. In purulent collections, after wounds from
accident or operation, on the suspension of the discharge, the patient
becomes affected with severe constitutional irritation, and gradually
sinks; the existence of purulent depôts in the viscera of the chest or
abdomen, being perhaps not indicated by any, unless very equivocal,
symptoms, and these appearing only a short time before dissolution. A
late writer has endeavoured to connect this with inflammation of the
veins; but such an opinion is not borne out by observation, although
the two circumstances may occasionally coexist. In many cases the veins
of a limb are found filled with pus, yet their coats present no marks
of inflammatory action having existed in them. Their mouths are open in
the wound, from failure of that healthy action by which they would have
been closed by coagulated lymph, and the matter appears to be taken up
by them as secreted.

From the discharge varying according to the state of the system, the
latter can in general be accurately ascertained by examination of the
sores which afflict the patient.

In collections of matter not far removed from the surface, the most
superficial, and generally the most dependent, portion of the parietes
appears inflamed; its inner surface is gradually absorbed; and, when
it has thus become attenuated, a portion of the integument sloughs or
ulcerates. A communication is established with the diseased parts,
through the external surface, thus providing an aperture for the
evacuation of the matter—of extraneous substances—or of parts of the
body which have either mortified, or otherwise become useless to the
system. In such collections, more especially if deeply seated, the
matter generally seeks the surface, or extends in the course of the
bloodvessels.

Cold abscesses, as they are called, often contain as much flaky
fibrinous matter as true pus: hence one of the signs of inflammation,
swelling, is absent; the fibrin being discharged instead of having been
added to the neighbouring parts.

As formerly remarked, suppuration occurs much more readily in some
constitutions than in others; and patients peculiarly liable to the
formation of abscesses, without any great degree of previous excited
action of the bloodvessels, are said to labour under _Struma_ or
_Scrofula_. These terms are by some used to denote a distinct or
specific disease, while others consider them merely as a peculiar state
of the constitution.

The strumous diathesis is said to be marked by hair and irides of a
very light colour, and by the skin being of a peculiar white hue; but,
in some instances, the complexion is unusually dark and sallow. The
upper lip generally presents a swollen appearance, as also the columna
and alæ of the nose. The organization throughout is delicate, and the
patient is frequently of a handsome, though infirm, structure.

Constitutions, in every respects strong and originally vigorous, may,
from various causes, become weak, and present many of the symptoms
usually termed scrofulous. I recollect a young patient, born of healthy
parents, who had enjoyed excellent health, becoming covered with ulcers
and chronic abscesses, in consequence of exposure to cold during
menstruation.

To the continued irregular and imprudent exhibition of mercurial
_alteratives_, as they are called, may be attributed the cachectic and
scrofulous constitutions of many thousands of patients of all ages.

The strumous diathesis is said to depend upon a want of balance, or
proportion, between the solids and circulating fluids. Want of action
and power in the organs forming and circulating the blood, disordered
digestion, and various other circumstances which it is unnecessary
to detail, have also been considered as causes of this state of the
constitution.

Many suppose that the diathesis, or a disposition to the diathesis,
is always congenital; and this opinion is supported by the majority
of cases. However, certain circumstances produce a scrofulous habit
of body in patients who previously appeared to be vigorous and
healthy, and untainted with any peculiar disposition to disease. Of
these predisposing causes may be mentioned, a poor diet, an impure
atmosphere, exposure to damp and cold, inattention to cleanliness, the
latter circumstance acting sometimes by producing local irritation:
in fact, whatever deranges the general health, seems, in many cases,
to induce the strumous diathesis. Some constitutions are incapable
of resisting any unusual incitement of the vascular system, or of
repairing the consequences of the action, or of any injury, in
whatever way inflicted. In such individuals, all the parts of the body
are deficient in power—some, however, are more so than others, and,
consequently, more readily give way; thus, the lymphatic system, the
mucous membranes, the skin, the bones and their coverings, generally
suffer in the first instance.

Glandular swellings of all kinds, and in all situations, often
followed by suppuration, are apt to occur from irritation of various
descriptions, but more so in constitutions originally weak, or which
have become debilitated by disease or any other cause. The larger
glandular tumours are formed by congregation and agglutination of
the smaller ones, and by the deposition of adventitious matter in
the connecting cellular substance; separation of the smaller tumours
composing these, naturally, or under the use of deobstruents exhibited
internally, or applied to the surface, is a highly favourable sign, and
equally encouraging to the surgeon and the patient.

Dentition, the presence of carious teeth, of stumps of teeth;
excoriations behind the ears, eruptions on the scalp, affections of
the lining membranes of the eyelids, mouth, or nose, of the skin of
the face, are daily found giving rise to glandular swellings in the
neck; whilst irritations in the urethra, excoriation or slight disease
about the anus, corns or sores about the feet or toes, produce similar
affections of the glands in the groin. Such sources of irritation are,
of course, to be looked for in the first instance, and will often
materially influence the diagnosis, though too much is occasionally
attributed to their influence. Such glandular tumours, however,
sometimes occur spontaneously, or, at least, without any evident
cause. They have been mistaken for other diseases, according to their
situation—for aneurism, hernia, or venereal bubo; the latter mistake is
often committed unintentionally by the ignorant, or designedly by the
unprincipled.

Tumours formed by the enlargement of glands are frequently productive
of dangerous consequences. If situated in the neck, they may render
breathing and deglutition extremely difficult, and in the event of
their suppurating, the purulent matter may be discharged into the
trachea or gullet; fatal results have followed the giving way of an
abscess into the former canal. The breathing is also seriously impeded
by enlargement of the bronchial glands, by the pressure of which
the lungs may be much condensed, and unfitted for their functions.
The immediate effect of enlargement of the mesenteric glands, is
interruption to the passage of the chyle, and a consequent decline of
the powers of life. Such tumours in the abdomen have been mistaken for
enlargement of the liver, spleen, ovarium, &c., and the most noxious
treatment employed.

Inflammatory glandular enlargements terminate either in resolution, in
delitescence, or in suppuration; sometimes in death of the part. When
the tumour, after having attained a certain size, gradually disappears,
it is said to be resolved; when, however, it is rapidly discussed, it
terminates in delitescence; the difference between the terms being
the same as when used to express the corresponding terminations of
inflammatory swelling in general.

Suppuration is by far the most usual termination, and the matter is
frequently evacuated through numerous small apertures, exposing the
gland denuded and prominent in the middle of the chasm; in such cases,
the gland proves the source of much irritation, and must be destroyed,
otherwise the cure is extremely tedious.

Though inflamed and swelled lymphatic glands very generally disappear
by suppuration, it is to be remarked that the conglomerate glands,
though often violently inflamed, seldom, if ever, have pus formed in
them; in mumps, for instance, the action often runs very high, yet
abscess of the parotid is rare. The submaxillary salivary glands are
often supposed and said to be inflamed and enlarged; the conglobate
glands superficial to them are in such cases only affected.

Collections of pus in the lymphatic glands or cellular substance, in
patients of a weak constitution, (whether naturally or in consequence
of disease,) are attended with little or no pain, or inflammatory
action; and although it is probable that inflammation does precede the
formation of such purulent depôts, still it is generally so slight
as not to attract the attention of the patient or his attendant. The
sensation is dull and uneasy, rather than painful; and, even after the
accumulation of a considerable quantity of purulent matter, redness of
the surface and pointing do not occur till a late period. The contained
matter is thin, flaky, and of a brownish colour. The collections often
attain a very great size, and, if improperly treated, terminate in the
formation of numerous and extensive sinuses.

The skin, particularly that of the face, becomes, in very many cases,
affected either primarily or secondarily with scrofulous ulceration,
which commonly extends to the neighbouring textures. The disease has
sometimes been mistaken for cancer, and other affections of a malignant
nature, and has received various names accordingly. The integuments
in the neighbourhood of the ulcer are of a purple hue, and become
undermined, from the extension of the disease in the subjacent cellular
tissue. The discharge is thin and gleety—the sore is of an unhealthy
and debilitated character, and makes but little attempt at reparation;
its surface is covered by a viscid fluid, and sloughing occasionally
occurs in consequence of the extreme debility of the parts. Numerous
sinuses frequently extend in a superficial direction, and render the
cure more tedious and complicated.

Those of a scrofulous constitution are most liable to be affected with
caries, softening, and other diseases of the bones and their coverings;
these, however, will afterwards be treated of, along with ulceration
of cartilages, diseases of ligaments and synovial membranes, lumbar
abscess, &c.; all of which affections, in the plurality of instances,
are connected with the strumous diathesis.

In the treatment of abscesses, the principal indications are, to remove
any degree of inflammatory action with which the surrounding parts may
be affected—to keep the part moist, clean, and at rest—to remove all
source of local irritation—to promote and accelerate the progress of
the matter to the surface—and, lastly, to give it free vent; for though
it sometimes happens that collections of purulent matter disappear,
still the occurrence is so rare, that to treat abscess generally when
in an advanced stage with the expectation of resolution would be highly
injudicious. By blistering and pressure, however, tumours containing a
small quantity of purulent fluid can occasionally be discussed. Warm
fomentations afford great relief, especially at the commencement, when
there still remains a considerable degree of surrounding inflammation.
These may be either what are termed anodyne, or not; in general,
fomentation with chamomile flowers or hops, contained in a woollen
bag, and wrung out of warm water, will be found the most convenient
and efficient, and is well entitled to the term anodyne, which is
usually applied to others of a complicated, and not more efficacious,
character. Poultices are of material service, particularly when the
collection is advancing to maturation; and their composition is of
little importance, provided they are moist, warm, and soft. Stale
bread soaked with hot water, or an equal quantity of grated bread and
linseed meal, (if not adulterated with mustard, as is sometimes the
case,) mixed with sufficient quantity of boiling water, form excellent
and soothing cataplasms. Their use, however, may be persevered in too
long; for, after an abscess has given way, the suppuration may be
kept up in consequence of continuing the poultice. The opening will
enlarge, the skin become undermined, loose, and flabby, the abscess
will extend, while the process of granulation may be in a great measure
suspended. In many cases, the poulticing cannot be continued until an
opening has formed naturally, and the cure is often much accelerated by
the artificial evacuation of the matter. When the abscess is situated
deeply, or beneath a fascia, a free and early opening must be made.
For example, when suppuration has occurred in the cellular tissue
beneath the fascia lata of the thigh, it at first naturally tends
towards the surface, but its progress is impeded by the tendinous
aponeurosis; a painful feeling of tension is thereby occasioned, and
the matter extends where there is least resistance, making its way in
all directions into the surrounding cellular tissue—separating the
muscles—isolating the arterial trunks—burrowing beneath the fascia
over the whole limb, and producing most serious, and often irreparable
mischief, with violent constitutional disturbance. The bad effects of
delay are again daily witnessed in neglected cases of paronychia; most
excruciating pain is produced—the system is seriously affected—the
tendons slough, and the member is rendered useless.

By the continued presence of purulent matter, absorption, ulceration,
caries, and even death, of bone, is frequently produced, all which
might have been prevented by its evacuation. If pus collect in the
neighbourhood of cavities or canals, it is of the utmost importance
that it be early discharged; and the evil effects of negligent and
dilatory treatment are well exemplified in the following cases:—A
patient had been allowed to suffer, for a long time, under an extensive
abscess at the lower part of the neck, beneath the origins of the
sterno-mastoid muscles. The abscess at length gave way externally; but
the patient was at the same time seized with profuse expectoration
of pus, and during expiration the air escaped through the external
openings in the neck. It was evident that the abscess communicated with
the trachea, and it also appeared to have extended deeply into the
mediastinum. The patient soon perished, but there was no opportunity
of examining the parts. In another case of extensive abscess at the
root of the neck, an opening was proposed, but delayed. At length, the
abscess gave way spontaneously; and from the circumstance of portions
of solid as well as fluid ingesta escaping by the external opening,
it was evident that the œsophagus had ulcerated. The cure was very
tedious, but ultimately complete, and apparently much accelerated by
free counter openings.

In suppuration of the cellular substance in the neighbourhood of the
anus, the matter may present itself externally, whilst it is making
extensive progress internally; and if a free opening is not made,
fistula ani is the result. The propriety of an early evacuation of
purulent matter in important, or very sensible, organs, such as the eye
and testicle, is very evident.

The larger arterial and venous trunks appear not to suffer from
suppuration, for in purulent depôts we find them entire, and much
thickened by copious effusion of lymph into their outer cellular coat
and sheath; the nerves, however, are not so much protected, or do not
appear to resist the pressure and insinuation of pus, and suffer along
with the other tissues.

[Illustration]

The most convenient and effectual mode of opening an abscess is with
a sharp-pointed bistoury, and the incision should vary in extent
according to the circumstances of the case. The straight instrument,
used as described and represented in the “Practical Surgery,” p.
5[6], will be found to answer best in deep-seated collections; in
the more superficial it may be slightly curved. It is used as here
shown, only that the edge of the knife should be turned more downwards
before the integument is divided by withdrawing it. The aperture must
always be made at the most dependent part, which is also, generally,
the thinnest; thereby a free exit is allowed to the matter. If the
incision be not made in a dependent part, a considerable quantity
of the matter will be retained within the abscess, and can only be
evacuated at the time by squeezing the parts—at all times a very cruel
and improper practice—applying compresses, &c., which produce much
irritation and unnecessary inconvenience to the patient. The cavity
of the abscess inflames, the discharge becomes bloody and putrid, and
great constitutional disturbance is apt to follow. When, again, the
opening is sufficiently large, properly placed, and the matter flows
out through the elasticity of the coverings, no air enters, the cyst
gradually contracts, and the cure is soon completed.

When the abscess has been deeply seated, and the incision made through
a considerable thickness of healthy parts, it is sometimes, though very
rarely, necessary to introduce a small piece of lint between the edges
of the wound, otherwise they may speedily adhere, and the discharge
of the matter be in this way prevented. In consequence of smart
hemorrhage, also, it may be proper to stuff the wound with lint, and
retain it for an hour or two; but in general the practice of stuffing
abscesses, or the openings into them, is hurtful. After the incision,
as already remarked, it is unnecessary and injurious to discharge the
pus by forcibly squeezing the sides of the abscess; the application
of a poultice will promote the evacuation of the matter, and allay
the irritation. In chronic abscesses of large size, it is sometimes
necessary to make a counter opening—that is, an opening in a part of
the tumour opposite to the original opening, in order that the matter
may be more completely discharged. Setons introduced into the cavity
of phlegmonous abscesses some time after their evacuation, are highly
injurious, as causing much irritation in parts which are already in a
morbid state of excitement; but in chronic collections, which show
no disposition to heal, their use may sometimes be followed by good
effects, on the same principle that they were hurtful in the preceding
case; if they should not cause a sufficient degree of excitement,
they may be smeared with some stimulating ointment. In extensive
collections, in which the matter is not sufficiently evacuated by the
external aperture, injections are by some recommended, and, perhaps,
occasionally employed: in those abscesses which are comparatively
recent, and in which the surrounding parts are still in a state of
over-excitement, they are quite inadmissible. The employment of setons
and injections in any case of abscess is not much to be commended or
trusted to. Caustic, the potassa fusa, may be frequently employed with
advantage for opening chronic abscesses, especially when they are the
consequence of glandular enlargement, and undermine the integuments,
which show no tendency to adhere to the subjacent parts. The potass
is best used in the solid form and well pointed; not in paste, as
is sometimes practised. By its application the unhealthy surface is
destroyed, and the surrounding parts are stimulated so as to assume
a sufficient degree of action to throw off the portions which have
become useless, and to form new and healthy granulations, whilst the
surrounding effusion of lymph or serum is for the most part speedily
absorbed. But it can never be employed in acute abscesses without
aggravating the disease; and in collections which are deeply seated,
it cannot be of much service, for in these a considerable thickness of
healthy parts must be destroyed, and if the potass be applied, it will
afterwards be necessary to cut through the slough, as was practised by
the older surgeons, in order to evacuate the matter and give relief to
the patient; or else to continue the application of the caustic for an
inordinate space of time, which is a practice altogether unnecessary,
extremely cruel, and productive of much irritation, constitutional as
well as local.

A too common result of abscess, when inertly treated, is the formation
of a _Sinus_; that is, a canal, the circumference of which is condensed
by deposited lymph, and which furnishes a discharge of unhealthy
purulent matter, frequently thin and gleety. Several sinuses frequently
unite, and evacuate their contents by one opening. Previously to
treating a sinus, its extent must be carefully examined by the probe;
this requires considerable caution, for the full extent of the canal
may not be discovered, in consequence of its tortuous course, or
from its diverging into collateral branches; or the probe, by being
used too forcibly, may pass into parts altogether unconnected with
the morbid cavity. Thus, in exploring a sinus at the lower part of
the leg, or in the foot, the probe may be pushed to a considerable
extent beneath the tendinous sheaths of the muscles, and induce the
surgeon to adopt treatment unnecessarily severe. In the treatment,
we may at first employ setons, injections, and graduated pressure,
as formerly explained; and if these fail, the canal must be freely
laid open by the knife—a mode of practice much more effectual; then
there is formed a cavity similar to that of a recent abscess, and to
be treated accordingly. Incision is most frequently necessary when
the sinus exists in adipose substance, in tendinous structure, in
parts possessed of little vitality, and in patients of a sluggish and
enfeebled constitution. In sinus, as well as in chronic abscess, the
potass is of essential service; a stick of it may be introduced into
the canal, and if the sinus is superficial, the integuments may be
divided by this caustic as effectually as by the knife. The indolent
and callous surface of the sore is thereby destroyed, and the effects
are similar to those which have been already mentioned, when speaking
of the use of potass in abscess; in fact, by its application the sinus
is transformed into an acute and open abscess. Foreign bodies, such as
diseased and dead portions of bones, must be early removed; for it is
to be remembered that these are much more frequently the cause than the
consequence of suppuration.

The healing of an abscess which has been opened closely resembles the
process of union by the second intention in a flesh wound; granulations
arise, attended by the secretion of pus, the cavity gradually
contracts; the surrounding effusion is absorbed along with a portion of
the adipose matter; and on the granulations reaching the surface, new
skin is formed, and the parts coalesce.

After abscesses have been opened, the fomentations, poultices, or
warm-water dressing, as recommended in the treatment of ulcers, are
to be continued, but only for a limited time. The power of the system
must be carefully supported by exposure to a pure atmosphere; by
nourishing food; by the exhibition of wine, tonics, and such medicines
as promote digestion. In cases where the system is unusually inert, it
may be proper to administer stimulants. The most powerful stimulants
are frequently necessary, and by steady perseverance in the use of
them, patients have often been saved in very hopeless circumstances.
Great attention must be paid to the bowels, and the secretions poured
into them, for on the condition and quality of these the state of
the constitution materially depends. The internal Use of cantharides
is often advantageous in chronic suppurations and abscesses, but
it is inadmissible in cases where enlarged glands occupy dangerous
situations, either externally or internally; unless the tumours are in
progress towards resolution, suppuration is certainly induced, and may
be productive of the worst consequences. The glands not unfrequently
become enlarged during the exhibition of this medicine; and such an
occurrence must be watched attentively. In illustration of the good
effects of stimuli in certain cases, it may be mentioned that the
cavities of abscesses are often speedily effaced by granulations, and
that obstinate sores frequently contract and cicatrise, after the
occurrence of a febrile attack, though they had previously shown no
disposition to heal.

In glandular swellings, Deobstruents, as they have been called, are
used; and with this view, mercury is often had recourse to; this
medicine, however, instead of producing a salutary effect, very
generally tends still farther to impair the constitution. Preparations
of iodine, exhibited both externally and internally, appear to be
sometimes of use when the swellings have become stationary, or are
inclined to subside. Iodine may be given in combination or not with
iron. It is a medicine exhibited very generally and indiscriminately,
and is very much more trusted to than it deserves to be. When the
tumours are irritable, fomentations may be employed, and advantage
taken of sea-bathing, warm or cold. The common adhesive or soap
plaster, spread on soft leather, or the ammoniacal plaster, are often
applied with advantage to indolent glandular swellings. Blistering is
sometimes resorted to with good effect, and in some situations pressure
may be usefully employed.

In the treatment of large indolent collections, it was proposed by
Mr. Abernethy to make a small and indirect aperture, and to evacuate
the contents of the abscess as often as the matter accumulated; but a
degree of constitutional irritation frequently supervenes upon this
proceeding, and the discharge becomes bloody, putrid, and mixed with a
considerable quantity of gaseous fluid. The discharge of blood probably
arises from the usual support being taken away from the vessels
ramifying on the surface of the cavity, in the same way that blood is
effused into the cavity of the abdomen, in consequence of the too rapid
evacuation of the serum in ascites.

Suppuration, more especially when extensive and long continued,
is attended with a peculiar species of fever, termed Hectic. This
fever is the remote consequence of local injury, or disease, whereas
symptomatic inflammatory fever is the immediate one. The incessant and
long-continued addition of pus to the blood may be the cause of hectic
fever. In cases of pulmonary consumption, pus globules are almost
uniformly detected in the blood. This fact has been noticed by Dr. Davy
and Mr. Gulliver. The pus is probably carried along the capillaries,
where it is always forming in chronic abscesses: in short, all the pus
formed is not separated from the blood. Hectic probably arises from
the never-ceasing addition of a little pus to the blood, inflammatory
fever from the sudden addition of a large quantity. In long-continued
disease, particularly internal, the hectic occasionally occurs before
the existence of suppuration is indicated; and it does not always
supervene upon suppuration, even though extensive. Hectic has been
supposed to arise from the absorption of pus; but pus cannot well be
absorbed without disintegration of its particles (and then it would
be no longer pus), for their diameter exceeds that of the more minute
bloodvessels and absorbents. Abscesses occasionally disappear, without
this event being followed by any unpleasant symptom.

Hectic fever is most apt to arise in constitutions originally weak; and
usually either from some incurable disease of a vital organ, or from
extensive affection of a part not essential to life; but it may also be
induced without any local assignable cause.

The general symptoms are those of a low and gradual fever, attended
with great debility; the pulse is frequent, unequal, small, and sharp;
the general surface is pale; there is flushing of the face, hands, and
feet; the skin, at one period, is cold and clammy, sometimes dry and
rough—at another, it is bathed in profuse perspiration, especially
towards evening; chills alternate with flushing; the appetite is much
impaired; diarrhœa supervenes; pale-coloured urine is voided in great
quantity, often with a lateritious sediment; there is want of sleep,
and great anxiety; the eyes are sunk, and of a glassy hue; the features
become changed; there is great emaciation; the patient, gradually more
and more weakened, falls into a state of coma, and expires.

A condition, somewhat resembling sympathetic fever, occasionally
supervenes in a constitution that has been suffering from hectic,
when any additional irritation occurs, and this fever has been called
_Irritative_. The sanguiferous system becomes more excited—the
secretions are suspended—the sensorium is disturbed; but still the
symptoms are accompanied with the peculiar debility characterising the
state of hectic. It frequently follows the opening of large chronic
abscesses by a minute aperture, in the manner formerly described and is
relieved only by free evacuation of the confined matter.

In the treatment of hectic, the local disease giving rise to the
symptoms, if it cannot be cured by other means, must be removed by
operation. Thus, if hectic is consequent on long-continued, but not
extensive, disease of bone, the affected portion is to be taken away;
if from extensive chronic disease of an arm or leg, the limb must be
amputated.

In general, the removal of the hectic cause is followed by immediate
melioration of the symptoms, even though the patient has been reduced
to an almost moribund condition: the feeble hectic pulse of 120 or 130
sinks in a few hours to 90, and becomes more full and strong; anxiety
and restlessness cease, and a patient sleeps soundly the first night
after the operation, who for weeks had scarcely closed his eyes; the
cold sweats and colliquative diarrhœa immediately subside, and the
urine loses its sediment; in effect, all the hectic symptoms disappear,
and are succeeded by such as indicate a marked improvement in the power
and energy of the constitution; and the rapidity with which these
changes take place is in many cases truly astonishing. Nourishing food,
wine, tonics, &c., must be given, in the first instance sparingly, and
afterwards gradually increased in quantity, according as the stomach
can bear them; for it is not to be overlooked, that incautious and too
liberal use of them may be productive of irretrievable evils, as the
action of the system may be increased beyond its resources, in the same
way as the imprudent application of stimulants to a part debilitated
by an excessive degree of cold causes its sphacelation, in consequence
of the arterial action induced being greater than what the power of
the part can support. The mineral acids may be useful in checking
the inordinate perspiration; opium, astringents, and absorbents, in
arresting the diarrhœa; but all are of little avail unless the exciting
cause is removed, and to this latter circumstance the attention of
the practitioner ought therefore to be chiefly directed. It is not
always quite safe, however, to free the patient at once of a great
suppurating drain. Upon the healing up of extensive and long-continued
ulcers, it is often necessary, in order to prevent oppression of and
congestion in the viscera of the chest, abdomen, or head, to insert an
issue or seton, and gradually withdraw it. In amputations also, more
especially in patients above the middle period of life, to rid them of
disease which has caused hectic and wasting, in consequence of profuse
discharge, it is often advisable to keep part of the wound open, so
that it may suppurate, heal, and dry up slowly.


_Mortification_, or the death of a part, is also one of the results
of inflammatory action, and the term has been subdivided into
_Gangrene_ and _Sphacelus_. Gangrene is that state in which the
larger arterial and nervous trunks still continue to perform their
functions; a portion of the natural temperature remains, and the part
may be supposed still capable of recovery. Sphacelus, again, expresses
complete death, when, putrefaction being no longer resisted, the part
becomes black, cold, insensible, and fetid; but, in general, the
distinction between the terms is not strictly attended to. A division
of more importance is into humid and dry, or traumatic and chronic,
gangrene; humid or traumatic being applied to mortification produced by
external injury; dry or chronic to that resulting from a constitutional
cause.

Mortification is not always a result of inflammation; it is sometimes
preceded by incited action of the vessels, sometimes not. It follows
as a matter of course that if inflammatory action is so violent as to
cause stagnation of blood in most or all the vessels of a part, and
this is continued, there must be a consequent failure of nutrition,
which will terminate in mortification.

Humid or traumatic gangrene frequently occurs without previous
inflammation, the injury being so severe as at once to deprive the
part of its vitality. Dry or chronic mortification is often unpreceded
by inflammatory action, or at least it is slight and of very short
duration. It is preceded by stagnation, or is at all events coincident
with this stagnation, not in the smaller vessels only, but in the
trunks leading to the affected part. In humid gangrene, swelling with
erethismus generally precedes the death of the parts; whereas in
the dry, whether the surface change colour immediately or not, they
shrink immediately. In the former they quickly lose their vitality,
and consequently retain a considerable portion of their fluids; in the
latter the process is much slower, and they become dry and shrivelled.

The most common remote cause of spontaneous mortification is a rigid
state of the arteries, most frequently met with in the inferior
extremities of elderly persons, in consequence of the deposition of
calcareous matter between the internal and middle coat; this calcareous
degeneration may be confined to a part of the limb, or may pervade
the whole of it, and even extend throughout the arterial system.
There are many cases in which disease of the arteries has existed,
though no gangrene occurred; but this by no means invalidates the
assertion, since, when arteries are thus affected, the part cannot
withstand sphacelus when exposed to any of its immediate causes. An
attempt has been made to connect mortification with an inflamed state
of the arterial coats. This opinion is not confirmed by experience.
Obstruction from coagulation of their contents, and inflammation of
the venous trunks, sometimes precedes death of the extreme parts in
old people, and seems to act as a direct cause. After wet seasons,
spontaneous gangrene has prevailed as an endemial disease on the
Continent, where rye is a principal article of food. The rye is subject
to a disease called _Ergot_; the grains become large, black, and have a
horny consistence; and the use of it, when thus diseased, is assigned
as the cause of gangrene. The patients who have suffered from the use
of this ergot or cockspur rye have experienced pain and heat, with
swelling, generally in the lower limbs, though occasionally in the
upper. These symptoms abating, the parts became cold, insensible, and
discoloured, and were gradually separated from the body. The disease
attacked patients of both sexes and every age, did not appear to be
infectious, and was frequently fatal. It has occurred in this country
from the use of unsound wheat. A tendency to mortification sometimes
arises from a peculiar state of the atmosphere, want of cleanliness,
poor and irregular diet, &c. Cancrum oris, for example, and sloughing
of the pudendum in children, occur in those of the poorer classes who
live in low, damp, and dirty situations; and little or no incited
action precedes the sloughing. The same may be said of the phagedænic
affections of the genital organs. Mortification and ulceration seem to
differ merely in this,—in the latter, a part which, from any cause, is
unfitted to remain a portion of the living body, is only prevented from
dying by absorption just as it is about to lose its vitality; whilst in
mortification the part perishes too soon, or in too great quantity, to
admit of absorption. Sloughing phagedæna is a sort of connecting link.

Mortification, to a greater or less extent, may be produced in any
constitution, and at any age, by the application of heated substances,
caustics, acids, &c.; by the effusion of acrid matter into the cellular
substances, as urine or putrid sanies; by the interruption of the
circulation and nervous energy, as from ligatures or improperly applied
bandages—or by natural strictures, as those in hernia and paraphymosis;
by continued pressure, more especially in such patients as have, from
long suffering and confinement, had the powers of the circulating
system weakened; and by violent contusions, as in fractures, compound
luxations, and gunshot injuries. A frequent source of mortification,
in inclement seasons and climates, is exposure to extreme cold. In
this case, the cold is not the direct, but the indirect cause; the
power of the parts is very much weakened by exposure to the low
temperature, and is thereby rendered incapable of resisting the incited
action which follows the stimulus of sudden transition from cold to
heat, even though the degree of increase in temperature should not
exceed that of the natural standard. That cold is not the direct cause
of mortification, has been undeniably proved by facts derived from
military practice. No symptoms of inflammation or gangrene occur when
the soldier is on duty, and continuously exposed to severe cold; but
they speedily present themselves after a rapid thaw has commenced, or
after the soldier has imprudently approached a fire. Soon after the
half-frozen person has begun to feel a little more comfortable from
sudden warmth, he becomes aware of pain, attended with a sensation of
itching in the extremities, generally the lower, which are considerably
swollen, and of a dull red colour; these, and other symptoms of
inflammation, are of no long duration, the action speedily runs its
course, and the part soon plainly indicates that gangrene has commenced.

When gangrene follows the tight application of a ligature, the death
of the part seems to depend more on obstruction to the circulation of
the blood, than on any diminution of the nervous energy, for we do
not observe that paralytic limbs are peculiarly liable to gangrene.
The surgeon frequently takes advantage of the fact that a part soon
dies when its supply of blood is cut off, or its return in the veins
interrupted; and has recourse to ligature for removal of parts, When he
considers it inexpedient to employ cutting instruments.

Mortification may be produced by the above-mentioned causes, either
immediately or consecutively; and it will occur in some constitutions,
or states of constitution, at some periods of life, in some structures,
and in some parts of the body, more readily than in others.

Inflammatory action is seldom so intense as to terminate in death of
the part, unless the power of that part has been diminished by previous
local or constitutional disease, or by injury; and the inflammation
preceding gangrene is all along attended by symptoms of so well-marked
debility, both local and general, that it is frequently designated the
Inflammatio Debilis. Of inflammatory affections, the erysipelatous
most frequently terminates in gangrene; in other words, the power of
resisting incited action is not so great in the cellular tissue and
skin as in other parts of the body.

[Illustration]

The period at which the symptoms of gangrene appear after an accident
varies, in general, according to the severity of the injury. As
was already observed, the part may be immediately deprived of its
vitality—if not, symptoms of gangrene sometimes appear within a few
hours after reaction has taken place; while in other cases, tension,
pain, and heat occur, and may continue for a longer or shorter time,
according to the degree of power remaining in the part. Tension often
exists to a great extent after severe injuries, from extravasation of
blood or serum; the functions of the vessels are thereby interrupted,
and gangrene is inevitable. As the action proceeds, the pain and heat
often subside—the parts become flaccid—dark-coloured serum is effused
beneath the cuticle, forming what are termed Phlyctenæ—the skin becomes
dull and livid—dark streaks extend along the limb, perhaps from the
colouring matter of the blood transuding, as in commencing putrefaction
in the dead body—air is effused into the subcutaneous cellular tissue,
causing a sense of crepitation when pressed by the finger—sloughs form,
either black or of an ash colour—and the gangrene involves a greater
or less extent of the limb. The mortification is here represented as
attacking a limb that had suffered from compound fracture. The dark
part around and above the protruded bone was in a state of sphacelus.
The dorsum of the foot and the integument towards the knee were only
gangrenous. The patient was advanced in life, and the state of the
constitution such as to induce a belief that there was a predisposition
to mortification. The removal of the limb was, under the circumstances,
reckoned inexpedient. In some instances, the mortification is most
towards the surface; in others, it is chiefly amongst the deeply seated
parts. Sudden cessation of pain is generally regarded as an unequivocal
sign of the occurrence of gangrene, especially in the internal viscera;
but it not unfrequently happens that the painful sensations suddenly
cease, whilst no gangrene supervenes, and that a part mortifies, whilst
the pain continues but little abated.

In compound fractures, dislocations, or severe bruises of the soft
parts, dark-coloured, prominent points occasionally appear, in
consequence of the effusion of bloody serum beneath the cuticle; in
these, however, the fluid is speedily absorbed, and the surface resumes
its natural aspect, the cuticle exfoliating and being reproduced;
and it is of consequence to know their real nature, for, if mistaken
for the gangrenous phlyctenæ, the inexperienced practitioner may be
alarmed, and, consequently, have recourse to very injudicious practice.

When the process of gangrene is checked, the skin immediately beyond
the mortified part becomes of a brighter hue, and is affected by a
more healthy species of inflammation, which ultimately terminates
in ulceration, with purulent discharge, and thereby forms what is
called the line of demarcation between the dead and the living parts;
the process, commencing in the integuments, gradually extends to the
deeply seated parts, so that the mortified portion is ultimately
attached to the living merely through the medium of bone or ligament.
Arteries appear more than any other texture to resist sloughing; and
those leading to a mortified part are found contracted and filled with
coagulated blood, so that the spontaneous separation of the sloughs,
and even incisions for their removal, made in sound parts, are followed
by little or no bleeding. This salutary change in the arteries may
be accounted for by supposing, that the inflammatory action which
leads to the separation of the dead substance from the living affects
the arteries at that point as well as the other structures, causing
adhesion of their internal surface, and obliteration of their cavities;
and the natural result is, that the calibre of the artery above
the obliterated point gradually diminishes in size, and the blood
coagulates up to the nearest collateral branch: but in consequence
of extension of the inflammatory action, the collateral branches may
also be obliterated to a considerable extent upwards, and thus the
contraction and coagulation in the larger trunk will also extend in
proportion. Besides, before the line of separation has commenced,
arteries cannot transmit their contents into the sphacelated part, any
more than into an extraneous body; so that the circulation of the blood
in them is as effectually obstructed as if a ligature were tightly
applied; in this way, also, the contraction and coagulation may be
accounted for.

Mortification is accompanied with great anxiety; coldness and
clamminess of the face and extremities; weak, irregular, and hurried
circulation; quick, short breathing; a cadaverous expression of
countenance; hiccup (which, however, often occurs in very slight
sloughing, or when no sloughing has taken place, in external or
internal inflammations, extravasations, &c.); by diarrhœa, vomiting,
and in hopeless cases, more especially of traumatic gangrene, by
delirium and coma; in fact, almost all the symptoms of severe
constitutional irritation are more or less fully developed. In some
cases, the patients are restless and unmanageable; in others, low
and dejected. The disease often proceeds with fearful rapidity to a
fatal termination, the patient becoming comatose from effusion within
the cranium; but in other instances, in which the vigour of the
constitution is greater, and the extent of mischief less, the system
bears up under the affection, and a separation is effected between
the dead and living parts. The danger is in general to be estimated
by a consideration of the size and importance of the part, and of
the age and constitution. The destructive consequences of sphacelus
arise both from a local and general cause; for the mere application of
putrid animal substance to a part still alive—the infiltration, for
instance, of dark serosity into the cellular tissue in the course of a
limb—causes a sort of inflammation attended with symptoms of diminished
power, and followed by constitutional disturbance; whilst the ultimate
extinction of life may be imputed to the effect produced on the system
by the part previously to its becoming sphacelated, and to the sympathy
between the system and the parts which are left in a weak and moribund
condition, and which seem endowed with a disposition to extend the
disease.

In the _treatment_ of mortification, no one would think of using
any means, local or general, so long as the cause remained; and it
therefore must in the first place be removed, otherwise the mischief
may speedily become irreparable; thus, a stricture must be divided,
irritating fluids evacuated, foreign bodies extracted, &c.

In chronic gangrene the cause is constitutional, and the means
employed must be directed accordingly. In general, the power of the
constitution requires support, though, in cases where much fever is
present, it may often be necessary to keep the patient on low diet:
exhibit salines and mild purgatives in the first instance. The effects
of food should be attentively watched, and its quantity increased
or diminished accordingly. On the subsidence of the fever, and when
sphacelus has occurred, wine and animal food must be given abundantly.
Stimulants, strictly so called, are not admissible until the line of
separation be formed, and their exhibition must then be regulated by
the circumstances of the case. Opium and other anodynes are found
necessary during the progress of the disease, to allay irritation and
produce sleep; opium has been recommended on very high authority, that
of Mr. Pott, in mortification of the lower limbs. The bowels must be
attended to. Peruvian bark was at one time supposed to be a specific
in this disease, but experience has not born out the opinion; it
seldom agrees in substance, and the decoction, with or without the
compound tincture or sulphate of quina, will be found much more useful
in supporting the power and tone of the digestive organs. After the
line of separation has been formed, and not till then, the surgeon may
interfere, and assist nature in her work, dividing the exposed bones
or ligaments by which the dead parts still adhere to the living; or
he may perform amputation immediately below the line of demarcation.
Amputation in the sound parts cannot be recommended: for vitality is
impaired throughout the system, and more particularly near and above
the line of demarcation, where, though the structure seems entire, yet
the incisions are made in parts really diseased, and which would almost
certainly and speedily mortify. In fact, amputation above the line of
separation, in whatever way performed, is seldom if ever productive of
advantage in spontaneous gangrene.

In order to prevent the occurrence of gangrene after exposure to
intense cold, the frigid part must be cautiously and slowly restored
to its natural temperature; first by being either placed in very cold
water, or rubbed with snow; afterwards, by the degree of warmth in the
applications, and surrounding atmosphere, being gradually increased.

In acute gangrene, and in robust constitutions, when the affection
arises from over-action, abstraction of blood is had recourse to with
marked advantage. In some cases it may be employed, but with due
caution, even after sphacelus to a slight extent has occurred. In
gangrene, purging and bleeding must not be had recourse to but with the
greatest circumspection; for it ought always to be remembered, that
however strongly they may be indicated, the time is not far distant
when they will be totally inadmissible, and when the weakening effects
of depletion will prove highly prejudicial, particularly in cases where
the mischief is proceeding rapidly.

The loss of blood is frequently beneficial in sloughing phagedena, as
is exemplified on the occurrence of spontaneous hemorrhage in such
cases.

When a portion of a limb, throughout the greater part of its substance,
is so injured that it evidently cannot recover, it ought to be removed
instantly, and before the constitution has suffered.

When gangrene follows inflammatory action, this is first to be
moderated, and then the strength by all possible means supported.

When only a portion of the soft parts of a limb is destroyed by
mortification, and it is likely that the member may be saved and prove
useful to the patient, measures should be adopted to hasten separation
of the dead parts, and reparation of the breach in the living.

After the separation of sloughs has commenced, the attention of the
surgeon is chiefly to be directed towards the constitution; it must be
supported and strengthened by nourishing food, wine, and tonics, or by
stimulants, if necessary. Bark in substance, acids, and other supposed
antiseptics, are of but little use.

The local applications which have been employed are numerous; poultices
of all kinds, charcoal, carrot, and effervescing; various lotions to
the surrounding parts, spirituous applications, such as several of
the tinctures, liniment of turpentine, balsams, &c., with the view of
correcting the fetor. But it is evident that such applications to a
dead part can be productive of no effect; the only beneficial result
that can be expected from such means is removal of the fetid smell,
which can be effected, if need be, by sprinkling a solution of the
chloride of soda on the body-linens and bed-clothes. Scarifications are
sometimes used; when these are made merely into the sphacelated part,
they can be productive of good only by allowing the escape of matter;
when they extend more deeply, they are injurious. This practice,
however, as will be hereafter noticed, is adopted with the best effects
when mortification is threatened.[7]

When the sloughs become loose, they must be removed bit by bit with
scissors; and when the sphacelated part has separated entirely,
the healing of the breach is to be promoted by judicious dressing,
bandaging, and by proper position.

In mortification of an extremity, in consequence of injury, removal
of the part by incision in the sound substance was formerly as much
dreaded as in chronic cases before the separation had commenced; but
such fears have now subsided, and the practice of delay has been in a
great measure relinquished,—amputation being performed in the sound
part, at a considerable distance from the mortified or even gangrenous
tissues, and during the progress of the disease, occasionally with a
favourable result. If the surgeon defer the operation until a line of
separation have begun to form, he will soon discover the danger of
his delay; the constitution will, in the majority of cases, rapidly
sink under the malady before the progress of the disease is in any
measure checked, or any attempt is made to throw off the mortified
parts. Two cases which lately occurred in my hospital practice, are
here introduced from the “_Lancet_,” to show how different the progress
is, and how opposite the practice ought to be. Both the patients made
excellent and rapid recoveries.

“Sarah Arnold, æt. 75, was admitted on the 26th of January. She has
been a person of great mental and bodily activity, and has enjoyed
excellent health from her infancy, until her present illness, although
necessarily exposed, from the nature of her occupation, a gatherer and
hawker of watercresses, to all varieties of weather. About six weeks
ago, without being more than usually exposed to cold, she was seized
with severe rigors. Two days afterwards she began to complain of slight
pain, with clinching of the fingers, which at the same time became
discoloured at the tips, and were partially deprived of sensation.
This at first did not give rise to much uneasiness, and no treatment
was employed; and it was not until a week after the commencement of
the disease, when the discoloration had passed the wrist, and the hand
had become dry and shrivelled, and motion and sensation in it were
completely lost, that a medical man was called in. Both internal and
local remedies were then employed, but without in the least retarding
the progress of the disease, which in about a fortnight from her
seizure had extended a little way above the middle of the humerus,
beyond which it did not pass. At present there is a well-marked line of
separation between the living and the gangrenous parts, but there are
two livid spots beyond it, on the outer side of the arm; on the inner
side, where the disease has extended a little higher up than the outer,
suppuration has already commenced. The integuments in the immediate
neighbourhood of the diseased parts are slightly reddened and tumefied,
and it is there only that she complains of some slight pain. The hand
and wrist are dry and shrivelled, but above this the parts are soft
and flaccid. Below the line of demarcation, the extremity is of a dark
colour, resembling the skin of a negro, and completely deprived of the
power of motion and sensation; but she complains of a disagreeable
tingling, referred to the fingers. The discoloured parts are quite
cold, and the pulse cannot be felt, even in the axilla. Though she
complains much of debility, the system seems to be but little affected.
The appetite is very good; the skin is moderately warm; the pulse is
98, and of good strength; the tongue is moist and clean. She sleeps
little. ℞. _Haust. c. Sol. M. Morph._ gtt. xxv. M. _Vini Rub._
℥iv. Water-dressing to the arm at the line of separation.

[Illustration]

“27. She continues much the same as yesterday; slept little, bowels
moved twice; tongue clean and moist; appetite very good; pulse as
before; heat of skin natural; intellect clear; no expression of anxiety
in the countenance. ℞. _Haust. Con. Vin._ Full diet.

“28. The suppuration on the inner side of the arm is more copious, and
the discharge is more fetid. The livid spots on the outer side of the
arm have not extended, and there is some slight redness around them.
Pulse 104, of good strength; tongue clean and moist; heat of skin still
natural; appetite good; bowels moved once since the last report.
Continue. A little _Sol. Chlor. Calcis_ to be added to the dressing.

“29. The dry and shrivelled state of the extremity has extended as high
as the middle of the forearm. The discharge is much the same as before
in quantity, but is more fetid. The separation between the gangrenous
and the sound parts, which had begun on the outer side of the arm when
she was admitted, is extending a little, both towards the inner and the
outer side. Pulse 90, of moderate strength; skin natural; tongue clean
and moist; bowels open; appetite excellent.

“30. Much the same as yesterday; sleeps a little better.

“31. The suppuration is more copious; the discharge extremely fetid.
The dead parts on the inner side of the humerus are gradually becoming
more detached. No change in the appearance of the livid spots beyond
the line of separation; pulse 102, of pretty good strength; bowels
continue regular, and the appetite is good. Cont. vinum et haust.

“Feb. 2. The separation of the gangrenous parts on the inner side
of the arm has advanced a little more since last referred to. The
livid spots have disappeared, with the exception of the largest,
where a small superficial slough has formed. The diseased parts were
removed to-day, the line of separation being fairly established, and
suppuration having taken place in a great part of its extent. The soft
parts were divided by means of a pair of scissors, cutting as near
to the living parts as could be done with safety; the bone was then
denuded as high up as possible, by passing a bistoury round it, and it
was then divided by the saw. There was no bleeding from the soft parts,
and only slight oozing from the bone, which was found to be alive where
it was divided. Cont. vinum et haust.

“3. Continues in much the same state as yesterday; pulse 104, of good
strength; tongue clean and moist; bowels moved once; skin natural;
appetite good; suppuration very free. Cont.

“5. Suppuration copious; a portion of the dead parts left have
separated, and left a healthy florid granulating surface. Continues
much the same.

“6. Discharge copious, and much less fetid; bowels regular; pulse 100,
of good strength; tongue clean; appetite good; wishes for more food. To
have an additional chop. Cont. alia.

“8. The greater part of the sloughs have separated, and have left a
healthy florid granulating surface; no change in the general symptoms.
Continue.

“9. The stump looks well, and the posterior part of the cut end of the
bone is covered by healthy granulations.

“In some notes of this case, kindly furnished me by the late Professor
Fergus of King’s College, who had an opportunity of watching the
appearances for some time before the admission of the patient here,
it is mentioned that the flow of blood in the veins was exceedingly
slow, and that hard knotty tumours could be felt in the parts before
they became sphacelated. These swellings all along preceded the
mortification. It is mentioned, besides, that the patient had a sort of
fit, but that it could not exactly be ascertained whether or not she
lost consciousness. Her left arm is said to have been motionless from
and after that time. There is considerable discrepancy in the accounts
of the mode of invasion, and of the duration of the disease, before the
line of separation became apparent. A period of six weeks is stated in
our case-book to have elapsed from the attack to the admission of the
patient into this hospital. It would appear, however, from the other
history, that not more than three weeks had passed over. The old lady
is not very distinct in her account; at one time she makes a statement
with great minuteness, and very soon after contradicts herself on
almost every point. When pressed on the subject, she states that she
got disgusted with her condition, became despondent and careless about
everything, and that her recollection is not now very good.”

“S.W., aged 16, was admitted March 12, under the care of Mr. LISTON.
She is a servant girl, of sanguine temperament and good constitution.
On Friday, March 9, she was cleaning the outside of a parlour window,
and stood on the sill. The window-sash, upon which she was depending
for support, being suddenly drawn down by a person inside, she was
precipitated into an area, a distance of fifteen feet. She was
immediately picked up, and conveyed to the hospital. The house-surgeon
detected a compound fracture of the ulna, and a fracture of the radius,
both fractures being a little above the wrist-joint of the right
arm. The fracture was adjusted, and the wound, which was inferiorly
to, and behind, the wrist, dressed in the usual manner. A dose of
house-medicine was administered; suitable directions were given in
case of the occurrence of pain or swelling; she was sent home, and
desired to remain quiet. The following morning (Saturday) she was
visited by the house-surgeon, who found her comfortable, but she had
passed a sleepless night. On Sunday morning the affected part became so
intolerably painful that she tore off the splints and bandages, which
one of the dressers of the hospital had a short time before readjusted;
in the evening she was in great pain, and the arm was much swollen.

“12. To-day (Monday) she was admitted into the hospital; water-dressing
was applied to the wound. The bandages were reapplied, and an anodyne
administered in the evening, with the effect of producing some rest.

“13. The pain and swelling were so great during the night that the
house-surgeon was called up to see her, and ordered the application of
fomentations; this morning she is much more comfortable.

“14. On removing the whole of the apparatus this morning early,
mortification was found to have taken place in the limb; at the time
of Mr. Liston’s visit in the middle of the day, the limb was very
swollen, the fingers were of a black colour, the forearm livid, there
were vesications near the elbow with fetid discharge. There was a good
deal of fever with slight delirium; pulse irregular, quick. Mr. Liston
considered the only chance the patient had was the immediate amputation
of the limb at the shoulder. The patient’s consent having been readily
obtained, Mr. Liston proceeded at once to the

“_Operation._—He first introduced a long double-pointed knife under
the acromion, and brought the point out at the lower and posterior
border of the axilla, by this means the joint was laid open; the flap
thus formed of a portion of the deltoid was raised, and the head of the
bone separated from its attachments. The other flap was formed from the
integuments and muscles in front. The axillary, and one other vessel,
required ligature. The edges of the wound were drawn together by three
points of suture, and cold water-dressing applied. One grain of muriate
of morphia was given. In the evening, several strips of isinglass
plaster were applied, and the edges approximated. The delirium ceased
after a short but refreshing sleep.

“15. Passed a good night; has had little pain; feels very comfortable
this morning; she is cheerful, and has little fever; pulse 86, regular.
The wound looks healthy.

“April 2. Since the above date, the patient has been gradually
improving in her health and strength, and she is now able to walk about
the ward.”

In gangrene occurring after exposure to cold, amputation should not be
had recourse to till after the line of separation has formed; and in
this case the constitutional symptoms are much less urgent, and the
object of the operation might be frustrated by its being performed in
parts, which would speedily become sphacelated. The amputation may be
performed either at the line of separation by cutting the ligaments
or bones, as was done in the case from which the accompanying sketch
was taken, and when the line of separation is well declared; or,
if by these means a good covering is not likely to be had for the
exposed surface, the incisions may, in these cases, be with safety and
propriety made in the living tissues, at the most convenient point.

[Illustration]

In gangrene arising from obstruction or injury of blood vessels, in
healthy constitutions, amputation must be performed early—for thus the
chance of ultimate success is increased, while the danger of delay is
the same as in cases of gangrene caused by severe injury.


OF ERYSIPELAS.

Erysipelas is an inflammation of the external surface, accompanied
with peculiar symptoms and appearances, the morbid action being
modified by the texture in which it occurs. According to the various
circumstances attending the disease, it has been divided into several
species: phlegmonous, bilious, œdematous, gangrenous, acute, malignant,
&c. The term _Erythema_ is applied to cases of rash or efflorescence,
unaccompanied with fever, swelling, or vesication.

Inflammation of the skin only, is marked by bright redness, not
circumscribed, and disappearing when pressed. By pressure, the
bloodvessels are emptied for a time, the part sinks and becomes pale;
but, on removing the pressure, it soon regains its former colour and
relative situation; when these circumstances concur, the part is said
to pit. There is no tension,—the pain is not throbbing, but of a
burning or itching kind, and there is often a degree of _œdematous_
swelling. Swelling does not occur to any great extent, however, during
the existence of the inflammation in the skin and rete mucosum;
but the parts sometimes become much swollen after subsidence of
the inflammatory action, the vessels having relieved themselves by
effusion of serum; and afterwards the œdematous surface often assumes
a yellowish hue. In some cases, the serous effusion is from the
first, more extensive than in others, and hence the term _œdematous_
erysipelas, or inflammatory œdema. Upon the decline of inflammation, a
serous fluid is often effused also in great quantity under the cuticle,
giving rise to vesications, resembling the blisters produced by the
application of boiling water to the skin; and from this circumstance,
erysipelas has been classed amongst cutaneous affections in the order
bullæ. The erysipelatous redness does not terminate abruptly, and is
not defined by a distinct boundary, as some have asserted, but becomes
gradually lost in the surrounding parts. It frequently involves the
contiguous parts one after another, and extends with great rapidity.
It often leaves one part suddenly, and attacks another, either in the
neighbourhood, or situated at a considerable distance; in other words,
metastasis takes place. The disease takes on this erratic character
without our being able to assign any good reason for it; and this form
of the disease is frequently attended by symptoms of typhoid fever.
When it disappears suddenly, or is repelled by cold applications,
affections of the internal organs sometimes supervene, as of the
bowels, lungs, or brain; the diseased action leaving the external
surface, and attacking the deeply-seated organs; thus, in a case of
erysipelas of the ankle and foot, the external symptoms disappeared
suddenly, and an affection of the lungs supervened, under which the
patient sunk; and in erysipelas of the face and scalp, the sudden
disappearance of the redness is frequently followed by delirium and
coma. Again, in acute disease of an internal part, the symptoms are
much meliorated, and often entirely removed, by inflammation of the
skin being induced artificially, or occurring spontaneously.

The integuments of the face and head are frequently attacked by
erysipelas, in consequence of wounds and bruises of the face or scalp,
even though very slight, and it often takes place here spontaneously,
as in other parts of the body.

Erysipelas commonly arises from constitutional derangement, as is
shown by the symptoms which precede it, and also by the efficacy
of internal remedies in checking its progress; in such instances,
external applications, unaccompanied with constitutional treatment,
produce little or no effect. It is often produced around a wound by
the employment of improper dressing, rancid ointments, or irritating
plasters, by a too free use of the part, or by the friction and
irritation of the patient’s clothes. It occurs most readily in those
who live freely, indulging in the imprudent use of spirituous liquors,
and whose constitutional powers are thereby considerably weakened. It
is also said to be sometimes caused by violent passions, as anger or
grief; and by exposure to cold, or to heat,—the former acting only
as a remote, the latter as an immediate cause. As an example of its
occurring in consequence of heat, it is a common remark, that cooks,
who are necessarily much exposed to the fire, are frequently the
subjects of erysipelas of the face; but in the majority of such cases,
there may be other causes in operation,—the abuse of ardent spirits,
and habitual overcharging of the system with stimulating food. It is
more commonly met with in summer than in winter. And in certain states
of the atmosphere, even in healthy situations, a degree of erysipelas
is apt to occur after wounds by operation or accident.

It is often periodical, especially in females who have ceased to
menstruate, always recurring at regular intervals; it attacks parts of
the body, most generally the face, and in some cases monthly, in some
once in the year, and in others once every two years. It sometimes
appears to occur as a natural means of relief from impending affections
of more serious nature, as of the system or of internal organs. Those
who have once been afflicted with the disease become more liable to its
attacks.

Erysipelas is generally preceded and accompanied with more or less
disturbance of the digestive organs. In _Bilious_ Erysipelas, the
portion of skin affected is said to present a more yellow colour than
in the phlegmonous, the derangement of the digestive organs is greater,
and hence the origin of the distinctive term; fits of shivering occur,
the patient complains of a bitter taste in his mouth, and the tongue is
furred and of a brown colour.

In the _Phlegmonous_, in which other textures than the skin are often
affected, viz., the subcutaneous and intermuscular cellular tissue and
the fasciæ, the pain is more intense, and of a throbbing kind; the
swelling is hard, more deeply seated, and more extensive; there is
considerable tension; and the redness is of a darker hue. Nausea and a
bitter taste in the mouth do not precede the erysipelatous appearance,
but the skin and tongue are dry, and there is great thirst. When the
disease begins to subside, then the foul tongue supervenes, with the
bitter taste and nausea.

Erysipelas, of a contagious and violent character, frequently occurs,
and is apt to spread extensively, in badly aired situations, where
a number of patients with sores are crowded together, without due
attention being paid to cleanliness and proper dressing.

_Hospital Erysipelas_, as this species is termed, is nearly allied to
that dreadful disease, Hospital Gangrene, and the two affections are
often blended. It comes on after operations, or in patients who have
sustained an external injury by accident. In unhealthy hospitals it
not unfrequently appears in previously sound parts, and without any
assignable cause; and, from its following the slightest wound, recourse
cannot be had with safety even to venesection, cupping or leeching.
It is a dreadful scourge in many hospitals, more especially during
particular seasons of the year—during hot, damp weather, and in spring
and autumn, attacking the patients indiscriminately.

Of late years Erysipelas appeared in the Royal Infirmary of Edinburgh,
during the wet and changeable summers which prevailed; some of the
cases were very severe, and a few terminated fatally. It was very
satisfactory, however, to observe that it did not spread as it used
to do formerly, that patients occupying the beds immediately around
those affected, though afflicted with sores and in indifferent health,
remained exempt from the disease; and that many of the most severe
cases did not originate in the house, but were brought from the crowded
and unhealthy parts of the city. The same may be said of the disease as
it has shown itself in the North London Hospital since it was opened
for the reception of patients up to the present time.

Hospital Erysipelas is for the most part preceded by violent
constitutional symptoms, derangement of the chylopoietic viscera,
shivering, brown tongue, and a bitter taste in the mouth; if there
is a sore on the body, it assumes a sloughy aspect; the surrounding
skin becomes of a dark red colour, and there is a feeling of tension,
accompanied with a burning pain. The erysipelas extends rapidly, and
generally terminates in suppuration and sloughing of the cellular
substance, or, if inertly treated, in immediate gangrene of the parts.
The concomitant fever is generally low, and though, in the first
instance, the circulation may be vigorous, symptoms of debility will
speedily appear. It will be more fully dwelt upon, along with Hospital
Gangrene.

In all cases of erysipelas there is more or less concomitant
fever, modified by the extent of the local affection—by the age
of the patient—by the previous habits and state of health—by the
constitution—and by other circumstances. The pulse is accelerated, and
is either of a sthenic or asthenic character, according to the state
of the system and type of the prevailing fever. There is headache,
languor, thirst, restlessness, and even delirium, especially when the
face or scalp is the seat of the disease.

Erysipelas may terminate in resolution. If this takes place in the
first stage of the disease, the redness gradually declines, along with
the swelling, the cuticle exfoliates, and the part regains its usual
appearance, the skin remaining loose and shrivelled. If it occurs after
vesications have formed, the effused fluid is absorbed, a scab forms,
and desquamates along with portions of the cuticle.

It may terminate in suppuration, when the inflammation has extended
to the cellular substance. This termination is most frequent when
the disease is situated in an extremity, seldom when in the face,
though small purulent collections occasionally form in the eyelids.
Circumscribed collections of pus often present themselves after the
disappearance of the erysipelatous inflammation; but the purulent
matter is generally diffused through the filamentous tissue, and is of
a thin, unhealthy appearance, and mixed with sloughs of the cellular
substance. By the infiltration of matter, the integuments, fasciæ, and
muscles are extensively separated from each other, in consequence of
which the parts frequently die, their nutritive supply being cut off.

Acrid sanious matter is often infiltrated extensively into the
subcutaneous cellular tissue round a wound or sore. The superimposed
integuments are of a dark brown colour, and the part is boggy.
Sloughing of the cellular membrane here takes place in consequence
of the infiltration, and not from inflammatory action having
been established. The affection has been termed Diffuse Cellular
Inflammation, but a more proper appellation is Diffuse Cellular
Infiltration; the cellular tissue, even where treatment is adopted at
an early period, can scarcely be prevented from perishing.

Erysipelas, if properly treated from its commencement, will seldom
terminate in gangrene of the skin. This termination is occasionally
observed, however, in patients whose constitutions have been extremely
debilitated.

In mild cases of erysipelas, attention to the state of the bowels, and
regulation of diet, will often be sufficient to remove the disease.
When there is much disorder of the digestive organs, and particularly
of the biliary secretions, emetics may be given at the commencement;
these are productive of but little good in the more advanced stage, and
their place is advantageously supplied by nauseating doses of antimony,
combined or not with purgatives. One-eighth of a grain of tartarised
antimony may be given in solution every hour, with or without a
due quantity of the tart. potassæ and sodæ, or Rochelle salt. The
hydrargyrum cum creta is often given with great benefit when the tongue
is dry and covered with a brown crust: it may be combined sometimes
advantageously with the compound powder of ipecacuanha. With the same
view calomel with antimonial powder may be exhibited. The exhibition
of saline purges is attended with great good in some severe cases.
Such medicines tend to subdue any arterial excitement that may exist,
evacuate the bowels, promote perspiration, remove the superabundant
bilious matter, and serve to restore the healthy functions of the
liver. In severe cases, more especially of phlegmonous erysipelas,
in which there is acceleration of the pulse, and a degree of febrile
excitement, general bleeding may be had recourse to; but it must be
employed with caution, for the symptoms of increased vascular action
may arise from constitutional irritation, and not be meliorated by the
depletion. The practice is superseded by the timeous and free local
bleeding from incisions, as will be noticed by and by. The exhibition
of the extract of aconite in this and other inflammatory affections, is
often followed by great abatement of vascular excitement, so that the
necessity for abstraction of blood is done away with. The medicine may
be given in doses of half a grain in substance, or dissolved in pure
water, and repeated every third or fourth hour. The sensible effect is
relaxation of the surface, and frequently profuse perspiration; the
arterial pulsations are diminished in frequency and force. The extract
of belladonna, in doses of one-sixteenth of a grain, may then be
substituted with great advantage, and often with the most extraordinary
effect upon the disease. In very many cases, the strength is from the
first to be supported by all possible means, by nourishing diet, by the
exhibition of wine, quinine, and other tonics; more particularly in old
people—in constitutions debilitated by disease—in unhealthy situations,
and when the fever is of a typhoid kind. Bleeding by leeches is not
admissible, for the leech-bites prove a source of irritation, and are
liable to suppurate; erysipelas has often been produced by leeching.

In erythema, the mere outer surface of the skin only being slightly
affected, and not to any very great extent, advantage sometimes
results from the application of nitrate of silver. A strong solution
may be pencilled upon the part, or, after being wetted, the affected
surface may be gently rubbed over with the solid caustic. The pain and
uneasy sensations in the part being thereby diminished or removed, and
extension of the disease seeming to be arrested. Discoloration caused
by such practice is of little consequence, as desquamation must follow.
It is questionable how far it may be safe to apply lunar caustic to any
extensively inflamed surface, more especially of the head and face,
lest metastasis should occur. The inflammatory action in the skin is
subdued by the application, whilst it may advance, in the cellular
tissue, to suppuration and sloughing, if other means are not adopted;
and from the hard and blackened state of the cuticle, the condition
of the subjacent parts is not readily perceived. The remedy is only
applicable to erythema, and most advantageously as a means of bounding
it. The line should be drawn at some distance from the affected
tissues; and if so, it is seldom that the disease oversteps it.

Local abstraction of blood, by puncture or incision, proves exceedingly
beneficial in cases of erysipelas, whatever its degree. It must be
borne in mind by the practitioner, when called to treat the disease,
that the state of parts is very various, and this may depend upon
the original nature of the disease, upon its site or duration. The
surface of the skin only may be affected—that and the subjacent
cellular tissue may be involved, gorged with serous, lymphatic, or
purulent infiltration—there may exist great tension of the parts, with
a sloughy state of the cellular tissue, established in addition to
suppuration—and again, there may be infiltration of the subfascial and
intermuscular tissues, leading ultimately to exposure and exfoliation
of bones or disease of articulations.

From inattention to these circumstances, the treatment being often
directed to the name of the disease, great discrepancy of opinion, as
to the most proper local management, has arisen; there has accordingly
been a controversy as to whether the blood should be drawn from mere
punctures from limited incisions, or from long gashes extending from
one joint to another.

In cases not very severe or extensive, when the skin only is affected,
the constitutional treatment already mentioned is first to be employed,
and then the affected part must be freely punctured with a fine lancet,
at numerous points, as recommended by Sir R. Dobson. These punctures
should reach the vascular layer, but not go deeper: the serous
effusion, if there be any, is thereby evacuated—the over-distended
vessels are relieved of a considerable portion of their contents—and
the œdematous swelling, with the formation of phlyctenæ, is prevented.
The part is afterwards to be fomented for half an hour, or an hour,
with bags containing chamomile flowers or hops; the fomentation,
repeated at intervals, proves highly grateful to the feelings of the
patient, allays any irritation which the making of the punctures may
have produced, and keeps the skin perspirable. Under this treatment,
every vestige of erysipelas will generally disappear in the course of
a few days. In more severe cases, especially in the extremities, the
parts must be freely incised. The incisions ought to extend through
the integuments and cellular substance, and their length and number
must be proportioned to the extent and severity of the affection. One
or two pretty free incisions, if made in the proper place, where the
greatest degree of boggishness, marking the disorganised state of the
tissues, is discovered, will generally suffice—the vast good and the
relief afforded depends partly upon the abatement of the tension,
in consequence of the evacuation of the effused fluids—upon the
unloading of the over-distended bloodvessels of the part, and upon the
acceleration of the suppurative process, which is often critical. The
constitution is, probably, relieved by the suppuration of the wounds,
and the consequent drain of the offending particles.

Some surgeons have disapproved of long incisions, alleging that they
are tedious in healing, and prefer making numerous small ones; but
it is difficult to understand how the cure should be more tedious in
the one case than in the other, when the actual extent of divided
surface is the same. According to my experience, several free incisions
are made with less pain than a number of trifling scratches, and
heal as soon, whilst by the former the purpose of the practitioner
is much better fulfilled: the same good effects result from them as
from punctures in the more slight cases, if they are made at the
commencement of the disease; and if the affection is in its advanced
stage, the effused fluid, and the sloughs, are discharged, and the
infiltration of pus, and destruction of parts in consequence of the
matter being confined, are prevented by its being allowed a free exit
as soon as it is formed. Incisions then are made both in the early
stage of the disease, and after effusion has occurred: in the former
case, they are justifiable, because they arrest its progress; in
the latter, they are absolutely necessary, to prevent its injurious
effects. The parts are to be fomented, and afterwards covered with
a common poultice, containing no oil or grease, or with soft lint
saturated with tepid water, and covered with oiled silk, to prevent
evaporation.

When the erysipelas has gone off, the incisions are treated as common
wounds, by dressing and bandage. After punctures, or incisions, more
or less blood is allowed to flow, according to circumstances. It often
escapes from the vessels of the part in great profusion; this, in many
cases, may be prejudicial or excessively dangerous. In the extremities
the flow can readily be arrested by elevation of the part, or by
pressure, for a short period. In erysipelas of the face, punctures
are preferable to incisions, as by the employment of the former the
countenance is no way disfigured; if, however, in erysipelas of the
scalp, the integuments become swollen, and present a puffy feeling,
whilst at the same time cerebral symptoms supervene, free incision or
incisions, through the whole thickness of the covering, and in the
direction of the fibres, must be made. If erysipelas be thus actively
treated, it may be safely affirmed that the disease will not often,
unless accompanied with symptoms of putrid fever, terminate fatally;
if these means are employed early, the constitutional disturbance will
be modified or prevented, and no derangement of the cerebral functions
will ensue.

Powders, such as flour, chalk, and camphor, &c., have been applied
to the erysipelatous surface, but are of little use, and, by their
irritation, frequently prove injurious on the bursting of the vesicles.
They are applied, according to some, with the view of cooling the
surface, and after all the part may be seen enveloped in folds of
flannel. Cold application, such as the spirituous and evaporating
lotions, containing vinegar and spirits, liquor acet. ammoniæ,
Goulard’s extract, &c., may, in many cases, afford temporary relief,
but their use is fraught with the utmost danger; for their direct
tendency is to produce metastasis, and if that be to an internal
organ of importance, the result is too generally fatal. Or if the
erysipelas, on leaving the part originally affected, attack another
also superficial, the local treatment has to be commenced anew. If
these lotions are to be employed at all in this disease, they must be
made tepid.

In case of the translation of erysipelas to any important part,
blisters may be applied to the surface which it has left, or to any
other in the neighbourhood, with the view of recalling the disease to
its original and less dangerous situation:[8] the actual cautery has
even been recommended. In the great majority of cases, however, such
means are unavailing.

In Hospital Erysipelas, purging cannot be carried to any great extent
with safety, and general bleeding is seldom if ever admissible unless
the patients previously robust and in good health, in whom the disease
has occurred in consequence of their being conveyed to a distance and
during hot weather, after an accident or wound, and in whom the fever
is of a violent inflammatory nature. In civil hospitals, the patients
are generally in a weak state before the accession of this disease; and
in their case, after the stomach and bowels are regulated, stimulants
are more requisite. Great attention must be paid to cleanliness, the
sores must be frequently dressed, and the same sponges must not be
used for different individuals: in order to prevent contamination by
the promiscuous use of sponges, it is better to clean the parts around
sores with lint or tow, and to destroy immediately such dressings as
have been used. The apartments must be well ventilated, and those who
are affected with the disease should be separated from the rest of the
patients. The local applications will vary according to the particular
circumstances of each case. Strong escharotics may be required to clean
the surface of the sores, and put a stop to the sloughing. The nitric
acid will answer the purpose well, and is less objectionable than some
remedies that have been used; such as the arsenical solution, or the
red hot iron.


OF FURUNCULUS AND ANTHRAX.

Furunculi, or Boils, most generally occur in unhealthy constitutions,
particularly in those individuals who are habitually addicted to the
use of ardent liquors: they seem to arise from, at least they follow,
disorder of the digestive organs. Their seat is in the skin and
subjacent cellular tissue.

They generally occur in those parts which are possessed of little
vitality, as in the back, buttocks, shoulders, the posterior part of
the neck, &c. They are seldom single, are often numerous, and vary in
size from a pea to a pigeon’s egg.

A boil is of a conical form, elevated above the surface of the body;
its base is hard and firm, whilst its apex is acute, soft, of a white
colour, and exceedingly painful; the pain experienced in the tumour
is severe and burning. From the comparatively trifling nature of the
affection, the assistance of the surgeon is seldom required, and hence
the apex of the tumour generally gives way either spontaneously, or
in consequence of being scratched by the patient, or rubbed by the
clothes; the purulent matter, which is generally small in quantity, and
mixed with blood, is thus discharged. This, however, is attended with
but little relief in bad forms of the affection; for at the lower part
of the cone is situated a considerable quantity of mortified cellular
tissue, which must be evacuated before the cavity can heal.

In this unhealthy species of inflammation, resolution cannot be
expected; on the contrary, suppuration is the natural termination of
the disease, and must be hastened by poultices and fomentations. A
simple or crucial opening, according to circumstances, must afterwards
be made in the apex of the tumour, so that the sloughs of the cellular
tissue may be permitted to escape readily. In the advanced stage, the
sloughs are the irritating cause by which the inflammatory action is
prolonged, and on their removal the cavity contracts speedily.

If there is much derangement of the digestive organ, it may frequently
be found necessary to administer an emetic. If the bowels are slow
and the liver torpid, calomel and antimony are highly useful, or
other mercurial preparations may be given, in combination with
active purgatives; if the state of the secretions is more natural,
these medicines may be administered in alterative doses. The mineral
acids are often usefully administered, with the view of removing the
disposition to the formation of boils. Twenty minims of the aromatic
sulphuric acid may be given twice or thrice a day in any convenient
vehicle. Anodynes are occasionally required.

[Illustration]

_Anthrax_ or _Carbuncle_ maybe considered as a severe form of boils.
It occurs in the plague, and is a characteristic symptom. It appears
in the same parts, and apparently from the same causes, as the boil.
The tumour is of a more flattened form, slightly elevated above the
surface, and frequently of great extent; the base is deeply-seated,
hard, and unyielding. The integuments are at first of a bright colour,
but afterwards assume a dark-red or reddish-brown hue. The pain is
violent and burning. The process of suppuration is very tedious, and
the matter that is formed is small in quantity. If the tumour is not
interfered with, ulceration occurs in its surface, producing various
apertures, through which the matter is evacuated, the discharge is thin
and unhealthy, excoriating the neighbouring surface; and the mortified
cellular tissue, remaining at the base of the swelling, keeps up the
irritation. The extent of a carbuncle is frequently great, both as to
width and depth; on the back, or buttocks, it not unfrequently attains
an immense size. In one instance, the whole posterior part of the neck
was involved; the cellular tissue, muscles, and tendons, sloughed;
and the vertebræ were ultimately exposed. In another case, the whole
occiput, the posterior and lateral parts of the neck, and the space
betwixt the shoulders, exhibited one continuous mass of carbuncle. By
making free incisions, procuring early separation of the sloughing
parts, and supporting the strength of their constitutions, both
patients recovered, though considerably advanced in life.

It seldom occurs in the face or head, and when it does, it generally
proves fatal. In a male patient in the Edinburgh Royal Infirmary,
aged forty-eight, a carbuncle of the size of a very large orange
was situated in the centre of the forehead; by active local and
constitutional treatment, he soon got well.

The affection is sometimes attended with typhoid symptoms, rigors,
profuse perspiration, nausea, vomiting, disordered bowels, loss of
appetite, anxiety, restlessness, difficult respiration, palpitations,
faintings, pale-white tongue, low pulse, pale or turbid urine,
headache, giddiness, drowsiness, and, in severe cases, with delirium.
In old or exhausted patients, the prognosis is unfavourable.

An early and free incision must be made into the tumour; if the
swelling is large or extensive, the preferable form of incision is
the crucial; the ill-formed matter is thus evacuated, the slough
exposed, and more readily allowed to escape. If the mortification
of the cellular tissue be extensive, and the sloughs prove firmly
adherent, the free employment of the caustic potass will be found of
much service, the half-dead cellular substance being thereby completely
destroyed, and the surrounding parts stimulated to a new and superior
degree of action, necessary for the removal of the mortified parts, and
reparation of the breach of surface. Poultices and fomentations may
afterwards be employed, followed by the warm-water dressing, medicated
or not. The stomach and bowels must be put into proper order by the
exhibition of suitable medicines; and the vis vitæ may be still farther
supported by the administration of tonics and stimulants. If, after the
separation of the sloughs, the exposed surface shall assume an indolent
or debilitated action, stimulating dressings, such as turpentine
liniment, or elemi ointment may be employed.

Such practice will be found sufficient to procure a speedy and
favourable termination of the disease, in this country, where we have
not to combat any of those malignant diseases with which carbuncle is
accompanied in other climates.


OF INFLAMMATION OF THE MUCOUS MEMBRANES.

Mucous Membranes and the skin are analogous in structure, somewhat
similar in function, and sympathise closely with each other in
health and in disease. Both are endowed with that peculiar degree of
sensibility which enables them to bear with impunity the impressions
of foreign bodies; and both are protected from the influence of these
bodies by an inorganic covering; the cutis and rete mucosum by the
epidermis; the corium of mucous membranes by a laminated epithelium.
They are the seat of all excretions, and by them all substances are
introduced from without into the system. The capillary portion of
the vascular system appears to have somewhat the same arrangement
in both; the distribution of blood to the mucous membranes being,
however, more copious. At the commencement and extremity of the
alimentary canal, they insensibly pass into each other by means of
an intermediate structure, of which the prolabium may serve as an
example. In particular circumstances, they change into each other,
both in appearance and in function. Thus, in prolapsus of the gut or
of the vagina, the discharge from the protruded mucous surface after
a time subsides, the rugæ disappears, the membrane becomes thickened
and indurated, and gradually assumes an appearance exactly resembling
that of the skin. In natural paraphymosis, the delicate membrane
which, in the healthy state of parts, lines the internal surface of
the prepuce, becomes converted into a cuticular covering. In neglected
and long-continued excoriation of the nates, the raw surface, which
was at first tender and irritable, and discharged a serous fluid,
becomes villous, less sensible, and discharges a fluid similar to a
mucous secretion. In sinuses also of long duration, the secreting
surface becomes changed, so as to resemble a mucous membrane, and the
discharge, from being purulent or gleety, becomes mucous, or at least
resembles a mucous fluid,

A mucous surface, when inflamed, has for a short time, perhaps,
at first, its functions suspended; it then furnishes a secretion,
increased in quantity, and but little changed in appearance from the
healthy fluid; afterwards the discharge resembles purulent matter, and
is termed muco-purulent. When, however, the inflammation is violent,
the discharge becomes bloody, or is altogether suppressed, and the
membrane is thickened. Inflammation of a mucous membrane is very
apt to spread with great rapidity, in this respect resembling the
corresponding affection of the skin. It is attended with a sense
of itching, and a burning pain. This pain is much increased by the
muscles surrounding the parts being thrown into action, as in expelling
their contents, more especially if these be of an acrid quality.
The membrane is thickened, and of a spongy appearance; its surface
is red, and sometimes covered with flakes of lymph; occasionally it
is much softened, and coated with a viscid adherent mucus; and it
would appear, in many instances, that, in acute inflammation, the
membrane is generally softened, whilst it becomes indurated from
chronic inflammatory action. When the inflammation is violent, and
consequently rapid, considerable quantities of lymph are effused either
on the surface of the membrane, or into the submucous tissue: and the
lymph subsequently becoming organised, the membrane is much thickened,
and a contraction is the consequence. The functions of a part lined
with mucous membrane are more or less deranged, in consequence of the
vitiation of the secreted fluid.

In inflammation of this tissue, metastasis is also apt to occur, from
one part of the membrane to another, and from the membrane to the
external surface. Cynanche, for instance, often follows upon erysipelas
of the face and scalp, and _vice versâ_.

The passages, the internal surfaces of which are invested by a mucous
membrane, are those subservient to respiration, nutrition, generation,
and the urinary secretions; in other words, the mucous surfaces are the
Pneumogastric and the Genito-urinary. Their particular diseases will be
treated of hereafter.


OF INFLAMMATION OF THE SEROUS MEMBRANES.

On such an extensive subject it is unnecessary to enter fully; not that
the inquiry is uninteresting, or that a knowledge of the diseases of
the internal cavities, and the mode of treating them, is not required
of the surgical practitioner before he can enter into practice, with
safety to his patients and comfort and satisfaction to himself, but
we have a very important class of diseases to bring under review in
a limited space, and it is properly the province of others to treat
of internal disorders, and to describe the best mode of alleviating
or curing them. It is, however, the duty of the surgeon to treat
the inflammatory affections of some of the serous membranes, and
the consequences of inflammatory action in most of them; and it is
therefore highly necessary that he understand the symptoms, progress,
and consequences of such actions. The affections of the serous
membranes are principally under the management of the physician; but
they not unfrequently follow wounds and surgical operations, and the
diseases of several of them are purely surgical. Inflammation of a
serous membrane is attended with heat and pain, aggravated by motion
of the parts and by pressure; the natural secretion is increased
in quantity, the process of exhalation being incited, and that of
absorption weakened; the serous fluid accumulates. The secretion
becomes altered in quality, and assumes a milky appearance; lymph
is effused, generally mixed with purulent matter, and floats in the
fluid, or adheres to the surface of the membrane, which is rough and
flocculent. The adherent lymph becomes organised, being penetrated
by numerous bloodvessels; and thus the original membrane is, in many
instances, much thickened, chiefly from the addition of new matter,
though also from enlargement of its bloodvessels and opening out
of the primitive tissues, principally the subserous cellular. When
inflamed serous surfaces, which have been altered, both in texture and
function, in consequence of inflammatory action, remain for a short
time in contact with each other, lymph is effused and penetrated by
bloodvessels from each surface; thus the new deposit is organised, and
forms a medium of connection. By this process the parts are intimately
united to each other, and consolidated into one mass; or are merely
approximated, and joined, at one or more points, by portions of lymph,
in some cases thin and narrow, in others extensive and of considerable
thickness; the adhering bands either extend in a straight direction,
from one surface to another, or interlace, forming a sort of network.
After adhesions of various kinds have been formed, they are often
lengthened and attenuated in consequence of the motion of the parts,
as is particularly the case with adhesions between the pleura costalis
and pulmonalis. When they have been of considerable duration, they
often resemble the original membrane from which they were deposited,
becoming thin and transparent, smooth on their external surface, and
furnishing a serous secretion. Not unfrequently, inflammatory action
in this tissue terminates in suppuration; and the pus, secreted by
the membrane, accumulates in the most dependent part of the cavity.
By collections of matter, whether serous, sero-purulent, or purulent,
within a serous cavity, the functions of the contained viscera are
deranged, much impeded, and in many instances morbid actions are
excited in them. The inflammation, whether it terminates in resolution,
or proceeds to serous effusion, adhesion, or purulent secretion,
is attended with constitutional disturbance, and the symptoms are
proportioned to the original intensity of the action, and the extent
and kind of its termination. The effusion of lymph, and consequent
adhesion, is, however, in many circumstances, a highly salutary
process, as in wounds and injuries of the hollow viscera: effusion of
their contents being thereby prevented, and the patient being saved
from the danger attending violent inflammation of those cavities and
their coverings, caused by the escape of a greater or less quantity
of irritating extraneous matter. Purulent collections also, in the
solid internal viscera, are thus allowed to discharge themselves
externally. The nature, symptoms, and consequences of inflammation of
serous membrane, will be more fully considered under the diseases of
particular parts.


OF INFLAMMATION OF TISSUES COMPOSING THE ARTICULATIONS.

Inflammation of the synovial surface occurs in consequence of wounds,
bruises, or sprains, and often from exposure to cold; from the latter
cause, the knee and elbow joints most frequently suffer, as they are
generally more exposed to its influence, and not so well covered with
muscular substance as the others. Constitutional diseases, such as
certain fevers, are followed sometimes by effusion of serous fluid into
joints. Purulent matter is also deposited in joints during certain
forms of suppurative fever; and this is attended by rapid change of
structure.

There is heat, throbbing, pain, and swelling of the part, sometimes
redness of the surface, and great constitutional disturbance; the
symptoms and appearances, however, vary much, according to the extent
of the joint which is involved. When part of the capsule is affected,
the inflammation spreads rapidly over all the surface; the synovial
membranes resembling the serous in this respect, as well as in healthy
structure and function. Like the serous, too, they are shut sacs, are
smooth on their surface, and furnish a secretion, the synovial, for
facilitating the motion between opposing surfaces; it is, however,
somewhat more glairy than the serous. Neither, in their healthy
state, are possessed of much sensibility, nor are ligaments, tendons,
tendinous sheaths, and bursæ, which two latter textures resemble in
every respect the synovial; when inflamed, they become most exquisitely
sensible. The incited action of the bloodvessels is followed by
increased discharge, which is less glairy and albuminous, partaking
more of the serous character. When the incited action soon terminates,
and the activity of the absorbents is diminished, the fluid accumulates
within the joint, producing _Hydrops Articuli_. This accumulation of
fluid in joints may take place without being preceded by any apparent
inflammation, and may remain a long time without any visible change
of structure in the membrane. The knee is more frequently the seat of
dropsy than any other joint.

When the action is more violent, and is not actively opposed, lymph
is effused on the inner surface of the membrane, or is deposited
amongst the ligamentous and cellular tissues external to the joint,
in consequence of which, the membrane and external ligaments become
thickened, and of an almost cartilaginous consistence. Serum is
effused into the more superficial cellular tissue, filling up the
hollows around the joint, concealing the protuberances of the bones,
and producing a globular swelling. The articulating surfaces become
ulcerated, and matter forms within the capsular ligament; or the
pus is deposited exteriorly to the joint, and gradually approaches
the surface. But although ulceration is so prone to occur in the
cartilages, the synovial membranes do not readily take on this action,
unless from the progress of matter, formed within the joint, towards
the surface. The synovial lining of the bursæ and sheaths of the
tendons are extremely indisposed to ulcerate; and it may be remarked,
that, while suppuration without ulceration is common in the synovial
membranes, the cartilages, on the other hand, afford frequent instances
of ulceration without suppuration, of which more particular mention
will be made in the sequel. The cartilage is occasionally swelled and
softened where the disease has long existed.

Along with ulceration of the cartilage, a portion of it may become
dead, or either state may occur separately; and in many cases, the
substance of the bone also becomes affected, of which two classes of
cases may occur, viz., great inflammation on the articular surface of
the bone, with separation of the cartilage by the ulcerative process
in this situation; and inflammation of the medullary web, leading to
atrophy of the cancelli, collections of pus therein, or even death of a
portion of the spongy texture of the bone, as will be more particularly
treated of in the chapter on diseases of the osseous tissue. These
changes often compose the primary disease, and to them the affections
of the synovial membrane and other parts succeed.

Such occurrences are attended with alarming disturbance of the
constitution, with fever, and even with the most threatening and
dangerous symptoms, such as delirium and coma. If the patient survive,
and the matter be evacuated from the joints by openings into its
cavity, hectic fever is almost certain to supervene.

An opinion has been broached lately by Mr. Key, that the ulceration
of cartilage was consequent upon the increased vascularity and
thickening of the synovial membrane, that the cartilage, in fact,
was removed by the action of the vessels ramifying in the membrane,
and the prolongations or fringes from it in its diseased condition.
Occasionally these fringes correspond, in a remarkable manner, to the
breach of surface in the cartilage; but again, ulceration is frequently
met with far removed from the membrane. It is also seen, in cases
where an opportunity is afforded of making the examination in the
earlier stage of disease, that ulceration exists to some extent whilst
the synovial membrane is unaffected. And certain cases, in which the
cartilage is affected with hypertrophy, and the common form of atrophy
of this part in old people, are altogether adverse to Mr. Key’s views.
When ulceration takes place at a point removed from the attachments
of the synovial membrane, it appears to proceed more frequently from
the attached than from the free surface of the cartilage; then the
adventitious membrane occupying the rugged spaces, and which under the
microscope appears highly vascular, is connected apparently with the
medullary web.

In acute inflammation of the synovial membrane, and in cases where the
cartilage is ulcerated, the pain is very intense, and the spasms of
the limb most distressing. This happens when the surface is ulcerated,
and perhaps to no great extent. We know that in the horse an ulcerated
hollow in the cartilaginous covering of the navicular bone, not so
large as to contain a grain of barley, will cause such lameness and
suffering as to render the animal so affected perfectly useless. If he
is not destroyed at this stage, as many valuable animals have been,
the mischief extends, and terminates in extensive disease of that
and the neighbouring bones and articulations. It is different if the
disease commence, as it sometimes does, in the human subject, in the
cancelli of the bone, and on the attached surface of the cartilage,
the free surface remaining some time entire and smooth. When the
synovial membrane is primarily affected by chronic disease, the pain
is in general trifling, often not complained of, and swelling of the
part, from effusion, into the joint or neighbouring bursæ, first
attracts attention, after it has existed, perhaps, in a slight degree,
for a considerable time. The joint is stiff, and pain is experienced
from extensive motion; on this account the patient is disinclined to
use it, and it is soon tired by the slightest exertion. The swelling
becomes more solid, though still remaining elastic, and the feeling of
fluctuation diminishes. Effusion of lymph follows that of serum, the
latter having been absorbed; the motion of the joint is still further
impeded, and the articulation is distorted; the patient keeps the limb
in the most easy position, generally that of partial flexion, in which
it becomes almost immovably fixed. The cause of the flexed position,
which is almost pathognomonic of knee disease, being preserved, seems
to be that the limb is insensibly brought into it in order to take the
pressure off the interarticular apparatus, the ligamenta mucosa and
alaria,—these swell—the muscles of the hamstrings get contracted from
habit, and a difficulty, even after the disease is completely subdued,
is often enough experienced in procuring complete extension. The
muscles, from disuse, shrink, the adipose substance is absorbed, the
shafts of the bones also are diminished in size, get into an atrophied
state, as the phrase is, and thus the whole limb is rendered slender
and wasted, so as to make the swelling of the diseased articulation
still more conspicuous. The bones are softened, and the muscles are
of a white colour, as in the limbs of the paralytic or bedridden,
and resemble more cellular than muscular tissue. The wasting of the
muscles and loss of power often precede the appearance of disease; this
is frequently observed in the shoulder-joint, the deltoid shrinking,
and almost disappearing, before any disease in the articulation
is suspected by the patient. Not unfrequently, also, this wasting
occurs without obvious cause, or any affection of the joint. When the
disease is advancing, the patient may feel no acute pain, but merely
a reluctance to use the limb; and from this, if long continued, the
muscles, and afterwards the bones, become wasted. Wasting of the limbs
in children, often of one of the lower, frequently arises from disorder
of the bowels, and the irritation and debility attendant on teething.
This must be distinguished from the wasting accompanying diseased
joint. The history of the case, the period at which the weakness of the
limb was observed, and its appearance, will lead to a correct diagnosis.

The swelling is often irregular, being more protuberant at one part
than another, from the fluid or the addition of solid matter being
accumulated where the least resistance is afforded; but the slighter
inequalities are generally filled up by œdema of the cellular
texture. As the disease proceeds, matter forms in the joint, and
is often attended with great pain and fever; or the pus is effused
into the bursæ, into the surrounding cellular tissue, or into the
filamentous tissue amongst the tendinous sheaths of the muscles in the
neighbourhood; being allowed to remain without an outlet, it at length
communicates with the cavity of the joint. Portions of the cartilages
are absorbed, though this, as already noticed, may occur at the very
commencement of the disease; the subjacent bone becomes affected by
ulceration, or perhaps its vitality is partially destroyed. When
matter has accumulated, a portion of the capsular ligament generally
ulcerates, the pus escapes, and is ultimately discharged externally.

When the disease begins with swelling, which is of a chronic character,
and produces but little inconvenience, and when the more urgent
symptoms supervene after the swelling has continued for a considerable
time, there is every reason to suppose that the disease has originated
in the synovial membrane, or perhaps in the osseous cancelli, and
this is generally met with in poorly fed and strumous subjects. But
when the first symptoms have been pain and stiffness of the joint,
without change of its appearance, and when the swelling has occurred
after these symptoms have been of some duration, then it is probable
that the cartilages are the primary seat of mischief. For the most
part, however, the symptoms have a general resemblance in most chronic
affections of the joints, and all the apparatus is sooner or later
involved. When the cartilage has been extensively absorbed, a grating
sensation is felt in moving the articular surfaces of the bones upon
each other. In consequence, also, of the softening and disorganisation
of the lateral and other ligaments, the affected articulation at length
becomes unnaturally loose, which is owing in some measure, also, to the
muscles being wasted and paralysed from pain and disuse. At an earlier
stage of the disease, the joint may be rigid from deposition of lymph
into the contiguous cellular tissue, and contraction of the muscles.

Purulent matter not unfrequently collects in the substance of the
bones, which in all cases ultimately become softened in a remarkable
manner. In many subjects, without actual disease of the osseous
tissue, the heads of the bones are so altered in consistence, are so
deficient of earthy matter, as to be easily cut with a knife. It has
been a matter of dispute, whether, in this affection, the articulating
extremities of the bones are enlarged or not; and the supposition that
they are always more or less increased in size, or hypertrophied, has
arisen from the extensive effusion and indurated state of the soft
parts being mistaken for this enlargement. In the first stages of the
disease, they are seldom, if ever, enlarged; but when ulceration of the
bone has occurred, new osseous matter is deposited to a greater or less
degree in the neighbourhood of the ulcer,—an attempt by nature towards
a cure, but too often an ineffectual one. The bones, in strumous
subjects, are often much enlarged, from collection of purulent matter
in their substance giving rise to a sort of spina ventosa. I removed
the upper extremity of a boy lately on account of extensive disease
about the elbow. The ulna to near the wrist was swollen enormously by
purulent collections in its medullary canal. In cases when the whole
of the articulating extremity of the bone is not enlarged, still that
portion which is more immediately concerned in the articulation is
often considerably expanded.

Frequently when the knee is the seat of the disease, the lymphatic
glands in the groin are enlarged; and when the elbow or wrist joints
are affected, there is often a similar enlargement of the glands in
the axilla: such glandular tumours have not rarely been confounded
with those accompanying malignant disease, and measures which were
absolutely necessary for the salvation of the patient, have thus been
delayed or neglected.

When the disease is extensive, and has endured for a considerable
period, hectic fever supervenes, and is aggravated after the abscesses
give way. The patient becomes much weakened and emaciated, and loses
his appetite; the pulse is rapid, with night sweats, diarrhœa, &c.;
and from a continuation of the hectic cause, the life is endangered.
In some cases, however, the health is restored, and the disease abates
spontaneously; in others, the disease is arrested, and a complete
cure accomplished, by the careful employment of such means as will be
afterwards mentioned.

The appearances produced by inflammation and consequent disease of
the synovial membrane, are the following. In the first stage, the
internal surface of the capsular ligament, and the rest of the synovial
membrane, is found of a red hue, its formerly colourless vessels being
now made apparent, from enlargement and consequent injection with a
greater quantity of red blood; and the serum within the cavity of the
joint is more abundant than in the natural state. When the disease
has been of longer continuance, the membrane is found considerably
thickened, its usual smooth glossy surface is destroyed, it is
irregularly flocculent, and frequently of a light yellow colour.

The interarticular adipose tissue also seems to be increased in volume,
from being infiltrated with a serous fluid, by the discharge of which
the diseased bloodvessels may have attempted to relieve themselves.
When the inflammation has been intense, or of long duration, lymph
is secreted, and deposited on the external surface of the membrane,
forming an intimate union between it and the ligaments, and producing
thickening of the external apparatus. Or the lymph is also effused on
the inner surface of the membrane, to which it adheres and becomes
organised; this is generally accompanied by the formation of purulent
matter; the organised effusion is often so extensive as to conceal
almost the whole of the synovial membrane, excepting portions of its
delicate reflexions which invest the articulating cartilages. By the
lymphatic deposit, to a less degree, the folds also of the synovial
membrane adhere to each other, whereby the motion is still farther
impeded, and the pain, when attempted, increased. Occasionally the
synovial membrane is found enormously thickened, much softened in
texture, and of a brown hue, when the disease has been of a very
chronic character. Along with these appearances, serum is generally
found effused, in a greater or less quantity, into the cellular tissue
exterior to the ligamentous covering. In cases in which the matter
has formed and remained long within the cavity of the articulation,
the synovial membrane and the ligaments become blended into one soft
mass, the internal surface of which is lined with a thick coating of
lymph, as in the case of common abscess. If purulent matter is effused
externally, and communicate with the joint, the capsular ligament will
be found to have ulcerated and given way at certain points, forming
apertures, usually of small size, and with ragged margins.

[Illustration]

All these appearances may exist without disease of the cartilages
or extremities of the bones; but generally they are also affected
at the same time. At first the surface of the cartilage is slightly
irregular and rough, and the change is not observed, unless on minute
inspection. Afterwards the surface is marked with small depressions,
which may be numerous, and are surrounded with irregular and somewhat
serrated margins. They gradually increase in depth and extent, and
the subjacent bone is ultimately exposed at one or more points, as
here shown. Often the greater part of the cartilage is removed by
absorption; the bone is exposed, opened out in its texture, softened,
of an irregular surface, and in some places excavated, containing a
thin ichorous fluid; the process of ulceration has also extended to the
osseous tissue. Sometimes scales of cartilage of considerable size are
either completely detached, having become dead, and been thrown off
by the natural process, and are found lying loose in the cavity of the
articulation; or they are all but separated, adhering by one or more
very slender attachments.

The incipient stage of such disease may exist without the synovial
membrane being much, if at all, affected; but when the ulceration has
made farther progress, all the articulating apparatus is more or less
diseased. It may be here remarked, that the synovial membrane may be
affected for a long period, thickened portions may extend over the
cartilages, and these may have lymph upon them and yet remain intact.

[Illustration]

The cure, resorted to by nature, and in which she may be much assisted
by the surgeon, is Anchylosis, ligamentous or osseous. New bone
is deposited in the neighbourhood of the disease, and the ulcers
become, as it were, cicatrised; the articulating extremities of the
bones are joined to each other by a firm osseous matter, either
universally disposed or consisting of processes extended between the
bones at various points: or again, in consequence of the effusion of
lymph into the cellular tissue, and the consequent thickening and
induration of that and of the fibrous tissue exterior to the joint,
this connecting medium is so strengthened and concentrated as to retain
the articulating surfaces in exact apposition; from one, and usually
from both, of these changes, the joint is securely fixed and rendered
immovable, or nearly so. In complete anchylosis, the cancellous texture
of the two bones, after some time, becomes perfectly continuous, so
that they in fact constitute but one bone, as seen in cut, p. 84. A
very perfect specimen of anchylosed knee joint is also delineated in
the cut above. But even after this happens, the disease is still apt
to recur from slight causes, the bony or ligamentous union being
disturbed or destroyed, and the original disease attacking the parts
with fresh activity; abscesses form,—may be extensive both in size
and number,—and thereby the health is again undermined. So that the
patient, after undergoing much suffering and risk, preserves, perhaps
only for a few years, a limb which is almost useless to him, and which
must be removed at last. In other cases, the union is permanent, the
disease does not return; by care and time the limb is brought into the
most convenient position, and proves of considerable service.

[Illustration]

The joints are often affected by rheumatic and gouty inflammation;
and there are three species of disease, tolerably distinct in their
pathological characters, generally attributed to these causes. In
one there is a deposit of chalky-looking matter, composed chiefly
of super-lithate of soda, on the articular surfaces of the synovial
membrane and cartilage, but most abundantly in the cellular tissue
outside the joint, an affection in which the cartilage is seldom
known to ulcerate. In the second, the cartilages are atrophied, as if
worn away by attrition, the articular surfaces of the bone being much
modified in shape, more or less denuded of cartilage, and remarkably
polished and hard, so as to have been compared to porcelain, as will be
described in another section. In the third, the fibrous tissue in the
neighbourhood of a joint is primarily affected, the synovial membrane
and cartilages not becoming involved till the disease is much advanced.
It is not uncommon in the elbow of middle-aged persons who have been
much exposed to the atmospherical vicissitudes, and is sometimes
attributed to the effect of mercury or syphilis. The periosteum
around the articular ends of the bones becomes swelled and painful;
the affection is very slow in its progress; abundant deposition of
adventitious bone takes place, often in short spiculæ, gradually
encroaching around the joint, which ultimately becomes involved. A good
specimen is here given. The disease was of twelve months’ duration, and
was attributable to rheumatic inflammation supervening upon sprain. The
affection involves extensively all the bones composing the articulation.

Although wounds penetrating the larger joints are attended with
danger, the synovial membranes are possessed of considerable powers of
reparation, and often heal readily after severe injuries. An occasional
result of inflammation is adhesion between the layers of the membrane,
but this is by no means so frequent as in the serous tissues. The
reparative power of cartilage is so low that the best termination that
can be expected from the ordinary forms of ulceration, is union between
the abraded surfaces. In experiments which have been made on the lower
animals, portions of cartilage which had been removed from their
joints were never reproduced, but the functions of the part were soon
restored by the cut surface becoming smooth. In like manner there is
occasionally to be seen in museums a circumscribed indentation in human
articular cartilage, as if it had been destroyed by a small ulcer in
this situation, which had cicatrized without any reproduction of the
destroyed tissue.


ON HYPERTROPHY AND ATROPHY OF THE ARTICULAR CARTILAGES, WITH EBURNATION
OF THE SURFACES OF THE BONES.

It has been already observed (at page 68), that the cartilages are
occasionally swelled and softened in cases of chronic inflammation; and
it now remains to notice instances in which they become hypertrophied
or atrophied, apparently without inflammatory action. Although these
affections are not likely to come often under the treatment of the
surgeon in civil life, yet they are of much importance to the naval or
military practitioner, since an accurate knowledge of them will lead
him to institute a careful inquiry when a man complains of inability to
sustain the fatigue of marching with the burden of a heavy knapsack;
and they are of considerable interest in a physiological point of view,
because they tend to show the inherent vitality of cartilage, and that
it is liable to serious organic changes quite independently of diseased
action in the surrounding tissues.

Some examples of hypertrophy of cartilage, principally affecting that
of the patella, have been described by Mr. Gulliver, and figured in the
third fasciculus of drawings from the Army Anatomical Museum. In these
the cartilage is swelled so as to form a ridge across the articular
surface of the bone, the hypertrophied part being perfectly smooth,
except where its continuity is interrupted by irregular fissures, as
if the perpendicular cartilaginous fibres were split into bundles of
variable size and shape. These cases occurred in young and middle-aged
men who died of pulmonary consumption; and it is probable that the
disease would be more frequently found, if it were more frequently
looked for, since it does not seem to have been accompanied by any
change in the surrounding parts, and would perhaps only be indicated by
weakness of a joint rendering it unfit for severe work.

The atrophy, or absorption of cartilage, is so frequently seen in
the joints of old subjects, that some authors have been disposed to
regard it rather as a physiological than a pathological condition.
It is, however, unquestionably a disease; and in the drawings above
mentioned, are some specimens of it from a soldier under the middle
age. The cartilage seems in the first instance to be opened out in its
texture, and numerous little villous processes appear on its surface,
often as if its fibres were enlarged after absorption of the substance
which connected them. The thinning sometimes takes place in patches,
occasionally in grooves, corresponding to the motions of the articular
surfaces; the subjacent bone becomes at length completely denuded,
and soon presents a polished porcelain-like surface, which is so
remarkable that it is commonly known under the name of porcellaneous
deposit. It is obvious that, when the disease has proceeded thus
far, the joint must become more or less deformed, and its motions
considerably impeded. Accordingly, old men are often seen at work
with much rigidity of the joints, particularly of the knee, which is
frequently projected inwards, from absorption of the cartilage from the
outer condyle of the femur and corresponding part of the tibia, with
a thinning and degeneration of the inner-articular cartilage into a
tissue resembling the cellular.

The hard, polished, and ivory-like appearance of the articular surface,
would lead us to suppose that it contained an unusual quantity of
earthy matter, yet an analysis by Dr. Davy, here given, shows the
contrary.


  _Composition of the Shaft._    _Composition of the polished
                                    Articular Surface._

  Phosphate of lime, &c. 58·8    Phosphate of lime   54·2
  Animal matter          41·2    Animal matter       45·8
                        ——-——                       ————-
                        100·0                       100·0


In many instances where the disease is of long standing, a deposit of
adventitious bone takes place around the articular surfaces, and this
may occur to such an extent as to produce anchylosis of the joint, the
articular extremities of the bone often presenting several irregular
depressions, and becoming variously altered in shapes, as shown in the
cuts, p. 86.

It is curious that the atrophy of cartilage is generally seen in
its early stage to attack the joints in pairs, and to occur also in
corresponding parts of the articular surfaces; a fact which coincides
with the disposition of caries to appear simultaneously or successively
in corresponding molar teeth.

Of the causes of the disease but little is known, although it is
generally attributed, like some other obscure affections, to the
effect of rheumatism. It often follows in old people upon long disuse
and confinement of a limb to one position, as during the cure of
fractures. A very valuable specimen was presented to me lately by my
friend Mr. Busk, of the Dreadnought hospital ship. The elbow had been
apparently subjected to great injury. The radius and ulna had been
fractured: the former had united, whilst a false joint had been formed
betwixt the portions of the ulna. There is profuse deposit of bone
around the elbow-joint, which must have been quite stiff, or nearly
so, as regarded flexion and extension; but the end of the radius and
corresponding articulation of the humerus are beautifully polished.
This polish is not unfrequently seen also upon disunited fractures, as
in the neck of the femur. Atrophy of the cartilages has been seen where
no rheumatism was ever known to have troubled the patients; and they
are more generally disposed to ascribe it to the effect of incessant
hard work. At all events it is comparatively rare among women, and in
the upper ranks of society; and the wasting often presents very much
the appearance which would result from the effects of attrition, as
if the wear of the cartilage had not been supplied by a corresponding
reproduction. It is probable, therefore, that the affection is
attributable to defective nutrition, somewhat allied to certain changes
in the cornea, which are known to proceed from this cause, and which
are also unattended by inflammation or the formation of pus.

The symptoms of the disease are generally obvious enough in the more
advanced stages by the crackling which may be heard when the joint
is moved; and in the early stage a grating may be felt by a careful
manipulation.


SCROFULOUS DISEASE OF JOINTS.

Affections of the membranes, ligaments, and bones, often occur in
persons of weak constitutions, and proceed very gradually. They have
been all classed under the general term of white swelling. They most
frequently present themselves without any assignable cause, or are
attributed to the slightest injuries. The disease generally commences
in the cancellated texture of the bones: these are soft and light, and
contain in their cells a quantity of caseous or tubercular matter. The
softness is attributable to an interstitial atrophy of the bony tissue,
as well as to an alteration in the proportion of its constituents; the
animal matter being in excess, with a corresponding deficiency of the
phosphate of lime. There is an increased vascularity of the medullary
membrane, and the cancellated texture contains thin brownish-looking
fluid instead of marrow. In cases of disease which has commenced
in the cancellated texture, there is hardly any pain at first, and
the progress of the disease is remarkably insidious. When the lower
extremity is affected, the child is observed to limp; the limb wastes;
it appears to be longer, partly from atrophy of the muscles, partly
from relaxation of the ligaments and effusion into the joint.

The term white-swelling, which ought to be discarded from surgery,
was at one time made to include all the different affections to which
joints are liable in weak constitutions—thickening of the parts,
with an external colourless swelling—collections of matter about
articulations, with or without an external aperture—effusion of fluids
into the cavities of joints, or into the bursæ—destruction of cartilage
by ulceration, or in consequence of portions becoming dead—absorption,
ulceration, caries, or intractable ulceration of the bone adjoining the
articulation.

Those under twenty years of age are most liable to chronic affections
of the joints, and they occur very frequently in children. Great
anxiety is often shown by friends of patients to account for chronic
disease of a joint, so as to save their whole generation from the
imputation of being tainted with scrofula. It is attributed, sometimes
correctly enough, to some injury perhaps trifling; to a sprain, or
twist, or squeeze from a tight shoe, or to a bruise from falling; and
it is no doubt true, that young or old people of the most healthy
constitutions, if thrown out of health from one cause, will present
all the appearances of scrofula, and become affected with chronic
diseases of the mucous membranes, glands, joints, or bones, from very
slight existing causes.

Such affections advance slowly; all the articulations are liable to
them; but those which are most subject to the disease are the hip,
knee, ankle, and elbow. Of these, the knee-joint is most frequently
affected, probably from the greater extent of cancellated and
articulating surface. In young persons of unhealthy constitutions,
the joints not unfrequently become affected one after another, and
superficial abscesses form, terminating in open sores. I was obliged to
amputate the upper extremity of a young lady a few days ago, in which a
metacarpal bone and its articulation, the entire chain of carpal bones,
the wrist and elbow joints, were all thoroughly involved in disease.


NEURALGIC AFFECTIONS OF JOINTS.

The joints, like other parts of the body, are very often the seat of
painful affections, without organic disease existing. These neuralgic
affections are often connected with, or followed by, hysterical
symptoms. They frequently also depend upon derangement of the digestive
organs,—upon the lodgement of irritating matters, sordes, or worms in
the intestinal tube; and when we reflect upon the extent of the lining
membrane, the expansion of nervous filaments, and upon the sympathy
which they hold with the whole system, we cannot be astonished at the
circumstance. Many cases of supposed hip-disease in children, with
the symptoms and some of the signs of it, have come under my notice,
which have yielded at once to the expulsion of offending matters or
worms. Some affections of joints seem to depend upon gouty diathesis;
others are intermittent: at one time the joint complained of is hot,
and somewhat swollen; at another cold, and bluish on the surface. In
these affections of joints the pain, indeed, is seldom constant: the
patient’s rest is not broken; there are none of the violent spasms
during sleep, which attend upon certain alterations of structure. The
pain is equally complained of when the part is touched with the utmost
gentleness, or when a thorough and searching examination is made, when
the joint is freely moved, and the articulating surfaces of the bones
are forcibly squeezed against each other. The pinching of the skin
causes pain. There is seldom throbbing, or heat, or swelling; though,
after long continuance of the diseased state, these may supervene to a
slight extent. The pain complained of is seldom referred to one point,
but to a large extent of the limb; and if the attention is diverted,
the examination may be carried to any extent, without complaint being
made.

Sir B. Brodie, who has done a great service to the profession by
directing attention to these nervous affections in his excellent work,
and in his lectures, notices that the knee, when the seat of pain, is
generally kept in the extended position, and this is very different
from what has been stated to be the position of one affected by
organic disease. The tumefaction following upon local treatment, and
especially when leeching and counter-irritants have been employed, is
sometimes, as he remarks, very perplexing.

This class of diseases generally affects females of delicate
organisation about the age of puberty, and in whom the menstruation
is irregular. Males in delicate health are also subject to similar
affections.


ON GROWTHS FROM THE SYNOVIAL MEMBRANE, AND LOOSE SUBSTANCES IN THE
JOINTS.

The synovial membrane is sometimes studded on its inner aspect with
loose fleshy or semicartilaginous substances projecting into the cavity
of the joint. The entire surface of the membrane is occasionally
covered with these bodies, which are of a white or yellowish colour,
and very variable in size and shape; the smallest presenting the form
of villi not much larger than those of the jejunum, the largest having
somewhat the magnitude and appearance of the appendices epiploicæ of
the large intestine, while many of an intermediate size approach in
appearance to a lemon-seed. In some instances the membrane is only
partially pervaded by them, and they are not unfrequently arranged like
a fringe around the edge of the articular surfaces. They are generally
very smooth on the surface, which appears to be perfectly continuous,
if not identical, with the synovial membrane. Their attachment is
frequently broad, and occasionally very narrow and pedunculated, often
merely filamentous, so that a little further thinning of the part, or
slight force acting on the body, would remove it from the capsule, and
throw it loose into the cavity of the articulation. The disease has
been most frequently seen in the knee, and sometimes in the elbow.

The affection is obscure in its nature; it is slow in its progress;
the joint is the seat of pain after and during exercise, probably from
the morbid processes interfering with the motions of the articular
surfaces. As the disease advances, the joint becomes swelled and
elastic, unattended generally by ulceration of the tissues within or
around it. In examining the part, when the articular surfaces are moved
on each other, it will be found that their motion is more or less
interfered with; and considerable irregularity in their action may be
felt by the hand placed firmly on the joint during the procedure.

Loose bodies may be found in the articulations, particularly in the
knee and elbow, under the circumstances just described; but we often
find others of a different structure loose within the capsule, which
may be throughout smooth and apparently healthy. These bodies are
extremely variable in size, generally rounded or oval, with a polished
surface; many of the smallest present the character of fibro-cartilage
or cartilage; the larger are often more or less modulated, very firm
and gristly, and sometimes contain a considerable nucleus of bony
matter. The articular ends of the bones are occasionally more or less
misshapen by the formation around them of knobs of adventitious osseous
substance.

The disease is common in the knee; and patients frequently go about
for years, who will tell you that they have something rolling within
the joint, which will often be found on examination to be actually
the case. It is obvious that loose bodies in the joint must prove
an obstacle to easy progression; and the smaller ones seem to be
particularly so, probably from becoming easily entangled by different
parts of the articular apparatus.

However difficult it may be to account for the cause of these
formations, the means by which they may get within the articulation
seems obvious enough. If a small knob of coagulated lymph should
form on the inner aspect of the membrane, the point of attachment,
as has already been noticed, might gradually become narrower, from
the motions of the joint or other causes, till the connection were
severed. But there is reason to believe that many of the substances
found loose in the joints are formed altogether in the cellular tissue
without the capsule; for it is difficult to conceive that they can
increase in size, or take on the ossific action in their centre, by an
act of independent vitality, after they have been separated from the
surrounding parts. Accordingly, dissection has occasionally disclosed
loose bodies within the knee-joint, and others of just the same
structure outside the synovial membrane, which was however protruded by
their pressure, and appeared to connect some of them by a pedicle only,
ready to break and allow the foreign body, with its covering of the
membrane, to fall into the cavity of the articulation.


AFFECTIONS OF SYNOVIAL POUCHES OR BURSÆ.

Bursæ are lined by a membrane, greatly resembling the synovial in
appearance, function, and disease. They are frequently the seat of
inflammation of an acute character; but in most instances the action
is of short duration, and generally terminates in an increase and
accumulation of the secreted fluid. The attendant pain is very severe,
and much increased by any motion of the neighbouring parts.

Occasionally a portion of the cellular substance, which is exposed
to pressure of motion, as over a prominent portion of bone, assumes
the appearance of a bursa, secretes a similar fluid, and is similarly
affected in consequence of inflammation. These adventitious bursæ are
met with in various situations. Bunion is a good example of such a
bursa thickened from long-continued pressure. They are seen on the
outer ankles of tailors, on the shins of boot-closers, on the forehead,
point of the elbow, &c.

Disease of the bursæ may occur from external injury, and they often
become affected subsequently to disease of the neighbouring joint.
If the action is violent, lymph is effused on the inner surface, or
external to its cavity, causing considerable thickening. The sac is
thus sometimes all but obliterated. Tumours, originally housemaid’s
knee, aggravated by continued pressure, are met with over the ligament
of the patella in almost a solid state. Occasionally the action
terminates in suppuration, pus being effused to a greater or less
extent into the cavity; and if allowed to remain or accumulate, the
abscess extends, and frequently communicates with the neighbouring
joint, which may not have been previously diseased. In chronic cases
of enlarged bursæ, especially of the bursal thecæ of the tendons of
the wrist or ankle, we not unfrequently meet with loose cartilaginous
bodies of various sizes, and of a flattened oval form, floating in
the accumulated fluid. These have been also supposed to be formed by
portions of lymph which have been deposited on the surface, condensed
in structure, and afterwards become detached.

When inflammatory action has commenced in a bursa, it must be subdued
by copious topical bleeding, along with the exhibition of purgatives;
in most cases general bloodletting will not be required. After the
inflammation has subsided, the parts remain swollen, from the effusion
either of serum or lymph; stimulating applications may then be employed
with advantage. In general, the ammoniacal plaster, or the brushing
over the surface with tincture of iodine will answer. Blisters are
sometimes employed with the same view. In obstinate cases, when the
tumour is of no large size, a seton may be passed, retained till
suppuration has taken place, and gradually withdrawn. Great risk
attends interference with bursæ of large size near joints or cysts
containing serous or glairy fluid in any situation. Even trifling
punctures into such have been sometimes followed by inflammation of
the inner secreting surface and violent constitutional disturbance.
When suppuration has occurred, it will in many instances be prudent
to evacuate the matter by one or more incisions, in order to prevent
farther mischief, especially if the bursa, a superficial one, is in
the neighbourhood of a joint. After the matter has been evacuated, the
cavity gradually contracts, and ultimately the bursa is completely
obliterated. Diseased bursæ, near the surface, and unconnected with
important parts, have been dissected out. The operation is not often
necessary, and in some situations attended with considerable risk.
Tumours, solid or nearly so, arising from diseased bursa of long
standing, may sometimes require to be so treated.


OF COXALGIA, MORBUS COXARIUS, OR HIP-JOINT DISEASE.

This disease has been supposed to commence in the cartilages; it
appears, however, to originate indiscriminately in the cartilage and
the bone, as well as in the membrane lining the capsule and investing
the cartilage and the ligaments; but whether it begins in one or other
of these tissues, it soon, if neglected, involves them all. It affects
patients of all ages, though children under twelve are most generally
its victims; and in these it often makes considerable progress without
its existence being suspected. The patient is observed to be a little
lame, and to be awkward in the use of the affected limb, but he
experiences little or no pain in the first instance; and if he does,
it is of a dull kind, and generally referred to other parts. Thus, pain
in the knee is generally the prominent symptom of this affection, and
occasionally pain is also referred to the ankle, or to the sole of the
foot: careful study and considerable experience are here required, to
guard the young practitioner from error in diagnosis. Parts remote from
the seat of morbid action have often been made the subject of treatment
in this and other affections; the knee, in morbus coxarius, has been
leeched, poulticed, blistered, and burnt, and that, too, when this
joint was not at all altered in appearance, and showed no symptom of
disease.

Again, and particularly in adults, the limb is easy only in certain
positions, and cannot be moved without great suffering; pain is also
complained of in the groin, and often immediately behind the trochanter
major. If an examination is made when the patient is thus halting, and
even though he complains of no pain, the limb is found shrunk, wasted,
and lengthened. The elongation of the limb occurs mainly in consequence
of the inclination of the pelvis towards that side. When the disease
has made progress, it has been supposed that swelling of the apparatus
of the joint, and effusion into its cavity, might separate the head
of the bone from the acetabulum, when pressure from the trunk was not
applied. The lengthening is often great, and its extent and cause are
ascertained by accurate comparison of the two limbs, laid in contact
when the patient is in the recumbent posture.

[Illustration]

The degree of lengthening is here carefully represented from a recent
case. But occasionally, even in the first stage, before destructive
ulceration has set in, in consequence of the pain and spasms, the limb
becomes remarkably shortened and retracted. This also will be found, on
careful examination, to depend upon the relative positions of the two
ossa innominata.

When the patient stands, the affected limb is considerably advanced
before the other, on which the weight of the trunk is chiefly, or
entirely, supported; the knee is generally bent, and the toes only
rest on the ground. In the advanced stages of the disease, and when
there is reason to suppose that ulceration of the cartilages has set
in, the patient, during progression, moves the affected limb with the
hands grasped round the thigh, and in bed it is moved by the aid of the
sound one. The spine is frequently affected, becoming bent in different
directions, to preserve the equilibrium of the body; and a deformity of
the trunk to a certain degree occurs, which, however, may be in general
easily remedied. The nates are much altered; they become flattened,
and those parts which are naturally most prominent are reduced to the
level of the others; the usual niche between the buttock and thigh,
in the erect position, is effaced, and the upper part of the thigh
is often considerably swollen. The alteration is at once manifest on
contrasting the healthy with the diseased side. Even from the first,
locomotion is difficult: in the morning, the movements of the joint
are constrained and stiff; afterwards, however, the patient walks with
more ease, though still by very slight exertion the limb is speedily
tired, and he is unwilling to use it. Pain is produced by pressing on
the groin, or by tapping on the trochanter, and by pushing the head
of the femur forcibly against the acetabulum. The inguinal glands
occasionally become enlarged. As the disease advances, the lameness is
more apparent; pain is produced and increased by motion, and by any
attempt to stretch, and more especially to abduct the limb whilst in
the recumbent posture. The emaciation of the member becomes more and
more visible. The muscles, as it were, are paralysed from inaction and
pain, abscesses form, and the constitution then sympathises remarkably;
hectic fever supervenes, with its usual train of symptoms.

[Illustration]

The circumstances attending the first stage of the disease in
childhood, in which the limb is lengthened, and there is no decrease,
but rather an enlargement of the parts composing the joint, have been
already described and illustrated. When, however, absorption occurs,
and the articulation begins to be destroyed, the second stage of the
disease commences, and the limb becomes then sensibly shortened; the
toes are turned inwards or outwards; in many cases there is every
appearance of dislocation of the thigh upward and backward; and in
others the limb is much bent, the toes only reaching the ground.
The ultimate position of the limb and degree of shortening will
depend much upon the extent to which the head and neck of the femur
is destroyed, upon the inclination of the pelvis, and also upon the
portion of the acetabulum which is most diseased. The joint becomes
tender, the slightest motion causing much pain, and the parts around
appear swollen. The patient retains the limb in the most comfortable
position, and it is generally bent upon the pelvis and inverted. This
may arise from relief being afforded when the psoas is relaxed, and
the pressure thus removed from the fore part of the joint. In many
cases matter forms behind, or rather below, the trochanter major, and
the collection often attains a large size. When the presence of matter
has been ascertained in this situation, it has been recommended that
an early opening should be made, on the supposition that the disease
arises from an acrimonious discharge into and round the joint, and
that, by the matter being allowed to escape, the cause of the disease
may be removed. The synovia has been compared by one old author to
bland oil, the vitiated secretion to oil of vitriol. Though the
principle is incorrect, still the rule of practice is important; for in
consequence of the long-continued presence of matter, accumulating in a
cavity which is not dilatable in proportion to the increase of purulent
secretion, the original affection will be much aggravated, and disease
induced in the neighbouring parts. But the existence of matter in the
joint could only be ascertained to exist in a very emaciated person.

[Illustration]

The formation of matter is preceded by great pain, and frequent
startings of the limb during sleep, accompanied with fever, and other
symptoms of severe constitutional disturbance. On the escape of matter
by the natural process from the capsule the painful feelings usually
subside. The abscess may appear, as already stated, near the trochanter
major, or in the back part of the thigh. Matter sometimes makes its way
into the pelvis, through a perforation in the acetabulum, thence it may
fall through the sacro-ischiatic notch into the thigh, and find its
way under the fascia, nearly to the knee; or again, it may present to
the side of the rectum, or even, as I have seen, burst into the bowel
and continue to be discharged thus for a long period. If the treatment
is neglected, abscess succeeds abscess; and in consequence of the
profuse discharge, which may be evacuated from one or many openings
round the joint, the patient is at length exhausted, and sinks. In
some instances the spontaneous cure by anchylosis occurs, as in the
instances from which these sketches are taken. In the one, the head and
neck of the bone had been almost entirely destroyed by ulceration,
before anchylosis had begun; in the other, the change is very slight,
but the head of the femur and os innominatum are inseparably united
by bone, and their cancellated texture runs into each other. Or when
the femur has been dislocated, which is a very rare occurrence, the
disease sometimes gradually abates, and a sort of new joint is formed;
the limb, after some time, may thus again become so far useful to the
patient.

[Illustration]

In many cases, the appearance which the various parts of the diseased
joint present, are similar to those which have been already described
when treating of affections of the joints generally. Frequently,
however, the osseous tissue in this situation is much more extensively
affected. Often the whole cartilage on the head of the femur is
completely removed, exposing the bone in an ulcerated condition; and
when the system has long borne up under the disease, the greater
portion of the head, neck, and even of the trochanter, is destroyed,
the extremity of the bone being completely altered in form, and
composed of a loose and spongy structure. A similar disorganisation
occurs in the acetabulum; the mucous gland is destroyed, the cartilage
is often wholly removed, and the margins of the acetabulum absorbed,
a large and flat ulcerated depression merely being left for the
reception of the diseased femur; in other instances the margins
remain unaffected, whilst the ulceration proceeds in the centre, and
the cavity is thereby much deepened. Not unfrequently the ulceration
proceeds farther, and an aperture is formed in the acetabulum, so that
matter accumulates within the pelvis. The opening is sometimes so large
that the femur is protruded through it. When matter has formed in the
soft parts round the joint, portions of the bones of the pelvis, in
contact with the pus, are ulcerated to a greater or less extent, and
sometimes these ulcers are surrounded by deposits of new bony matter.

From such changes in the osseous parts of the articulation the limb
is shortened, sometimes to a great degree, though no dislocation has
occurred. Indeed, dislocation is by no means so frequent a cause of the
shortening as is generally believed.

If the head of the femur has been dislocated, and if the disease in
the joint has afterwards subsided, the acetabulum is found to be much
contracted, with its margins smooth and little elevated, and, if
the patient survive for a number of years, it will be almost wholly
obliterated. But a portion of the dorsum of the ilium, upward and
backward, which is the most frequent dislocation in this disease, is
gradually absorbed, so as to form a sort of glenoid cavity for the
reception of the femur, the extremity of which becomes more solid in
texture, and more smooth on its articular surface. The remaining neck
of the bone is in the sketch here given turned forwards, and must
have given rise to great eversion of the toes. I have seen one other
specimen of this form of luxation. The limb is generally, however,
inverted; and what remains of the head of the bone consequently points
backwards. The consecutive luxation occasionally, also, though rarely,
takes place upon the pubis. Whilst a depression is thus formed, new
bone is sometimes deposited round its margins, whereby the cavity is
increased in depth, so as to resemble somewhat the original acetabulum,
the new deposit having become smooth and of a regular form.

[Illustration]


ON CERTAIN ALTERATIONS OF FORM IN THE HEAD AND NECK OF THE THIGH BONE.

[Illustration]

When treating of atrophy of the articular cartilages, it was observed
that, in the latter stages of the disease, the subjacent bone was
liable to become denuded, and its articular extremity more or less
deformed. Now one of the most interesting of these changes occurs in
the head of the thigh bone, which becomes polished on its surface,
flattened and expanded, with a corresponding alteration in the
acetabulum. In other cases the head of the thigh bone is somewhat
elongated, and the acetabulum becomes deepened in proportion, by a
deposition of new bone around its margin, as shown in the preceding
page, frequently to such an extent as to render the removal of the
head of the bone, even after the removal of all the soft parts by
maceration, almost impossible without fracture of the edge of the
socket. The head of the bone may also become still further misshapen,
and anchylosis result; while in some instances the new bony matter
presents in the form of nodosities, sometimes projecting towards the
cavity of the articulation. This cut represents a section of the
upper end of the femur of a labouring man, aged 49, who had fallen on
the trochanter ten years before death, and became gradually lame in
consequence, with shortening of the limb and anchylosis of the joint,
although he had never been confined more than a day or two on account
of the injury.

[Illustration]

[Illustration]

But there is another affection in which the femur may be shortened in a
comparatively brief space of time from absorption of the intra-capsular
portion of its neck, generally succeeding to a fall on the trochanter,
and sometimes occurring in young and middle-aged subjects. In treating
of fractures of the cervix femoris, it will be observed that retraction
of the limb is occasionally delayed for a while: hence the importance
of an accurate knowledge of those cases in which shortening of the
neck of the thigh bone may succeed to an injury short of fracture. The
deficiency of accurate anatomical details concerning such cases led to
a doubt as to their existence; but this question has been completely
put at rest since the history and dissection of two unequivocal
examples by Mr. Gulliver; and the annexed cut represents the changes
of form in the head of the bone, the shortening of the neck and
comparative length of the femora, in a young man from whom these bones
were obtained, and who walked about as many others have done, during
the progress of the disease.

In the above, and in many other cases, the shortening of the neck of
the bone is unaccompanied by any absorption of the articular cartilage
of its head. A section of another well marked specimen may be here
added. This bone also exhibits approximation of the head to the shaft,
from absorption of the neck. The head is somewhat flattened and
expanded, but the articular cartilage is entire, and of its natural
thickness. The acetabalum was diminished in depth, but enlarged
laterally, so as to correspond with the alteration of shape in the head
of the thigh-bone. The preparation was obtained from a man at 32, who
died at the General Hospital at Chatham of pulmonary consumption, after
a confinement of two years in hospital. Previously to his admission,
he had regularly performed his duty as a light infantry soldier, from
which it is plain that his limbs were then of equal length, although,
when the body was examined, the affected femur was upwards of one inch
and a half shorter than the other. From a careful inquiry after his
death, it appeared that he had, five years previously, fallen on the
trochanter, in consequence of which he often complained of pain in
the hip, but continued to do his duty long after, never having been
confined on account of the accident. It therefore results, that morbid
change had taken place during his long confinement in hospital, a
circumstance not very favourable to the recommendation by some surgeons
of the horizontal posture, as a remedy in such cases, and equally
adverse to the opinion of certain continental pathologists, who inform
us, that shortening of the neck of the femur is to be attributed to the
gradual operation of the superincumbent weight of the body.

[Illustration]

In old subjects, particularly in fat women, the neck of the femur is
often shortened, and becomes more transverse and brittle than natural,
from a true interstitial absorption or atrophy of the osseous tissue.
This has sometimes been described as a natural effect of age, but it
is undoubtedly disease, for in the greater number of old people the
neck of the thigh-bone presents its usual length and obliquity. The
affection is obviously a very serious one, as predisposing to fracture
of the part, under circumstances which render its reunion almost
hopeless.

_Treatment of Affections of the Joints._—After the infliction of
a wound, accidental or not, in order to prevent inflammation of a
joint from becoming violent, it is of the utmost importance to bring
the edges of the wound into close apposition. Sometimes neither
local action, nor disturbance of the constitution, supervene on an
opening, even of considerable size, being made into a joint, while the
slightest puncture often gives rise to the most dreadful symptoms,
both local and general. An incised wound, of no great extent, will be
sufficiently closed by the careful application of adhesive plaster,
and attention to the position of the limb; but if it is extensive
stitches become indispensable. The parts must be kept in a state of
complete relaxation and rest; cold cloths or iced water, allowed to
drop or run over the surface by capillary attraction, should be
assiduously applied. The patient’s bowels must be freely opened, and
he is to be kept on low diet. If inflammatory action occur, bleeding,
locally and generally, must be had recourse to energetically,
accompanied with warm fomentations to the parts; and, at the same
time, preparations of antimony, and other saline medicines, are to be
administered internally. If there be reason, from the symptoms, to
suspect the formation of matter, the parts ought to be attentively
examined, in order to detect its presence; and, when discovered to
exist, it must be evacuated without delay. In chronic cases, even local
bleeding to any great extent is inadmissible. In some a few leeches
may be applied, followed by counter-irritation, with advantage. The
employment of counter-irritation is, perhaps, chiefly to be trusted
to in the treatment of those more chronic affections of the joints in
which, from the painful feelings, there is reason to dread disease
of cartilage or bone. Of these, blisters are most in use; though,
from my own experience, I cannot much recommend them. Their constant
repetition is exceedingly annoying, and the slow progress which is
made towards a cure under their use is far from encouraging. Tartrate
of antimony, applied in the form either of ointment or of plaster,
is generally productive of much advantage, in the first instance, by
causing a great degree of superficial irritation, and relieving the
internal parts. After the pustules have been fully developed, its
use is to be discontinued till the surface be nearly whole, when it
is again to be resumed, if the recurrence of painful feelings should
demand it. Caustic issues have been much praised, and are occasionally
beneficial. An eschar is made by the caustic potass applied to the
skin, or by rubbing the bichloride of mercury, or any other caustic,
into scarifications made by the lancet: the slough separates, and pus
is discharged. Instead of promoting a continuation of the discharge, by
applying savine ointment, and inserting foreign bodies, or employing
other irritating dressings, it is better, when the sore begins to heal,
to repeat the application of the caustic to another part; or, when the
issue begins to dry up, to apply for a few hours a pledget of strong
antimonial ointment.

The employment of the bichloride of mercury, though a most efficient
escharotic, appears not to be unattended with danger, as in many
instances violent purging, with tenesmus and bloody stools, follow its
application. When swelling exists without pain, considerable advantage
may be derived from frictions and liniments of various kinds, with
careful bandaging. No applications can be of the least avail unless the
joint be kept completely at rest.

When there is no pain in the joint, when swelling exists, with or
without fluctuation, and there is every reason to believe that the
extremities of the bones are not much diseased, a cure may be, in
general, obtained by the employment of rest, support, and slight
superficial excitement. A practice which has been extensively and
rather indiscriminately pursued in diseases of joints and of other
parts, in affections of synovial membrane, ulceration of cartilage,
disease of bone, and even in cases of necrosis, is here detailed. It
is useful in proper cases, very hurtful in others. The joint is well
washed with soap and water, and afterwards rubbed with camphorated
spirits of wine: it is then covered with an ointment spread on lint,
and composed of equal parts of the unguentum hydrargyri cum camphora
and the ceratum saponis—in the majority of cases the mercurial ointment
would be better omitted—strips of lead, soap, or adhesive plaster are
then applied with a moderate degree of tightness round, from two or
three inches below the joint to the same distance above it: these are
covered with soap-plaster spread on thick leather, and the whole is
surrounded with a bandage, which extends from the extremity of the
limb. The bandage should be put on as far as the joint, before the
plasters are applied. The irritation produced on the surface tends
to check the deep-seated action, whilst the compression excites the
action of the absorbents to remove the effused fluids, and thus to
reduce the swelling: by the joint being kept completely motionless,
not the least salutary indication of the treatment, the cartilage and
bones, if ulcerated, are placed in a condition tending much to expedite
their restoration to a natural state. If they are diseased to such an
extent that the process of cicatrisation cannot be expected, a cure by
anchylosis is, by these means, much more likely to occur. The dressings
may be left undisturbed for the space of a week or two; at which
period, and, in many cases, sooner, they will be found much slackened,
in consequence of the swelling being greatly reduced. By repetition
of the application at intervals, the disease will, in a great many
instances, rapidly cease, and the joint resume almost its natural
appearance; but the period at which this takes place will be found
to vary much according to circumstances. If, however, the plasters
produce such irritation as to cause a return of inflammatory action,
their use must be discontinued till such action has been subdued by
the usual means. If the thickening of the external parts has occurred
to such an extent as to cause immobility of the joint, or if partial
anchylosis has ensued, the limb may be brought to the most convenient
position, the knee nearly, but not quite, straight, the elbow half
bent, and so on, by the cautious use of a jointed splint, fitted with
an extending screw. The practitioner is not to be deterred from having
recourse to the above practice, even when matter has collected and
burst externally, for sometimes under its employment the cavities of
abscesses contract rapidly. After the swelling and other symptoms of
disease have subsided, the joint is to be slightly moved, but with
great care; and, by a gradual increase of the movement, the natural
motion of the part may be ultimately restored. The great object in
treating chronic affections of joints must be to give them support, and
prevent motion as much as possible. This is effected pretty well in the
articulations, removed from the trunk, by the process above described,
modified according to circumstances. The filth and smell arising from
the plasters often becomes annoying, and, above all, the eruptions and
excoriations produced by them prove so troublesome that the application
requires to be discontinued. The principal and most essential
indication, that of securing repose to the affected parts, is fully
as well obtained by the application of well-adjusted splints. These
may be formed of lint soaked in a mucilage of gum acacia, as described
in the _Practical Surgery_, p. 150, or coarse linen may be smeared
over thickly with a coating of mucilage mixed with common whiting,
and another layer of linen spread over that. This is laid out smooth
and allowed to dry; portions of this sheet are cut to the form of the
affected joint, and, after being moistened, are applied and retained
by a roller. A firm case is thus formed, which may be afterwards lined
with lint or cotton wadding, and so reapplied. The most suitable
splints of all are made of leather, prepared without oil, softened
in warm water, and put on as above described. They are, when they
have become dry, pared and well fitted, then lined with wash-leather,
and padded as may be required. The employment of these splints gives
great relief in cases where further excited action has been lighted
up in the joint in consequence of the surface of the articulating
cartilage having become ulcerated from its free or attached surfaces,
or in consequence of matter finding its way into the synovial cavity
from the cancelli in the head of the bone. In cases, also, where the
painful sensations have existed from the first, and even before any
great alteration in the external form of the joint has taken place,
indicating primary ulceration of cartilage, this practice affords
immediate relief. These splints are easily applicable to the shoulder
or hip-joints; and, in the majority of instances, nothing further
requires to be done. It appears that Dr. Physick of Philadelphia had
been for many years in the habit of confining the motions of the
hip-joint by means of hollowed wooden splints, and his practice was
marked by very favourable results.[9]

It is seldom that local abstraction of blood is at all required, and
its employment in cases of morbus coxarius in weak constitutions,
which it generally seizes upon, is very questionable. Neither is
counter-irritation called for; and it is only in extreme cases, when
the suffering is intense, that small blisters over the fore part of the
joint, or a slight drain in that situation, or behind the trochanter,
is admissible. The nitrate of silver rubbed on the surface causes
vesication and discharge; and its early repetition is often followed
by good effects. The tincture of iodine, or a liniment containing
sulphuric acid, may sometimes be applied with the same view. There
is no doubt whatever, that much of the benefit that attends upon
counter-irritation, both in the human body and in the lower animals,
is to be attributed to the rest that is at the same time enjoined,
and often indispensable. It is thus that the firing and blistering
of horses does good in the majority of the diseases of tendons,
bursæ, bones, and joints. In some instances, it may be necessary to
have recourse to soothing applications, as fomentations to affected
joints, and to employ general antiphlogistic means suited to the age,
strength, and constitution of the patient. In the greater number of
cases in young subjects, after the stomach and bowels are unloaded, the
system must be supported by tonics and nutritious food; none are more
beneficial than the preparations of iron.

When the occurrence of anchylosis affords the only hope, this process
ought to be encouraged by rest, and the limb at the same time kept in
that position which will be most useful in after life; this will be
effected here also by the employment of splints.

In cases of disease of the knee, ankle, elbow, or wrist joints,
notwithstanding everything that can be done, the disease often runs its
course, abscesses form and give way, the patient’s health declines,
and he becomes emaciated and hectic. In such cases amputation, when
not contraindicated by internal disease, must be had recourse to, as
the only remedy. In some few instances, the excision of the diseased
extremities of the bones may supersede this operation; but this will
be discussed in a future part of the work. Every circumstance must be
well weighed before mutilation be resorted to; and there can be little
doubt that thousands of limbs have been saved by the employment of
the means above mentioned, which would have been otherwise doomed to
amputation.

Hydrops articuli will in general be got rid of by the use of friction,
either dry or with liniments; by stimulating plasters or by blisters;
and by the proper application of bandages. Mercurial ointments are used
in this affection, and often with very great benefit. Electricity has
been recommended.[10]

In neuralgic affections of joints, it is clear that the symptoms are
to be combated by general and not by local means, at least of a severe
nature. The patient must be amused and occupied, exercise in the open
air must be enjoined, and attention paid to diet. The state of the
digestive organs and secretions should be looked to, and corrected if
need be. Medicines directed to the regulation of the functions of the
uterus are essential in the majority of cases. When there is reason to
suspect the lodgement of sordes or worms in the intestinal canal of
children so affected, the balsam of copaiba, in doses of Ʒss., or
more, on an empty stomach, followed, if need be, by brisk purgatives,
will be found to answer admirably. Tonics, such as preparations of
iron, of quina, &c., are then given with advantage: many apparently bad
cases yield at once to such treatment.

As local applications, anodynes, fomentations, or cold lotions are
employed, according to circumstances. Frictions with gently stimulating
liniments, belladonna, veratria, &c., may be used as occasion
demands. The patient must be encouraged to use the affected limb as
much as possible; and the use of all severe and heroic remedies, as
bleeding, blistering, counter-irritation, setons, issues, or moxas,
discountenanced.


OF INFLAMMATION OF BONE, AND DISEASES THENCE ARISING.

Bones grow and are nourished by the same means, and are subject to
the same laws, with other parts of the system. Like all the tissues
of a white colour, particularly when their growth is completed, they
are less freely supplied with bloodvessels and nerves than other
parts. When incited action of the bloodvessels occurs in the harder
textures, sensibility is roused to an exquisite degree, and the healthy
and perverted processes often advance with great vigour and amazing
rapidity.

Inflammation of bone often arises from external injury, and in some
constitutions from very slight causes. Its occurrence is supposed to
be favoured by a syphilitic taint, but the inflammatory disposition
is much more frequently produced in a system vitiated by the abuse of
mercury. From the unyielding nature of the tissue, the pain attendant
on inflammatory action is dreadfully excruciating; it is also most
violent during the night, even in chronic cases, a circumstance which
does not admit of satisfactory explanation. The integuments over the
inflamed bone are swollen, and the tumour is œdematous; whilst a hard
and solid tumefaction exists in the more deeply-seated parts, caused
partly by enlargement of the osseous tissue and partly by effusion of
lymph into the cellular substance. The bone is imbedded in a gelatinous
or lymphatic effusion, situated mostly beneath the periosteum. This
membrane is more vascular than in its natural condition, thickened,
and at the same time opened out in texture. The bloodvessels of the
affected bone are much increased, both in activity and in size; and,
in consequence of enlargement of the vessels, and thickening of the
naturally delicate membrane on which the vessels ramify, the bone is
swollen and increased in size; its texture, as shown in the annexed
cut, is loose, somewhat resembling the cancellated structure, and
its surface is occupied by numerous foramina, which are enlarged in
proportion to the size of the vessels which they contain. The limb is
often enormously swollen and indurated. The gelatinous effusion beneath
the periosteum speedily becomes organised, nodules of osseous matter
project into it, and adhere to the surface of the bone frequently by
a narrow neck; these increase in number, gradually assume a solid
appearance: the bone is thus thickened, often to a very great extent.

[Illustration]

It has been supposed that the new osseous matter is deposited by the
vessels of the soft parts and of the periosteum; but there can be
little doubt but that it is secreted principally by the vessels which
ramify within the substance of the bone, and by the vessels of the
periosteum after they have entered the osseous tissue. Thus, in the
case of fracture, the new osseous particles lie between the periosteum
and bone at a distance from the broken ends, where the vessels are
enlarged and increased in activity, or adhere to fragments which have
been detached in part and retain their vitality, but not to the under
surface of the periosteum. There is no doubt that thin laminæ of bone
are now and then found attached to the periosteum, or impacted within
its substance; but this is to be attributed to that morbid action of
the tissue, to which this as well as several other membranes is subject.

When bone is extensively affected with inflammation, motion is
impaired; the muscles being displaced and retarded in their action by
the swelling and irregularity of the bone, by effusion of lymph into
their tissue and intermuscular spaces, and, perhaps, also, by their
partaking, in some measure, of the inflammatory action. Any attempt
to move the parts very much aggravates the patient’s suffering.
Occasionally inflammation attacks almost all the bones in the body,
and causes great constitutional disturbance, by exhausting the powers
of life: it sometimes terminates fatally. Bones become inflamed from
various causes. However it originates, the action ends, as in the other
tissues, in resolution, suppuration, or mortification. The effusion
by which the diseased vessels naturally relieve themselves in softer
textures cannot here take place so readily, or to such an extent as
to prove beneficial: the intensity of the action is with difficulty
subdued, and, consequently, resolution is comparatively rare. When it
does occur, the parts do not soon regain their natural condition, but
often remain considerably swollen and indurated, as is seen in nodes,
which continue during the life of the patient, without causing pain or
much inconvenience.

Suppuration on the surface, or in the centre, and partial or total
death of a portion of bone are the most frequent consequences of
external injury and incited vascular action; but suppuration in the
cancellated texture frequently follows very slight incited action
in those of a scrofulous habit. Tubercular matter exists, in all
probability, previously, and it leads very often to long continued
disease, curable only by operation. The matter may find its way to the
surface after long suffering and great constitutional disturbance.
Again, it may be confined for months, or even years, the patient
suffering from time to time the most excruciating agony. The bone
becomes thickened towards the surface by new deposit, as the cavity
is increased by ulcerative absorption, and relief is only afforded, a
correct diagnosis having been formed, by artificial evacuation of the
matter. In many cases small sequestra lie in the cavity; and though
the matter escapes naturally, or is evacuated, the patient’s strength
becomes worn out, and he perishes, unless the limb is removed. So
long as dead portions of bone remain, the discharge cannot cease
permanently. Fresh collections are apt to form in the soft parts if
the original openings close. It is no easy matter to discover or
remove sequestra from deeply seated bones. A section of the femur is
represented on the next page, showing a cloaca leading to the cavity
of an abscess in the medullary canal. The bone is very dense in
consistence, and irregular on its surface.

[Illustration]

Suppuration in bones is necessarily connected with loss of substance,
and condensation of the surrounding parts; and purulent collections
exteriorly, if allowed to press long, or if bound down by unyielding
sheaths, will sooner or later produce a breach of continuity, by
causing absorption of the outer lamella and the subjacent cancellated
texture. A similar effect is produced by aneurismal and some other
tumours. Such loss of substance is, in some instances, speedily
repaired, after removal of the cause, by effusion of new matter
from the surrounding bloodvessels of the bone; thus, in disease in
consequence of pressure from large aneurism, there is reason to suppose
that the healing process commences as soon as the aneurismal sac begins
to diminish, as after operation. But, as has been already observed,
the healthy actions are more vigorous in the softer tissues than in
bone; and when ulceration has occurred in the latter, it is generally
attended with weak action, and presents the same general characters
as an ulcer in the soft parts, connected with a feeble action of the
bloodvessels; the discharge is thin and fetid, absorption gradually
proceeds, and there is little or no effort towards reparation.
Cavities in bones are necessarily slower in healing than those in
the soft parts; the vitality and power of reparation are lower; and
there being no elasticity in the parts, the walls cannot come rapidly
together, contract and coalesce. It may tend to prevent confusion of
the two different morbid states, if we confine the term ulceration to
suppuration in, and absorption of, bone, whilst the vessels retain
a considerable power of action, throw out new matter, and procure a
reparation of the breach; and this condition of the osseous tissue
exists when the disease is situated in the surface of the bone, and
when it has been produced by an external cause. On the contrary, the
term caries will denote that peculiar kind of ulceration in which
reparation is hardly attempted by nature, and is with difficulty
obtained by the most active interference; and this disease will most
generally be found to affect the cancellated structure. The comparative
frequency of one or other of the terminations of inflammation depends
much on the kind of bone implicated.

CARIES most frequently occurs in the heads of long and in the
cancellated structure of the short bones, as unhealthy suppuration most
frequently takes place in the loose, fatty, and cellular tissues of
the soft parts. The formation of abscess in the cancelli is generally
preceded by deposit of tubercular matter, isolated or collected in
masses, and by the softening of this cheesy substance. When pus has
formed in the substance of a bone, the outer lamella, in the end,
becomes absorbed, and the effusion undermines the periosteum, which,
from the distension, also ulcerates: the matter then spreads into the
neighbouring cellular tissue, or makes its way to the surface, and is
evacuated, or, what is still worse, it escapes into an articulation.
The discharge is often continued, as already stated, in consequence
of a dead portion of the cancellated structure being imbedded either
in the carious cavity, or in the soft parts, where they sometimes are
lodged for a long period.

[Illustration]

It was formerly remarked that bones become highly sensible from incited
action; hence, during the progress of this disease, which is attended
with more or less inflammation, the patient generally suffers most
excruciating agony—so great, in general, as to prevent him, perhaps
for weeks, from enjoying the least repose. The affected part is
considerably swollen, but the enlargement is seldom so general, or so
great as in the diseased state of the ligaments and other apparatus
of a joint. White swelling, however, may be the precursor of caries;
or, in other words, a disease commencing in the bursæ, ligaments,
synovial membrane, or cartilage, may extend to the bone; and breach
of continuity, attended with weak action, be the consequence. In
caries the affected portion appears neither to possess vitality enough
to enable it to repair the breach, nor to be sufficiently deprived
of vitality to be thrown off by the surrounding parts. Considerable
portions of dead bone are occasionally found in carious cavities, in
the heads of bones, and even in the vertebral column. Small portions
are also detached piecemeal in the progress of ulceration, and
discharged; but it is seldom that the whole surface is thrown off, so
as to give place to a healthy and reparative action. When the parietes
of the cavity have remained a considerable time in this inactive state,
the surrounding vessels become more active, and the surface of the
bone in the vicinity is studded with nodules of new osseous matter.
The disease here delineated affected only a small portion of the
cancellated texture of the condyle. An ashy looking substance fills the
cavity, and this again was concealed in the recent state by lardaceous
matter. The elbow joint is unaffected, excepting only that, from the
deposit of new bone in spiculæ and nodules, and the condensation of
the soft parts, almost complete anchylosis had taken place. This
deposit is not always limited to the affected bone, if one only be the
seat of the disease, but frequently extends to those articulated with
it. The soft parts are commonly more or less thickened, and rendered
exceedingly dense by effusion of lymph into the cellular texture; and
so great is this thickening sometimes, that the knife is resisted as
if by cartilage. The discharge which proceeds from the carious part is
generally highly fetid, very profuse, is often poured through several
openings, and the surrounding skin is excoriated and generally of a
livid colour. The ichorous discharge occasionally dries up for a short
period and again breaks out more violently. The surface of the ulcer
is, in some cases, occupied by soft unhealthy granulations; in others
the earthy part of the bone is most prominent. When the parts have been
macerated and dried, the disease is often found to have proceeded more
in width than in depth, and the absorption has not reduced all points
of the diseased surface to the same level, thin portions remaining
somewhat elevated, and giving the part a cancellated appearance; and
there often project numerous minute osseous fibrillæ of considerable
length, which intermix with one another, and form a most delicate
network. In other instances, the ulceration has extended more deeply
and uniformly, and a considerable cavity is formed, with irregular
margins and surface; not unfrequently it contains dead portions of the
cancellated structure, in some of a dark, in others of a light colour;
or it is occupied, in the recent state, by a substance resembling
lard. The surrounding bone is much softened, and, after maceration,
becomes exceedingly light. The disease is generally confined to one or
two bones, but occasionally involves a whole chain. It may be limited
to a part of one bone in a joint, or may embrace the whole of it. Its
extent will depend on the severity of the primary action, or on the
degree and duration of the pressure of fluid which has been allowed to
exist, whether from the nature of the superincumbent texture or the
carelessness of the surgeon.

Interstitial absorption of those bones which are in the neighbourhood
of the carious ulceration often occurs in the tarsus and carpus. The
superincumbent integuments are livid and cold, and pain is felt in
the situation of the bones; yet they are not affected with continuous
ulceration, but portions of their substance are gradually removed
by absorption, so that they are much loosened in texture, and may
be altogether destroyed, or come to consist merely of a thin and
reticulated osseous shell, whilst at the same time their cartilaginous
surfaces often remain in their healthy condition.

The constitutional disorder attendant on caries is at first very great;
the sympathetic fever is followed by hectic, under which, and the
discharge, many patients sink. The general affection in some degree
keeps pace with the local in violence and duration. The irritation is
in some cases so great as to destroy the patient in a very few months
or weeks; but not unfrequently a constitution, by no means strong, will
be enabled to bear up for a long period under very extensive disease of
a bone. The paroxysms of pain and inflammation occasion fresh attacks
of constitutional derangement: this occurs till the patient’s health
and strength are exhausted, and he sinks under the disease, or is
relieved by the spontaneous or artificial removal of the cause.

A natural cure of caries may occur in consequence of the diseased
parts so far recovering their natural degree of vascular action as to
form granulations and repair the breach; but most frequently it is
necessary, for the accomplishment of this purpose, that incited action
occur to a very considerable degree; and the diseased parts, already
extremely weak, have not sufficient power to withstand the action, but
perish; whilst the action of the surrounding parts, not being increased
to such a degree as to overcome their powers, throws off the dead,
secretes a more bland discharge, and deposits healthy granulations,
which gradually fill up the cavity.

_Treatment._—In inflammation of bone, resolution must be brought
about, if possible; the other terminations are to be prevented by all
possible means, since they frequently endanger the limb, and even the
life, of the patient, and, at best, never admit of a speedy cure. To
promote resolution, blood must be drawn copiously from the part; and
general bleeding may also be required, though in some constitutions it
cannot be safely carried to any great extent. After local bleeding,
fomentations assiduously applied will tend much to relieve the
sufferings of the patient. Purgatives, nauseating doses of antimony,
and all safe measures likely to subdue the vascular action, must at the
same time be adopted. Free incisions through the periosteum sometimes
relieve the pain, and cut short the disease, the distended vessels
being thereby emptied; but such practice is only a last resource, when
the action has resisted all other means, and threatens an unfavourable
termination. If, notwithstanding the resolutive means employed, the
inflammation proceeds unabated, and suppuration occurs, the effused
pus ought never to be allowed to remain on the surface of the bone,
but must be evacuated by early incision. Otherwise the pressure of
the extraneous fluid will cause absorption of the bone, or detachment
of periosteum and superficial necrosis; the absorbed surface will,
in its turn, secrete pus, and thus an ulcer will be produced; and,
from the vascular action becoming debilitated in consequence of the
previous incitation, that ulcer will in all probability degenerate into
caries. Much mischief is produced by squeezing and bandaging tightly
the inflamed parts, as can readily be understood; yet such practice is
frequently adopted after suppuration. By it the inflammatory action
is excited anew, the formation of matter is very much increased, and
however useful such manipulation may be in stiffness of a joint, or
mere swelling of bursæ, and sheaths of tendons, still, in inflammation
and abscess of bones or joints it is extremely prejudicial, and from
its indiscriminate employment by those ignorant of the profession,
many limbs have been destroyed. General chronic periostitis, which
is produced by exposure to cold, or occurs after or during mercurial
courses, and is often supposed to be a symptom of syphilis, is relieved
by the internal exhibition of the bichloride of mercury, or other
mercurial preparations, combined with sarsaparilla and diaphoretics.
In many instances such an affection will yield to no other treatment;
and thus the practitioner is occasionally obliged to have recourse to
a somewhat paradoxical practice, that of giving mercury for a disease
which seems to have been produced by that mineral.

In inflammation of the short bones or heads of the long bones, if
the action does not yield to topical bleeding and becomes chronic,
counter-irritants must be employed. Blisters repeated are often useful
in subduing the remaining action, and in obstinate cases small caustic
issues are sometimes of service. During the adhesion of the eschar, the
best application is a common poultice or water dressing, which, on the
separation of the dead part, may be exchanged for any simple ointment,
it not being at all desirable in general to check the discharge and
heal up the breach of surface. Moxa is sometimes employed to make an
issue in these and other cases, but it is not superior in any respect
to the potential cautery, whilst its employment is generally very
alarming to the patient. The sores following the use of the moxa are
in some instances tedious in healing; and this may be ascribed to
the vitality of the surrounding parts having been diminished by the
application.

In cases of atrophy of bone, and where there is reason to suspect
the scrofulous or tubercular deposit to be going on, the affected
part should not be much used, and means taken to give tone to the
system. Preparations of iron are often exhibited with advantage. The
combination of iodine with iron may sometimes answer. Abscesses should
be opened early, so as to prevent extension of the mischief. In abscess
in the shafts of the long bones, it is occasionally necessary to make
an opening through the outer lamella by the trephine, so as to evacuate
its contents. Some instructive cases have been given by Sir B. Brodie,
illustrative of the good effects of this practice. I subjoin one out of
many from my own hospital practice.

“W. A., aged 22, was admitted Oct. 26, 1837, under the care of Mr.
Liston. He is a policeman of weak conformation. He states that when
about six or seven years of age he was first attacked with an aching
pain in the right leg, near its middle, and since that period has
been subject to three or four attacks every year. These usually were
experienced in the spring, during rough, windy, and cold weather, and
continued from one to three weeks. The pain was always aggravated at
night, and so trifling in the day that he was always able to go about.
These attacks ceased to occur when he was between 15 and 16 years of
age, and since that time, until last May, he has been free from them.
He states that up to about his 16th year the bone of the leg gradually
enlarged in its middle portion, but then became stationary, and at
the period of entering the police the difference between the bones of
both legs was not great; this was about two years ago. Since then he
has been accustomed to walk for a considerable length of time daily.
During some months he was obliged to do the night work, and then he
was much exposed to cold and wet. Last May, while thus engaged, he
experienced again an aching pain in the middle of the right tibia; this
was aggravated at night; and after a fortnight’s duration, during which
it became gradually worse, he was obliged to give up his duties in
the police, being unable to continue them any longer. At this time he
consulted the surgeon of the subdivision with which he was connected;
his treatment was fomentations to the leg and aperient medicine
occasionally. Not being much relieved by this, he afterwards ordered
the application of leeches on three several occasions, and mercury to
salivation. At the end of three weeks he returned to his duty. In the
latter part of September he was again attacked with pain during night
duty; this pain increased rapidly in severity, and after three nights
he was again obliged to leave duty. He was now treated again with the
frequent and copious application of leeches at different intervals,
and likewise took some pills, which did not affect his mouth. This
treatment, with frequent fomentations, was persevered in for a month,
but without permanent benefit, and then he was brought to this
hospital. Has never had any syphilitic complaint.

“_Present state._—Has an enlargement of the tibia about its middle
third, of a diffused character, and which seems to extend a good
deal inwards and backwards; in this part he experiences a throbbing
and lancinating pain at night; during the day he is in general easy;
at night there is considerable heat and swelling in the leg; tongue
whitish; appetite good. The following pills were ordered:—℞.
Bichloride of mercury, two grains; powder of gum guiacum, two scruples;
oil of sassafras, ten minims; extract of sarsaparilla, four scruples.
To be divided into twenty-four pills, of which let two be taken three
times a day. Apply eighteen leeches to the affected part.

“Nov. 4. The leeches were repeated; much the same.

“8. Symptoms as before. As he complains of pain over the eyebrow, with
nausea, let the mercury be left off. A variety of constitutional and
local treatment has been pursued during Mr. Liston’s absence from the
hospital, but without affording any relief; the patient’s nights were
passed in great agony, and his general health began to suffer. On the
27th, after consultation with Mr. Fisher, the surgeon to the Police
Force, Mr. Liston had the patient carried into the operating theatre.
He made an incision along the spine of the tibia of about three inches
in extent; another shorter one was made to fall on this at right
angles from the inner side. The surface of the bone thus exposed was
perforated to the depth of fully half an inch by a small trephine. A
very dense circle was removed from the perforation; still the fluid,
which was suspected to exist, did not appear. Mr. Liston, encouraged by
the intense pain complained of as the process of perforation proceeded,
again applied the crown of the instrument, and after a few more turns,
brought out a further circle of considerable thickness, and this was
forthwith followed by a flow of well-digested purulent matter.

[Illustration]

“28. Complains of no pain comparatively; slept well last night after
an anodyne draught; has felt much relieved since the operation; a
good deal of matter was discharged from the sore during the night;
water-dressing to be applied to the wound.

“30. Slept well without any anodyne the last two nights. The relief
afforded by the operation is felt more now than it was at first. The
wound discharges a good deal. A tonic mixture, containing infusion of
gentian, sulphate of magnesia, and sulphuric acid, was ordered.

“Dec. 2. The wound looks florid and clean; granulations are springing
up; general health very much improved.

“4. The edges of the wound are thickened by the granulations; the
discharge from the wound still considerable; feels quite well in health.

“12. The wound continues much the same; the rollers have been
discontinued.

“14. Feels himself gaining strength daily; can walk without pain; wound
is contracting and hard; granulations seem to lessen the depth of the
opening in the bone; there appears to be no sequestrum.”

When caries is fairly established, and the integuments have given
way, the best and most successful proceeding is that pointed out by
nature—destruction of the diseased portion; and the means must vary
according to the particular circumstances. In many cases, nature seems
to wait but for the separation of the sickly parts, either by accident,
or by the interference of art. The means are to remove, partially or
wholly, the diseased part, or to effect such a change of action as will
throw it off. The first indication will be accomplished by trephines,
scoops, saws, and forceps; the second by active escharotics; frequently
both are required.

If there be extensive disease in the medullary canal of a bone, several
perforations may require to be made, and these may be connected by the
use of a small saw, or the cutting forceps. The diseased cancelli, thus
exposed, can be readily removed by the scoop or graver, as recommended
by Mr. Hey, primus, in his excellent work. If, with the probe, it
is ascertained that a portion of the cancellated texture has become
dead and loose, it is to be removed after dilatation of the external
opening. It may frequently be difficult to distinguish in the effused
blood, between what is diseased and what is not; it will often be
necessary afterwards to cauterise freely the exposed surface, and
for this purpose the oxidum hydrargyri rubrum ought generally to be
preferred. The slough will soon be thrown off, and healthy granulations
fill up the breach. The application of the actual cautery may be by
some considered necessary: at one time I employed this remedy very
extensively in caries, and occasionally with very good success; I have
since, however, been led to change my opinion, and am now inclined to
prefer the potential cautery already mentioned. By the application of
the red-hot iron, the diseased portion is destroyed effectually, but
at the same time the vitality of the surrounding parts is often very
much weakened and their power of reparation diminished, so that they
are incapable of assuming a sufficient degree of action for throwing
off the dead part; their action being increased whilst their power is
diminished, they may become affected with caries, and thus, instead
of being arrested, the original disease will either be increased,
or extensive necrosis may take place. The red oxide of mercury is
not calculated to produce such bad effects; it does not spread or
insinuate itself into the bony tissue, as liquid caustics are apt to
do; and it is sufficiently powerful for complete destruction of the
diseased parts. It will be necessary to keep the wound open, by proper
dressings, till all the dead portions of bone be discharged, and every
part of the parietes of the cavity produce healthy granulations: if
the discharge be offensive, its fetor may be corrected by the use
of spirituous applications, such as the tinctures of myrrh, opium,
or aloes, separately or combined. After healthy granulations have
appeared, and the cavity has begun to contract, light dressing is all
that is necessary.

In operating on the carpal and tarsal bones for removal of caries, the
surgeon must be well acquainted with the connexions and relations of
the parts. If one bone is diseased, its removal will be sufficient; if
several, the operation becomes more painful and difficult. When one
only of the tarsal or carpal bones is almost completely destroyed,
and the surfaces of those articulated with it are also more or less
affected, it is not sufficient or safe merely to remove the loosely
attached portions of the one primarily attacked; the diseased parts
of those surrounding it must also be taken away, and it will often be
necessary to apply the caustic afterwards. In caries of the distal
range of bones, the bases of those supported by them are in general
involved, and must also be removed. If one only is diseased, with the
base of the metacarpal or metatarsal bone attached to it, the removal
of these will be enough, and can be accomplished without difficulty.
Some have recommended the total extirpation of a metacarpal or
metatarsal bone, leaving the finger or toe appended; but the member,
when thus left unsupported, can never become of any service to the
patient, and may be productive of much inconvenience; whilst removal
of them, along with the diseased bone, renders the operation much more
easy of execution. If the whole disease can be extirpated, leaving the
surfaces of the surrounding bones covered with healthy cartilage, the
use of the caustic is not required, and would be productive of harm;
but wherever it is impossible to avoid encroaching on the cancellated
texture, such as of the os calcis, which it would be unsafe or
imprudent to take away entirely, its use is then indispensable. After
the removal of carious bones, the symptoms soon disappear, and the
patient obtains a rapid, and often permanent cure. The instruments for
these operations, and the method of performing them, will be afterwards
mentioned. In conclusion, it may be remarked that the temporary
cicatrix of a sore leading to a diseased bone has a very different
appearance from the sound scar which is formed after its removal. The
former is bluish, soft, on a level with the surrounding parts, and
moveable; the latter is depressed, white, and firmly adherent to the
bone.


Death of bone, or NECROSIS, is an effect of violent inflammation,
particularly of the medullary web, or external injury; a termination of
inflammatory action in bone corresponding to sphacelation in the softer
tissues. It has been observed, that the bones are not extensively
supplied with bloodvessels, and that their natural powers are inferior
to those of the softer parts; and from this circumstance the frequency
of necrosis can be readily accounted for. The short bones and the
heads of the long bones, are more vascular than the flattened bones
and the shafts of the long ones. Hence necrosis most frequently occurs
in the latter. Necrosis, fortunately, seldom occurs in the heads of
the long bones, or penetrates the separation betwixt the cancelli of
the shaft and the epiphysis. Bits of dead bone in the articular ends,
however, very often lead to disease in the joint. There are in my
private collection a few specimens of necrosis, in which matter found
its way into the neighbouring joint, leading to disease of the tissues
composing it, and rendering amputation necessary for the preservation
of the patient’s existence. External injury may produce this disease
by causing a violent increase of action, or it may be so severe as at
once to deprive part of the bone of its vitality. Destruction of the
periosteum, and of the vessels which enter the surface of the bone,
frequently gives rise to superficial necrosis or exfoliation. Such a
result, however, does not always follow; for we not unfrequently find,
when the periosteum has been forcibly torn off, to a considerable
extent, by external injury, that the part still retains its vitality.
When, however, the bone has been at the same time contused, it is
extremely probable that external necrosis may occur. Again, when the
periosteum has been removed in the most careful manner possible,
exfoliation occasionally takes place. If the exposed bone remain of a
brownish hue, it will generally retain its vigour; if, on the other
hand, the colour is white, it will most probably be cast off. Necrosis
may come on at various periods of life, but is most commonly met with
in young subjects, in whom the inflammatory action is allowed to
make progress before it is noticed or attended to. It may affect the
external or the internal part of a bone, or nearly its whole thickness.
The whole of a bone seldom or ever dies in consequence of increased
action, and it is not often that the entire thickness of any part of
it is found to be necrosed. If the entire thickness dies to a great
extent, there is no reproduction; the epiphyses approximate, and the
limb, if there is only a single bone, must be lost. A large portion
of a bone, or numerous small irregular portions, may die; but still a
part of the original shaft remains, and by its vessels reproduction is
accomplished. The articulating extremity is very rarely destroyed by
this disease. Many writers have talked of death of a bone throughout
its whole extent, and, in fact, the term necrosis was originally
adopted on this supposition.

[Illustration]

[Illustration]

The progress of necrosis is, as has been said, similar to that of
sphacelation. The affected bone gradually changes its colour, and
loses its sensibility; a line of demarcation is formed, and ultimately
the dead portion is completely detached from the living. Previous
to its separation, the surrounding parts, the portions of bone
which are not doomed to perish, have commenced forming new osseous
matter, which is secreted in nodules, and from continued deposition
soon becomes consolidated. The commencement of the process is well
seen in the following sketches from specimens in my collection. The
disease, as represented in the two first cuts, was of the most acute
kind, and a great part of the shaft of the tibia had perished. This
is seen at various points through the sort of cortical deposit of
new bone. The new bone, in its turn, secretes a texture similar to
itself, whereby the deposit becomes more and more extended, and not
unfrequently affords an almost complete encasement to the dead portion,
or sequestrum, as represented in the cut on the right-hand side of the
page. In general bone dies irregularly, so that the sequestrum presents
an uneven surface, and its margins are rough and serrated by numerous
sharp projections, as seen in the one taken from the tibia, and
represented here. From the appearance of the dead bone, it was imagined
that after its separation, portions of it were removed by absorption;
and this opinion was strengthened by the thin exfoliations of the
external lamina being found perforated at several points by minute
apertures,—worm-eaten, as it was called. These cases of death of inner
or medullary shell are irregularly separated, like any other slough;
the remaining living outer shell is enlarged by inflammatory action
and deposit. But a dead portion of bone, detached from the surrounding
parts, is in every respect an extraneous body, and is not, and cannot
be, acted on by the absorbents, any more than a piece of metal, wood,
or stone. Some have gone so far as to affirm that portions of foreign
bodies, ligatures, &c., are absorbed; but this opinion is altogether
too absurd to require any contradiction; the knots of ligatures, like
portions of glass, or other foreign substance, become surrounded with
a dense cyst, and often remain in the body for a long time; so do
portions of dead bone separated by the process here described. A series
of experiments were made by Mr. Gulliver, in order to put this question
at rest, many of which I witnessed and assisted at, and several I also
repeated. Setons of bone were inserted and worn for a long time; thin
plates of bone were confined on suppurating surfaces; pieces of bone
were inserted in the medullary canal of various animals, and kept there
for months, and in one instance for more than a year. These foreign
bodies were weighed with the greatest care and accuracy before and
after they were so exposed to the absorbents, and were found unaltered
in any respect. A paper, detailing these experiments, is published in
the _Medico-Chir. Transactions_.

The separation of the dead part from the living is accomplished with
greater or less ease, according to the bone which is affected, the
state of the constitution, and the general health; in the bones of the
superior extremity, this, as well as every other action, proceeds more
rapidly than in those of the inferior. It occurs in consequence of
absorption of the living part of the bone, which is in close proximity
to the dead. The sequestrum, if large, is not pushed off, as some
have supposed, by granulations, deposited on the living margin of the
bone. A small portion of the inner shell, when completely detached,
may sometimes be observed to be extruded from a cloaca by granulations
from the living bone. During its progress, matter forms, makes its way
to the surface, and is discharged through minute, and often numerous
apertures, which afterwards become fistulous. The soft parts are
thickened and indurated, and the integuments are red, and sometimes of
a livid colour.

Formation of matter upon the bone is occasionally the cause of
necrosis, the periosteum being destroyed or separated from its
connections by the pressure or insinuation of the pus. I have seen
several instances in which it followed neglected erysipelas of the
lower extremity.

The matter is in general thick and laudable; at first it is secreted
profusely, but afterwards in smaller quantity. The external openings,
or papillæ, through which it is discharged, are found to lead to
cloacæ, or apertures in the new and living bone, which encase the dead,
and through these the dead portions can be discovered by the probe;
and it will thus be ascertained whether the sequestrum is fixed or
detached: when loose, it can sometimes be moved upward and downward in
the cavity. When the shaft of a bone is much affected, the whole limb
is enlarged, by the inflammation having extended to a considerable
distance above and below the portion about to become necrosed. The
unshapely appearance of the limb continues until the sequestra are
discharged; for by their presence incited action is still continued,
and subsides only after their removal. Some time before any portion of
bone has become dead, or begun to be separated, great effusion of new
bone has, in general, occurred; thus a preparation has been made for
the strengthening of the limb, which, after a considerable portion of
the bone has been detached, would otherwise be incapable of supporting
the weight of the body. The unnatural bulk of the limb is afterwards
much diminished, for the new bone gradually becomes consolidated, and
smooth on the surface by the action of the absorbents. Nature seems to
construct her substitute after the model of the original, and in some
instances but very little change can afterwards be observed in the limb.

In external necrosis, or death of the outer lamella, reparation is
chiefly made by the subjacent parts; and this species of necrosis
occurs most frequently in the flat bones. In necrosis involving a
greater thickness of the bone, the new matter is also furnished by
the subjacent parts, which, however, are materially assisted in the
process by the living bone, which forms the margins of the void caused
by the absorbent process for the detachment of the dead portion. The
bony matter is deposited with great activity, and frequently columns of
the new deposit cross over the sequestrum, binding it firmly down, and
rendering it almost immovable, although it may be completely detached
from the living parts.

It has already been stated, that those vessels which ramify within the
substance of the periosteum have no share in the reproduction of bone,
but plastic matter is effused by the ramifications extending from the
membrane to the bone: this effusion becomes organised, and greatly
assists in forming the substitute.

It has been formerly remarked, that a limited, and, on after
examination, an apparently trifling necrosis of the cancellated
structure, may produce the most violent local symptoms; the painful
feelings, the discharge, and the thickening of the bone, continue, as
long as the cancellated sequestrum remains; severe symptomatic fever
is induced, endangering the life of the patient, and often rendering
removal of the limb absolutely necessary.

Occasionally abscesses form at a considerable distance from the
necrosed part, and terminate in sinuses, which communicate with
the diseased bone, and are consequently long and tortuous, so that
examination by the probe is rendered difficult. When necrosis is
extensive, there is a risk of fracture occurring, if motion of the limb
be permitted before a sufficient quantity of matter has been effused,
before nature has had sufficient time for the consolidation of her
substitute, and consequently before the new bone has come to resemble
the old in thickness and cohesion.

Violent inflammatory fever attends the incited action of the vessels
of the bone and periosteum which precedes necrosis. But after the
abscesses have given way the painful symptoms subside, and the health
seldom suffers to any great extent, the system becoming gradually
accustomed, as it were, to the new condition of the parts. Hectic
supervenes only when the disease is very extensive, and joints become
involved. Frequently fresh collections of matter form as each piece of
bone approaches the surface. When the effusion of new bone has extended
to the neighbourhood of a joint, its motion may be very much impeded,
and, from the limb being kept in a state of rest for the cure of the
necrosis, anchylosis may even occur.

_Treatment._—The means of preventing inflammatory action from
running high and ending in death of bone have been already alluded
to—abstraction of blood, rest, purgatives, and antimonials. When
necrosis has occurred, no interference with the bone is allowable,
unless the sequestrum is quite loose, or unless the patient’s health
is suffering severely under the discharge and irritation. When the
sequestrum can be readily moved about, or when, projecting through the
external opening, it can be laid hold of by the fingers or forceps,
attempts must be made to remove it. The surgeon ought not, however,
to allow it to approach the surface, and project externally, for the
natural discharge of the sequestrum is a much more tedious process
than the removal of it by art, and by the irritation produced during
its spontaneous ejection the inflammatory action is continued, and may
prove alarming. Long before it has appeared externally, it must have
been completely separated from the living parts, so as to admit of
ready extraction by the proper means. When it has been ascertained that
the sequestrum is separated, it ought to be laid hold of by forceps,
and moved freely upward and downward, so that any slight attachments
by which it is connected to the neighbouring parts may be destroyed,
whether these be minute filaments which still in some degree retain
their vitality, or small portions of newly deposited bone, which are
so situated as to prevent the free movement of the sequestrum. In
general, no impediment of this nature exists, and the dead bone is
easily removed. Before extraction can be accomplished, it is generally
necessary to enlarge freely the external opening, in all cases where
the dead portion of bone is of considerable size. If, on thus exposing
the parts, the sequestrum be found detached, but still firmly bound
down by the substitute bone, deposited over it either in one continuous
sheet, or in irregular columns, this must be divided by a trephine, a
small saw, or cutting pliers, before the sequestrum can be extracted.
When a dead portion of bone, of considerable length, is exposed at its
centre, whilst its extremities are entangled by the old or substitute
bone, the division of the exposed part of sequestrum, by means of the
cutting pliers, will often be sufficient for its removal, the cut ends
being seized by the forceps, and one half removed after the other;
thus the perforation or removal of any portion of the substitute will
be rendered unnecessary. The instruments, and especially those for
extraction, ought to be very powerful, and suited to the purpose; for
in the employment of inefficient means there is much folly and cruelty.
Incisions into a necrosed limb are attended with profuse hemorrhage
from the enlarged and excited vessels; and in some cases it is with
difficulty arrested, in consequence of retraction of the cut ends of
the vessels not taking place within the condensed and indurated parts.
Pressure, and an elevated position of the part, will generally be
found to answer. When necrosis has been extensive, the limb must be
carefully supported by the application of splints and bandage, till
the process of reparation be completed, in order to prevent fracture
of the recently formed substitute. This proceeding is seldom, however,
necessary.

The treatment may be summed up in a very few words. Prevent the
necrosis, if possible; open abscesses whenever they appear; encourage
the patient to move the neighbouring joints; support the strength;
remove sequestra when loose, but do not interfere till they are
ascertained to be so; give the limb proper support and rest, when a
large sequestrum is formed. When fracture has taken place, when the
health has been undermined, or when neighbouring joints have become
diseased, amputate, in order to save the life, if it be impossible to
save the limb.

[Illustration]

It is almost superfluous to remark, that leeching and blistering are
worse than useless after necrosis has occurred, however useful they may
be in preventing it; and that the adoption of measures to promote the
dissolution and absorption of the sequestra are glaringly absurd.

Necrosis, after amputation, was formerly frequent; but in the present
improved state of this operation it is so rare as scarcely to demand
separate consideration.

[Illustration]

Such specimens as here depicted are common enough in the collections
of those who have practised the old round-about operation; in fact,
it is only by this painful and tedious interference of nature that a
tolerable stump is formed in many of these cases. Death of a small
portion will sometimes, though very rarely, follow even a very well
performed amputation, if through any mischance the recovery is
slow, and wasting discharge takes place with emaciation. It happens
sometimes, as when secondary hemorrhage (that is to say, bleeding after
the fourth day) has taken place, that the flaps are separated by the
coagula, and it may be impossible to bring the parts together and give
them due support; then the muscles, wasted and shrunk, may leave the
bone a little, but the exfoliation is but very trifling.

The inner shell of bone, as may be seen in the above sketch, perishes
more extensively than the outer; and this arises probably from
inflammation of the medullary membrane, in consequence of exposure, or,
perhaps, from its being sometimes injured by the operator or assistants
seizing the bone rudely to steady the stump, in order to facilitate the
ligature of the vessels. In experiments on animals, the disturbance
and injury of the medullary membrane is followed by internal necrosis,
thickening of the outer living shell, and effusion betwixt the
periosteum and bone. New bone is also furnished from the medullary
canal, as is also shown in the sketch.


FRAGILITAS OSSIUM

Occurs chiefly in old people, whose bones contain an undue proportion
of earthy matter, are endowed with little vascularity, and filled with
an oleaginous fluid. They contain an undue quantity of phosphate of
lime compared to the gelatin; and the liability to fracture is further
increased by the interstitial absorption of the outer shell. They are
in an atrophied state, and this is often in part attributable to disuse
of the limbs. This state of the osseous system very often follows upon
an attack of rheumatic fever, and is met with in patients who have
laboured under cancerous affections.

The bones, when in this condition, often break from the slightest force
applied; as from the action of the muscles when the patient turns
himself in bed, whilst walking across the room, or when endeavouring
to attain the erect posture when seated on a chair. After fracture
the process of reunion is extremely slow, and it does not take place
at all in patients very old and of worn-out constitution. With a view
to prevent the occurrence of fracture when the bones are in this
condition, for it is impossible by any treatment to prevent the change
in the texture of the bones, the only rational indications seem to be
to keep the patient on a generous diet, and to prohibit him from making
any great muscular exertion—to avoid, in fact, all circumstances likely
to produce a sudden action of any particular set of muscles.


OF MOLLITIES OSSIUM, RACHITIS, ETC.

These affections differ only in this, that in the latter the earthy
matter is not deposited originally, whilst in the former it is absorbed
after having been deposited; in both the result is the same. The latter
is peculiar to the very young, the former to those of an advanced
age.[11]

Rickets and mollities ossium seem to differ also in this. In the latter
there is seldom, if ever, any reparative action. The diseased process
of deposit continues in the bone, the softening increases, and the
patient ultimately perishes. Whereas, in rickets, the softened and
yielding state of the bones is only temporary: after a time earthy
matter is deposited in due quantity, and the bones become compact,
firm, and solid, capable of supporting the weight of the body, though
necessarily permanently bent and deformed, if proper means have not
been employed during the softened condition. The thickness of the
rickety bone, as Mr. Stanley has shown, takes place on the concavity,
which is the situation where the greatest strength may be added with
the least expense of new matter. In the same way the reparation
of fractures not accurately adjusted goes on most actively in the
concavity formed by their displacement.

[Illustration]

Softening of the bones is met with at all ages, and in different
degrees. It seems sometimes to be congenital, and combined with
hydrocephalus. It often follows dentition, measles, hooping-cough, or
other infantile diseases inducing debility. In females it seems to be
produced, or at least often accompanied, by the debilitating effects
of leucorrhœa, miscarriages, and floodings. Loss of blood, in any way,
predisposes to it. Mercury, given in immoderate quantities, produces
a softening of the bones; and, in some most remarkable instances on
record, the free use of common salt was the only cause assigned. When
the disease affects children, all the bones generally suffer, those of
the extremities as well as those of the trunk; the limbs become bent
in an extraordinary manner, and the heads of the bones are swollen,
and appear to be much more so in consequence of the wasted and flabby
state of the muscles. The child walks with difficulty, and in many
cases the legs are utterly incapable of supporting the weight of the
body, so that he cannot remain in the erect position. The chest and
pelvis become deformed, breathing is oppressed, the digestive organs
are deranged, and the belly is tumid. The bones of the limbs become
flattened as well as bent, and in their concavities, as remarked in the
preceding cut, new bone is effused, in order that the column of support
may be thereby strengthened. The new deposit is of extremely dense
consistence, and is effused in greater or less quantity, according to
the degree of curvature.

The bones of rickety subjects are soft, cellular, and of a brown
colour, contain a dark fluid, and are very deficient in earthy matter.
As a simple proof of the latter circumstance, it may be mentioned
that distortions of the pelvis can be, and often are, accurately
imitated by soaking the bones for some time in acid, whereby the earthy
matter is extracted. In many instances this component of the bones is
almost entirely removed, and soft matter deposited instead; they then
consist merely of an extremely thin external osseous shell, covered by
thickened periosteum, and containing a pulpy substance resembling fatty
matter. During the progress of the disease, the urine deposits, often
in great quantity, a white sediment, which, on analysis, is found to
be the phosphate of lime. In rickets the head is generally enlarged to
a greater or less degree, and the bones of the cranium are thickened
and spongy; not unfrequently the intellectual faculties remain acute.
In adolescents and adults the limbs seldom become affected; the
bones composing the spinal column are the seat of the disease, and,
along with the distortion of the spine, the position of the ribs is
necessarily altered. Certain rare cases have occurred, in which all
the bones of the adult were softened to a very great degree. In one
remarkable instance, the patient complained of an annoying sense of
tightness in the limb most affected, and, on examination, the softened
bone was found greatly depressed at that point, as if a strong ligature
had been drawn tightly round it. Mr. Howship, who attended the patient,
was so kind as to present me some years ago with a portion of the
altered femur, which consists of a fatty-looking substance, and appears
to contain little or no earthy matter.[13]

Though incurvation of the spine occurs in boys, and even in adults,
still it is most frequently met with in young females; and in them it
is often induced by their having assumed a bad habit by sitting long in
one constrained and awkward posture, as in writing or drawing, without,
perhaps, the bones being unnaturally soft in the first instance.
It often follows affections of the lower limbs, as of the knee or
hip-joint; and is also caused by shortening of a limb, which has been
negligently or ineffectually treated after fracture during childhood,
or by the patient being allowed to continue a custom of standing
awkwardly on one leg. In a very remarkable specimen in my possession,
the curvature seems to have resulted from the tremendous enlargement
and consequent weight of the head. The whole skeleton (head, thorax,
pelvis, and extremities) is deformed, flattened, and twisted. This may
have arisen more readily in consequence of the atrophy of the bones,
and retardation of their growth, produced by the long confinement
to bed. The number of ossa triquetra in the lambdoidal suture was
unusually great. The patient attained the age of twenty-five. The
affection commenced from birth.

[Illustration]

At first, during slight curvature from such causes, the spine can be
brought into its original straight position by the voluntary action of
its muscles. After some time, however, the curve cannot be remedied
by any effort; interstitial absorption of the bodies of the vertebræ
towards the concavity of the curve occurs; they become changed in
form, and accommodated to their altered position, as shown in the
accompanying sketch; the muscles also accommodate themselves to the
new position, as do also the various ligaments connected with the
spinal column. When the curvature is seated in the dorsal vertebræ it
is generally to the right side; this shoulder is raised, and the chest
is protruded, whilst the opposite side is depressed and flattened. The
clothes hang loose, or fall off on the left side—the patient rests
the weight of his body chiefly on the left leg—on stooping the right
scapula projects, and, on examination, is found to be nearer to the
spinous processes of the vertebræ than the left. The left cavity of
the chest is diminished, and the ribs press upon the heart and lungs,
causing difficulty of breathing. To preserve the balance of the body,
a curvature occurs below the former, and in the opposite direction;
and not unfrequently there is a third incurvation situated above the
primary one.

The bones of the pelvis become distorted, and are twisted to one side;
or, when the softening is great, and the patient confined to the
recumbent position, the introitus of the cavity becomes diminished
in the antero-posterior diameter; and, if the patient walk about,
the ossa pubis are squeezed together, in consequence of the pressure
of the ossa femora against the acetabula. The crests of the ilia are
often bent inwards, in consequence of the pressure of steel apparatus
injudiciously applied with a view of removing deformity. When the bones
become consolidated after such distortion, they present most serious
obstacles to parturition; and, most unfortunately, crooked and deformed
women possess, it is said, “great aptitude for conception.” When, in
such females, the untoward circumstance of pregnancy has occurred,
it has been necessary, in some, to have recourse to the Cæsarean
operation, and others have been delivered with the greatest difficulty
and danger; notwithstanding which, many of these latter have, after
recovering from a long and tedious illness, again become pregnant.

In some cases the softened ribs not only compress the organs of the
chest, but are also pressed down upon the abdominal viscera, or even
into the pelvis. The symptoms arising from such displacement are at
first urgent, as can readily be imagined, and are often treated as
inflammatory, to the detriment of the patient.

After some time, as the state of the patient’s health improves, the
bones in some degree regain their original firmness, and the curvatures
are rendered permanent. New bone is deposited in the concavity of the
curve, at first in irregular masses, but afterwards becoming condensed,
and assuming a more regular form, the column is thereby supported and
strengthened.

Bending of the spine backward, with depression of the spinous
processes, is extremely rare. But curvature forward, with projection of
these processes, is by no means uncommon, and is generally supposed to
be caused by caries of the bodies of the vertebræ; in many instances,
however, it arises from interstitial absorption only.

Curvature from caries of the vertebræ, though not so frequent as the
curvature from other causes, is met with pretty often. In adults, the
curvature from ulcerative absorption is more common than that from
softening of the bones. It is attended with the formation of purulent
matter, which presents in the loins, at the top of the thigh, or near
the anus; the bones may become affected secondarily, though much
less frequently, in consequence of the formation and accumulation of
purulent matter in their neighbourhood. There is pain in the loins; the
patient walks in a stooping posture, and often complains of pain in
the knee or thigh. The lower limbs sometimes become paralytic, as also
the sphincters and extremities of the hollow viscera; this, however,
may arise, without curvature, from softening of, or effusion on, the
chord, or diseased thickening of its membranes. In some cases the
palsy supervenes slowly; at first the patient has an awkward gait; he
lifts his feet high to avoid stumbling, and afterwards puts them down
clumsily and suddenly; the foot, in some cases, is extended, so that
the patient is unable to plant the sole on the ground. Retention of
urine occurs, and is followed by incontinence, with copious deposits.

In the _treatment_ of Rachitis, the chief indication to be fulfilled
is to support and increase the powers of the system; and this may
be accomplished by affording the patient a generous diet, keeping
the bowels in good order, enjoining gentle exercise and exposure to
pure air, by the assiduous use of frictions, and by supporting the
softened bones by properly applied and light machinery. Much mischief
may be done by clumsy and heavy apparatus which confine the movements
of the patient; the muscles are wasted, consequently the spinal
column is weakened, the general health is impaired, and the disease
is aggravated. Some have recommended the internal administration of
the phosphate and muriate of lime, but their efficacy is extremely
doubtful. Preparations of iron seem to answer much better in the
greater number of cases. In cases of curved spine, apparently arising
from bad habit, the patient should be in no degree confined at writing,
or drawing, or music; her posture while at work or play ought to be
attended to, as well as her mode of walking or standing; and, if
awkward, prohibited. Gymnastic exercises of the more gentle kinds ought
to be enjoined, such as those with poles and light wooden clubs, the
turning of a wheel, the exercise with balls, &c. Carrying weights on
the head can only be applicable in certain cases. The shoulders, in
some instances, ought to be kept back by means of a light back-board;
and in aggravated cases the weight of the shoulders, and sometimes also
of the head, must be taken off the spine by a light and well-contrived
apparatus. Sea-bathing, good air, out-of-door exercise, and attention
to diet, are of material importance. Frequently advantage will result
from the patient’s sleeping on a hard mattress; and, in bad cases, from
lying down, when tired, on an inclined plane.

In great softening, it will be necessary to confine the patient
entirely to the recumbent position, and to support the head and
shoulders by a light and firm machine. The causes, symptoms,
appearances, and treatment of caries of the spine, in its different
regions, with or without curvature, will be afterwards considered.


OF INFLAMMATORY AND OTHER AFFECTIONS OF THE ARTERIAL SYSTEM.

During inflammation of arteries, the actions of the vessels are
accelerated and attended with pain; the internal coat is found to be
of a red colour, from increase of its vascularity, and not from its
being merely tinged with the colouring part of the blood; or it is of a
yellowish hue and rough, from the deposition of lymph on its surface,
whilst the external coat is thickened by the infiltration of serum and
lymph. When bloodvessels are inflamed from mechanical irritation, lymph
is secreted on their internal coat, becomes organised, and obliterates
their calibre; if deficient in nervous influence and circulating fluid
at a particular point, there ulceration of their coats occurs; if
violently injured or completely isolated, their coats mortify; and
these circumstances must all be calculated on in the surgical treatment
of arteries. A universal inflammatory state of the arterial coats is
said to have existed, and its symptoms have been minutely detailed; but
its occurrence seems to be extremely rare, and the treatment is medical.

Inflammation is supposed to precede degeneration of the arterial
coats. As a person advances in life the arteries lose elasticity, and
the heart its balance with them; either the one or the other becomes
dilated, their parietes are thickened, and the valves are altered
in structure; the enlargement of the vessels is generally greatest
towards their origin. The dilatation of arteries, more especially of
the internal ones, is often very great; ultimately the internal coat
gives way, and the external, with the surrounding tissues, yields
in proportion as the blood diffuses itself. The internal tunic is
occasionally burst in consequence of violent and sudden muscular
exertion; and, even when the vessels are pretty limber and sound,
effusion of lymph, and obliteration of the vessel ensue, or, more
frequently, aneurism.

Previously to the rupture of the internal tunic, however, there is,
in most cases, a morbid alteration in the texture of the vessel. The
internal coat becomes dry; its textures is more dense and less elastic,
and consequently more brittle. Morbid matter is deposited between the
middle and internal coats, and this, by stretching the latter still
further, diminishes the elasticity and cohesion of their texture.
The deposit is at first to a slight extent and of soft consistence,
somewhat resembling condensed fatty matter. Afterwards it increases
in quantity and consistence, becoming, instead of soft and yielding,
dense, hard, and incompressible; in short, calcareous.

[Illustration]

Though the morbid deposit is at first confined, as above related, its
limits are afterwards extended; calcareous matter is insinuated, either
in minute particles or in broad laminæ, amongst the fibres of the
middle coat, is also found external to it, and occasionally situated in
the cellular coat. In fine, the various component parts of the parietes
of the vessel degenerate, according to the degree of advancement which
the disease has attained; and such a condition is the predisposing
cause to ulceration of the internal coat, and subsequent effusion of
blood. The steatomatous, ulcerated, earthy degeneration of the proper
coats of an artery, as Scarpa, the celebrated professor of Pavia, has
it, are well exhibited in the accompanying sketch.

During violent and sudden exertions the more brittle parts may burst,
either at a certain point, or throughout the whole circumference of the
artery; and on this such results will supervene as on ulceration of the
internal tunic. Ecchymosis then takes place under the cellular coat,
which becomes thickened, and incorporated with, and strengthened by,
the surrounding tissues; this is the incipient state of an aneurismal
tumour. The effusion of blood, gradually increasing, distends the
cellular coat, forming the cavity into which it is poured, and produces
a tumour of a size proportional to the distensibility of the tunic and
the force of the effusion. Sometimes the external coat is separated
from the others to a considerable extent by the insinuation of blood.
An aneurism, however, may exist from simple dilatation of a portion of
the vessel, gradually increasing, and forming a cavity in which the
blood accumulates. At one time it was supposed that all spontaneous
aneurisms were caused by simple dilatation of the canal; but such an
opinion has been long shown to be incorrect, and the term of true
aneurism is now confined by many to that tumour and accumulation of
blood consequent on the giving way of the internal coat, and situated
externally to the canal of the artery. It is true that dilatation may
occur previously to the giving way of the coats, and thus the two
causes are combined. The dilatation occurs from the calibre of the
artery being considerably diminished, in the first instance, at the
point where its coats have undergone the calcareous degeneration, and
only acts as a predisposing cause to the failure of the coats when
thus diseased. When there is mere dilatation, the tumour is generally
of an oval form; but when the internal coat gives way, a lateral
prominence is formed, and gradually increases in size. The shape of
the true aneurism is various: sometimes the tumour is globular, with a
narrow neck; and, from this being of considerable length, it becomes
difficult, in some situations, as above the clavicle, to ascertain the
particular artery which is the seat of disease, the globular extremity
of the tumour presenting itself at some distance from the vessel with
which its pedicle is connected. This is rare, however. At other times
its form is very irregular, being most prominent at the part where the
accumulation of the blood is least resisted. Pulsation in the tumour
is distinct from the first, and is painful to the patient; and in the
external aneurisms it is so strong as to be perceived by a bystander
at a considerable distance. The tumour is at first compressible, and
completely disappears on firm pressure being applied, either directly
to the sac, or to the artery above, the sac being thereby emptied of
its contents, or prevented from being filled. It may sometimes be
difficult to form an accurate diagnosis, from the circumstance that
tumours, not aneurismal, receive a pulsatory movement from an artery
or from arteries immediately beneath them; such difficulty is obviated
by attention to this simple test—that in an aneurism the pulsation is
felt equally in all directions. Besides, if the tumour is moveable,
it can be partially displaced, so as not to lie immediately over a
large artery, and, if it be not aneurismal, it will then be found to
possess no pulsation; if it be an aneurism, its pulsation will not be
diminished by any change of position.

The blood contained within the aneurismal sac, being comparatively
motionless, coagulates, and the coagulum is attached to the inner
surface; at first it contains red globules, but it afterwards loses
them, and becomes of a pale hue, consisting solely of fibrin. This
coating gradually increases, and attains no small thickness, fresh
portions of fibrin being superadded in concentric laminæ. These layers
are chiefly deposited from the blood within the cavity, but they also
appear to receive addition from lymph being effused by the vessels
proper to the original parietes of the tumour. By such thickening, it
can be easily conceived that the pulsation will be somewhat lessened.
In large aneurisms the accumulation and deposit of fibrin may be much
greater at some points than at others, and hence pulsation may be
rendered “not equal in all directions.” It is not, however, diminished
to any great extent; for absorption of one or more points occurs, and
the coating is again attenuated.

In some rare cases the deposition of fibrin has gone on gradually
accumulating, filled completely the aneurismal cavity, and thus
effected a spontaneous cure, the remaining solid tumour imperceptibly
diminishing by the action of the absorbents. After obliteration of
the aneurismal cavity, the fibrin is generally deposited in so great
quantity as to occupy the calibre of the vessel above and below the
tumour, obstructing the progress of the blood, causing it to flow by
the smaller and collateral branches, and effecting a spontaneous cure,
somewhat similar to that produced by the artificial application of a
ligature. Coagula are seldom formed in the dilated vessel, to whatever
size it may be enlarged, unless there is fissure of the internal
coat; for in no other way can a portion of the blood readily become
stagnant, while the calibre of the vessel remains pervious. There
is in my collection a preparation of dilated aorta, to the coats of
which adheres a large firm coagulum. Occasionally, though rarely, a
dilatation of the internal coats is met with accompanied by thinning of
the external ones. Of this sort of diverticulum, there is also a good
specimen in the collection here alluded to.

A spontaneous cure may also be accomplished from the original aneurism
being compressed by one of a more recent origin, causing ultimate
obliteration of the canal. Of this I recollect one remarkable instance;
the patient was afflicted with an aneurism of the axillary artery,
which had attained a large size, and the cure for the disease in
this situation being then unknown or unattempted, the patient was
considered as lost; but some time after the tumour began to diminish,
and disappeared. The patient died; and the cause of death was found to
be the giving way of an aneurismal tumour of the arteria anonyma, which
was situated so closely to the aneurism of the subclavian as to have
acted as a mechanical compress, causing obliteration of the vessel at
that point.

When a cure has been effected, the vessel is found to be converted into
a dense and impervious cord at the site of the tumour. The canal above
is dilated; the coats are thickened, especially the middle; and from
the thickening and increased action of the fibres, the internal coat
becomes somewhat rugous, the rugæ being in a transverse direction.

The aneurismal tumour in general increases, and approaches the surface,
involving and destroying all the intervening textures. If resisted in
its enlargement by bone, even this is not sufficient to impede its
progress; the bone is absorbed, and perhaps ulcerated, at the point
where it is compressed by the tumour. The osseous is more liable to
destruction from this cause than the cartilaginous tissue, contrary to
what occurs from compression by abscess. Ultimately the sac gives way,
and its contents are discharged either externally, or into an internal
cavity or canal, in consequence of its parietes sloughing from the
compression made by the tumour; and such termination is instantly fatal.

[Illustration]

An aneurism of the descending aorta, in a great measure one from
dilatation, is here represented: the patient also laboured under
popliteal aneurism of one limb, and inguinal of the other. He died
suddenly, in consequence of the giving way of the internal tumour.
The escape of blood into the cellular tissue may even take place to
such an extent as to prove fatal in a few hours. The disease may also
prove fatal by mere compression, as of the trachea, impeding breathing,
and inducing disease of the respiratory organs; or by pressure on the
gullet preventing the passage of food: in the latter case, however, the
dissolution is generally more sudden, in consequence of the compressing
part of the tumour giving way, and the contents being evacuated into
the stomach or mouth. If the aneurism compress a plexus of nerves, or
the spinal chord itself, the anterior part of the vertebræ having been
previously absorbed, paralysis is produced.

In consequence of aneurism, the circulation of blood in the vessel
is obstructed; hence the collateral branches above the tumour become
enlarged, and through them the circulation is continued; by their
anastomosis with collateral branches which arise below the seat of the
tumour, a portion of the fluid is brought back into the canal of the
original artery. The circumstance of collateral enlargement used to be
distinctly enough demonstrated in amputation, one of the old cures for
the disease.

The tumour may be suddenly increased by a portion of the parietes
giving way, and the blood being propelled into the cellular tissue,
which becomes thereby condensed, and supplies the deficiency in the
original sac; diffuse is thus superadded to the true or encysted
aneurism.

The disease is generally accompanied with great pain, the neighbouring
nerves being much stretched by the enlargement of the tumour, as in the
axilla or ham; in these situations also the limb below the aneurism
is much swollen from the compression of the absorbents and veins and
consequent infiltration into the cellular tissue. Diffused aneurism
from wounds, and the other species of the disease, will be afterwards
treated of.

The peculiar degeneration of the coats of the vessels has been already
stated to be the predisposing cause of aneurism; and the disease
may be directly caused by over-excitement of the circulation, or
by an over-exertion of the muscles. It is more frequent in males
than females.[14] In men somewhat advanced in life the arteries get
hard and rigid, whilst at the same time the muscles are strong, the
general health good, and the whole frame stout and active; so that the
patient is capable of violent muscular action, such as the arteries
are ill able to bear, and consequently the internal coat of a vessel
yields, and lays the foundation for an aneurism.[15] The lower limbs
being chiefly subject to such exertions, aneurism in them is most
frequent;[16] and for the same reason it is said to be common in those
who ride much on horseback. Degeneration of the coats of the vessels
in the superior extremity is extremely rare. This is another reason why
spontaneous aneurism seldom assails them.

_Treatment._—In internal aneurism the only indication which can be
followed, with any chance of success, is to favour the occurrence of
a spontaneous cure, by abstracting all stimuli, mental and corporeal,
by enjoining complete rest, by keeping the patient on low diet, and by
repeated bleeding. Thus the force of the circulation is diminished,
and coagulation, it is said, promoted; by this practice aneurisms,
the progress of which defies external means, are occasionally, though
very rarely, cured. Ice and other cold applications to external
aneurisms, or those which have made their way to the surface, have been
recommended to induce coagulation, but their use is not unattended with
danger; for they may, in some stages, so far diminish the vitality of
the coverings as to cause sloughing, and fatal hemorrhage.

In the treatment of aneurisms exterior to the great cavities, important
improvements have been made in modern times. No success can be expected
to follow palliative and temporizing measures, and a cure can result
only from operation. Formerly it was the practice to lay open the
aneurismal tumour, to search for the extremities of the artery opening
into the cavity, and to secure them by a ligature, or close them by
pressure, styptics, or both. In some few instances this method had
permanent success; but in the majority the operation proved wholly
abortive, and not unfrequently fatal. It was necessarily tedious in its
performance, and attended with much danger, the blood being discharged
in great profusion immediately after the opening of the sac, and the
extremities of the vessels being with great difficulty detected and
secured. Besides, the vessels in the immediate neighbourhood of the
tumour having generally undergone the degeneration already mentioned,
were incapable of taking on any healthy action; the application
of ligature on a vessel thus circumstanced could consequently be
productive of no advantage. From this method having almost invariably
proved unsuccessful, practitioners in those days generally preferred
amputation, when the tumour was so situated as to allow it; and when
the disease occupied a situation in the limb so high as to prevent
amputation, the case was deemed incurable, and the patient abandoned
to his fate. But amputation was accompanied with circumstances almost
equally alarming with those attendant on division of the sac: the
hemorrhage was very great; for as a consequence of obstruction to the
free passage of the blood in the aneurismal vessel, the circulation
was chiefly carried on by the collateral anastomosing branches, which
were thereby so much enlarged, as, on their division, to pour out
blood with a profusion resembling that of arteries of the second or
third magnitude. Continued pressure was employed as a less hazardous
method of cure, but was equally inefficacious; and was also attended
with danger, from the risk of sloughing. If the practice ever proved
successful, it was only after a tedious perseverance in its use, and
long confinement of the patient.

The operation of applying a ligature on the vessel at a distance from
the tumour, and thus intercepting or weakening the flow of blood into
the cavity, so as to allow complete coagulation to take place, is of
comparatively modern invention, and is the one now practised with
almost invariable success. To John Hunter without doubt belongs the
merit of proposing and putting it in practice; it has been claimed also
for the celebrated Desault. This operation has been variously modified.
Some have advocated the temporary application of a ligature, conceiving
that the effects produced will be as complete and permanent when it
has been allowed to remain only for a certain time, as when it is left
undisturbed and ultimately separated by nature. Such a theory, however,
has proved to be incorrect in most of the instances in which it has
been reduced to practice on the human subject; and the operation is
at best very uncertain, and not to be relied on. Others have employed
a double ligature, and some of the Continental surgeons have applied
a great many; some were tightened, others left loose, and looked upon
as ligatures of reserve to be tightened, should hemorrhage take place,
an occurrence likely enough to follow their clumsy and unsurgical
proceedings. A thick broad ligature like tape has also been used, from
an ill-grounded apprehension that all the coats of the artery would
be cut completely through by the tight application of a thin and firm
one. With the same view, a roll of linen or plaster has been interposed
betwixt the noose and the vessel, and this practice has been advocated
even by good surgeons—as Scarpa. Such complications can do no good,
and may do much mischief. The artery must be greatly detached from its
surrounding connections before the numerous and flat ligatures can be
applied, in consequence of which its coats will be apt to slough or
ulcerate, and hemorrhage occur. When, from any cause, the vessel has
been detached to a greater extent than is sufficient for the passing of
one ligature, two ought undoubtedly to be used, and one applied close
to each extremity where it is attached to the surrounding parts.

Again, it has been proposed, after the application of a double
ligature, that the vessel should be cut through betwixt the two
deligated points; it being supposed that in this way the closure of
each extremity will be more rapid, the cut ends retracting, and being,
in fact, in the same circumstances as the extremities of arteries
which have been tied on the face of a stump. Mechanical contrivances
have also been invented for the compression of the artery,—such as the
serrenœud and presse artere; these, however, are clumsy, insufficient,
and often injurious.

The single ligature, when properly applied, is the most safe, and
preferable to any other, for arresting permanently the flow of blood
in a vessel. In its application, the artery must not be separated from
its connexions farther than is barely sufficient for the passage of the
armed needle beneath it; but the external incision ought to be free,
in order that this may be readily effected, and that the operation
may be easily and speedily performed. By the firm application of a
single ligature, the vessel is rendered impervious; the internal and
middle coats are divided, so that the ligature only encircles the outer
or cellular one, which resists the influence of any moderate degree
of force by which it may be tightened. The blood coagulates above
the deligated point,—the coagulum is of greater or less extent, in
proportion to the vicinity of a collateral branch, and is of a conical
form, the apex of the cone pointing to the free portion of vessel.
Incited action in the vessel takes place at the deligated point; the
divided margins of the internal and middle coats secrete lymph, by
which they adhere, and so obliterate the canal of the artery. Lymph is
also effused on the external surface, and in this deposit the ligature
becomes imbedded. The direct influx of blood into the aneurismal sac
is thus intercepted, and time is allowed for coagulation of the blood
which it contains; the artery for a considerable distance below the
ligature becomes ultimately converted into a firm and impervious
chord. The coats of the vessel above the ligature are much thickened,
and the internal membrane is occupied with the transverse rugæ
occasioned by projecting fasciculi of the fibres, which are always
apparent after obstruction of an artery. If this operation be properly
conducted, success must almost uniformly follow. Before determining
on its performance, however, the state of the arterial system ought
to be examined as carefully as possible; for not unfrequently the
degeneration of the coats is almost universal, and therefore an artery,
or even arteries, may be diseased at more points than one; and if this
aneurismal diathesis exist, the patient may be found to labour under
an internal aneurism of the aorta. In such a case, an operation could
not with propriety be undertaken for the cure of the external aneurism;
there might be no inconsiderable danger of the patient’s death being
suddenly accelerated by the operation, the sac of the internal aneurism
giving way perhaps during its performance: such a circumstance has
actually occurred.

Ligatures composed of animal substance, such as catgut, have been
proposed as preferable to all others, on the supposition that they
would be absorbed, and occasion less irritation; the fallacy of any
such theory has already been adverted to. After the ligature has been
applied for some time, it induces ulceration of the external coat which
it envelopes, by which means it becomes detached from the vessel;
acting as a foreign body, and causing a slight degree of suppuration,
it makes its way by nature to the surface and is discharged. The
period at which it separates may be said to be from the tenth to the
twentieth day; sometimes sooner, seldom later. If, however, much of
the surrounding parts have been extensively included along with the
vessel, a longer period will probably elapse before the separation of
the ligature. One end only of the ligature should be cut away close
to the artery, the other being left hanging from the external wound;
perhaps it is even safer to leave both, unless a third knot is made
upon it; thus the extraneous body, when detached, can be gently pulled
at so as to hasten the separation: this must be done with very great
caution. When both ends are cut short, and the knot closed in, there is
a risk of secondary hemorrhage, from the ligature causing formation of
matter round it, perhaps detaching the vessel from its connections, and
causing ulceration of its coats.

The operation ought to be performed at as early a period of the disease
as possible. Some recommend that it should be delayed in recent cases,
with the view of allowing sufficient time for the anastomosing vessels
to enlarge, in order that the circulation may be more vigorous in the
smaller branches after obstruction of the principal vessel. Such delay
prolongs the patient’s sufferings, which are in many cases extremely
acute, and the precaution is altogether unnecessary, as has been amply
proved by experience. On the same principle, the previous application
of pressure to the vessel has been recommended; but few surgeons,
if any, are now afraid of trusting to the resources of Nature when
the principal vessel of a limb is obliterated, and that suddenly,
without previous dilatation of the anastomoses. Cases are on record,
in which the abdominal aorta has been completely obstructed by a
natural process, without much impeding the inferior circulation; and
in one remarkable instance of this description, the inconvenience was
so slight that the disease was not suspected during the life of the
patient, the lower limbs retaining their usual size and activity. In
plethoric habits it may sometimes be prudent to abstract blood, even
more than once, previously to the operation.

When the ligature is placed immediately below a collateral branch
of considerable size, a bloody coagulum is not formed, though
adhesion may occur; but if the excited action should extend to the
collateral branch, and its canal become thereby obliterated, a
coagulum is speedily deposited. In consequence of the enlargement of
the anastomosing branches, and the increasing circulation in them,
pulsation generally returns in the tumour, to a slight degree, some
days after the operation. This, however, is by no means a sign that
the operation has been ineffectual; for the renewed pulsation almost
always disappears in the course of a very short time. In one instance
only have I found it assume a more permanent and troublesome aspect; in
that case, it recurred about ten months after the performance of the
operation, but speedily disappeared under the careful use of a compress
and bandage.

On account of the aneurismal diathesis, it occasionally happens,
that after the cure of one aneurism, another appears in a different
situation; in two instances, I operated on both thighs, at a
considerable interval, successively and successfully, for popliteal
aneurism, in the same patients.[17]

When the tumour is so situated as not to admit of the application of a
ligature between it and the heart, it has been proposed to place the
ligature on the distal side of the aneurism, upon the supposition that
coagulation will occur within the sac in this case as after the common
operation.[18] The practice has been made trial of, but its expediency
appears very doubtful; neither has the success attendant upon it been
such as is generally supposed: the _post mortem_ examinations have been
very unsatisfactory in some of the cases. The application, indeed, of a
ligature in that situation can seldom be of any advantage, the artery
being already obliterated, in aneurisms of some standing, a long way
beneath the tumour; and it is, perhaps, from this circumstance that, in
such operations, great difficulty has been experienced in securing the
vessel, and that it has been thought necessary even to pass a needle
under a thick mass, somewhat in the situation of the artery. It would
appear, in some instances, that the artery when pervious had even
remained untouched, not being even exposed by the burrowing process
employed by some of the operators; and that if any vessel was tied, it
was not the trunk in which the disease existed. It would appear that a
very correct diagnosis had not been formed in some of the cases.

[Illustration]

The appearance of the vessel after the application of a ligature
above the tumour has been already shown. The obliteration of the sac
proceeds, in some cases, very rapidly; it assumes a harder feel,
decreases, and disappears; being connected with the vessel by means
of a dense impervious chord, to which condition that portion of the
artery has been reduced. The anastomosing vessels enlarge more and
more, carry blood freely from above to below the ligature, and thence
to below the tumour; some even passing to the latter situation directly
from above the ligature. Along with the muscular and other branches,
the neurilemmal vessels also become enlarged, and compress the nervous
filaments; and to this are to be attributed the annoying pains which
sometimes occur in a limb after the operation for aneurism. The
enlargement of the arteries of the neurilemma can be distinctly shown
by dissection.

Immediately after the operation, the circulation in the limb cannot
be so vigorous as before; its temperature is consequently diminished,
and it possesses less power of resisting the influence of stimuli. The
limb ought to be kept only moderately warm; for if too much heat be
applied, there is a risk of gangrene. The temperature afterwards rises,
and soon gets above the natural standard; the blood, from obstruction
in the internal parts, being chiefly determined to the surface. After
the collateral circulation has been completely established, the limb
regains its natural temperature.

Secondary hemorrhage is occasionally a consequence of this operation;
nor is it to be wondered at, should one ligature only be used, seeing
that this is often clumsily applied; the cellular tissue being
lacerated, and the vessel detached from its connections by the use of
blunt instruments, directors, and silver knives. When many ligatures
are employed and foreign substances placed in the wound, the patient
can scarcely be expected to escape profuse bleeding. If, however, the
operation by single ligature be properly performed, and the coats of
the artery be sound at the deligated point, the occurrence of secondary
hemorrhage must be rare. It generally supervenes when the ligature
is about to separate: at first there is a thin bloody discharge,
afterwards the quantity of blood is more copious; it is evacuated at
first in a gentle and continued stream, but afterwards _per saltum_,
and in profusion. The discharge not unfrequently stops for a short
time, but, on the circulation being excited, it again returns; and
the patient soon dies, unless active measures be practicable, and
immediately resorted to. Compression can be of no use; nor can
astringents, nor venesection, which I have actually seen practised in
such cases. The application of a ligature betwixt the heart and the
open point of the vessel affords the only chance of saving the patient;
the surgeon must interfere, and do what is in his power—he cannot look
on and see the patient bleed to death.

Occasionally the aneurismal sac deviates from its usual structure and
appearance. Sometimes osseous or calcareous matter is found deposited,
to a greater or less extent, in the substance of the parietes of the
sac, or between the laminæ of fibrin which it contains. The tumour
may also occupy unexpected situations, occurring after fracture of
the bones and laceration of an artery, and perhaps from more slight
external injuries. A disease of bone, somewhat resembling aneurism in
that tissue, will be afterwards noticed.


OF ANEURISM BY ANASTOMOSIS.

This disease is generally seated in the external cellular tissue. It
has been supposed to attack occasionally the internal organs; and
a case is related in which it was situated in the cellular tissue,
between the vagina and rectum. Frequently the congenital marks of
children, termed Nævi, degenerate into this disease: occasionally,
though very rarely, it occurs in sound skin and in adults. A good
case of this kind will be found in the _Practical Surgery_, p. 336.
When the cutaneous tissue is involved, the colour of the tumour is
a dark red, or inclining to purple; it is irregular on its surface,
and has a soft, spongy feel. Often it is raised distinctly above the
surrounding parts; at other times it is flat, scarcely prominent, and
seems to enlarge chiefly in a lateral direction. The skin is then
frequently unaffected; pulsation, in some instances, is perceived;
often, however, the tumour is of an inactive character, affords
no pulsation, and, on being handled, feels like a doughy, elastic
intumescence, appearing to be composed of a congeries of distended
vessels, in which the blood circulates slowly, and resembling varix.
The tumour is formed by enlargement, tortuosity, and increased activity
of the capillary and other vessels; in some cases the arteries are
chiefly affected, in others the veins. That such is its structure, can
be distinctly proved by dissection; the vessels are found enlarged to
many times their natural size, and their coats are much attenuated;
it is certainly not cellular, as some have supposed. The tissue is
similar to that of the cavernous and spongy bodies of the penis, and
has hence been named erectile. A natural structure of the same kind
is met with in the lower animals in different situations. The tumour
is much increased on the general circulation being hurried, as by
crying in children, by fits of passion, by the excitement of ardent
liquors or venery, and during or before the menstrual discharge. On
such occasions the surface frequently gives way, hemorrhage ensues,
and is often profuse; in females it sometimes takes the place of the
regular discharges. The tumour, in general, increases rapidly in
size, and bleeds from time to time; now and then, however, it becomes
stationary, even in circumstances where it could hardly be expected,
and remains so during the remainder of the patient’s life. Again, in
children, the surface of the tumour is not unfrequently ulcerated,
even to a great extent, without hemorrhage occurring; when such is
the case, the ulceration for the most part extends, with surrounding
induration and condensation of the parts. The whole or part of the
adventitious tissue may thus be destroyed; the parts cicatrise, and a
spontaneous cure is sometimes accomplished. In other cases, though the
disease is not extensive, frequent and most violent hemorrhage occurs.
A hemorrhagic tendency also occasionally occurs in affections of a
different nature,—a trifling sore pouring out blood on the slightest
touch. In some constitutions, leech-bites, trifling punctures, or the
extraction of a tooth, have been followed by dangerous hemorrhage. The
disposition very often exists in many members of the same family, and
is sometimes hereditary. Great trouble has been experienced in staying
the bleeding; large vessels have been tied without effect, and some
patients have even perished notwithstanding every exertion on the part
of the attendants. It becomes a difficult matter to treat surgical
diseases in such constitutions: openings cannot be made with the knife
for the evacuation of matter or any other purpose. A good case will be
found in the _Lancet_, 1838-39.[19] The same patient again presented
himself with a very large and deep abscess of the hip, which was opened
by caustic, though nearly one inch and a half from the surface. It is
not easy to account for this disposition to bleed so profusely, or
from slight causes. The blood is in a diseased state, probably as in
the patient here referred to, in whom it contained pus globules, and
coagulated slowly; there is probably also a want of tone in the vessels
themselves. Many such cases are on record. The cause, or causes, of
aneurism by anastomosis are also unknown.

In very slight cases of erectile tumour, or in nævus threatening to
assume an aneurismal action, cold and pressure are sometimes, though
very rarely indeed, sufficient for the prevention or removal of the
disease. The most effectual remedy is excision, though this can very
rarely indeed be had recourse to with safety; for when the disease is
extensive, the vessels in its neighbourhood are much enlarged, and
their action increased; so that any attempt to remove the tumour by
the knife is followed by profuse, and often an uncontrollable, flow of
blood. When excision is practicable, it ought to be accomplished by
cutting very clear of the disease; the tumour, like every other, must
be cut out, not cut into. If the incisions encroach on the substance of
the tumour, or are made in the immediate neighbourhood of the diseased
part, the tremendous bleeding which invariably ensues will convince
the practitioner of the impropriety of his conduct, and rashness of
the proceeding. Attempts have been made to arrest the progress of
the diseased action, by tying the principal arterial trunks entering
the tumour; but these have proved ineffectual, as might be expected,
considering the unusually free and numerous inosculations which then
exist. In a few instances, ligature of the carotid artery, on the same
side with a tumour on the face or head, has put a stop to the disease;
in the others, it has been unavailing.

When the tumour is so situated, or of such a size, as to render
the expediency of excision doubtful, it may often be safely and
expeditiously removed by ligature. In some cases the tumour is
prominent, so that it readily allows of the application of a ligature
around its base; in others, it is flat and broad; in which case, a
long needle, or needles, armed with a double ligature, can be passed
beneath it, and the ligatures can then be separated, and so disposed as
to cause sufficient constriction of the entire mass.—Vide _Practical
Surgery_, p. 331, 336. In many cases, incisions may be made with great
advantage, either before or after introducing the ligatures; the
diseased mass is thus more effectually included and strangled, and much
pain and deformity are avoided. The disease, however, occasionally
occupies such situations as are totally beyond reach. The application
of potass has been recommended; and this caustic is certainly
sufficiently powerful to destroy the diseased parts; but its use is
attended with danger from profuse hemorrhage. Superficial nævi may
occasionally be got rid of by the application of nitric acid, but it
requires to be applied over and over again; and, after all, some more
effectual means must probably be resorted to. Stimulating injections
into the substance of the growth have been sometimes employed. Cures,
it is said, have followed the use of setons, or the repeated puncturing
and breaking up of the tissue with a needle. None of these means are
to be depended upon. The cases are innumerable in which I have been
obliged to employ the ligature in an effectual manner, combined or not
with incision, where caustics, injections, puncturings, setons, and
even imperfectly applied ligatures, had been previously resorted to in
vain. Besides, in children there is as much resistance and crying, and
as much anxiety in parents, produced by a slight operation, as by a
more effectual one.[20]


OF INFLAMMATION OF VEINS.

Veins are very susceptible of inflammation, and the action is very
apt to extend along the coats rapidly; in some cases it reaches the
right side of the heart, producing most violent symptoms, and speedy
dissolution.

Inflammation in the venous, as in the other tissues, may terminate in
resolution. Otherwise, lymph is secreted, whereby the coats of the
vessel become thickened, and its internal surface agglutinated, causing
obliteration of the canal to a greater or less extent. Suppuration
also occurs, and the pus may be deposited in a cyst formed amongst
the coats of the vessels; or, as is most frequently the case, it is
secreted from the internal coat, and occupies the canal of the vein.
It then generally accumulates, its passage into the circulation being
prevented by a deposition of lymph sufficient to occupy the calibre of
the vessel betwixt the heart and the seat of the purulent matter. The
termination in purulent secretion is accompanied with a high degree of
constitutional irritation, and typhoid symptoms, more especially if any
pus finds its way into the circulation.

The integuments in the course of the inflamed vessel or vessels are of
a dark red colour, and great pain is caused by pressure. Often there is
a considerable œdematous swelling of the limb, occasionally followed
by the formation of unhealthy pus, diffused in the cellular membrane,
causing sloughing of that tissue, or of the soft parts more deeply
seated.

This disease generally follows an accidental wound or operation, as
venesection or amputation; it is also of frequent occurrence after the
application of a ligature to the extremity of a vein. Many patients
have died of this disease, induced by the application of a ligature
to the vena saphena major, for the cure of varix. Wounding of large
veins ought to be studiously avoided; and if wounded, the bleeding
from them should, if possible, be arrested by pressure. When from any
cause the extremity of a large vein in a wound is not closed, when it
is not plugged up by plastic matter, pus seems to enter it readily, and
by mixing with the circulating fluid causes dreadful mischief; great
constitutional disturbance accompanies the purulent deposits which
follow in the solid viscera and in the joints.

Inflammation of veins is a very unmanageable disease; the exhibition of
purgatives and antimonials will be prudent, in order to evacuate the
bowels, produce diaphoresis, and diminish the force of the circulation;
the pain will also be much relieved by the application of warm
fomentations to the affected part. General depletion is not admissible
unless at the very commencement of the disease, and local bleeding
must be had recourse to with very great caution; for by copious
abstraction of blood, gangrene may be induced, or at least hastened.
The limb must be altogether disused and elevated, the patient being
kept in a state of complete rest, and not exposed to any excitement or
anxiety. Blisters have been employed, but with no good effect. If the
vein is much distended, and it is evident that it contains a confined
accumulation of pus, it ought to be treated as a common abscess, the
matter evacuated by an incision, and various dressings employed,
according to circumstances. Such practice I have found successful, and
not followed by any untoward symptoms. The abscess is often limited at
each extremity by the deposition of lymph in the canal of the vessel;
and after the evacuation of its contents, the cavity contracts, and the
portion of the vessel which has been the seat of suppuration becomes
completely impervious.

Inflammation of a vein is also occasionally followed by the sudden
appearance of a purulent depôt in some part of the body, external or
internal, at a distance from the inflamed part. Thus, in inflammation
of a vein in the forearm, it is not unusual to find an abscess formed
suddenly in the axilla on the opposite side; after amputation, or other
capital operation, the patient is often suddenly affected with violent
symptoms of disease in the chest, and, on examination, abscesses will
probably be discovered in the substance of the lungs, the existence of
which had only been suspected a short time previous to death. Possibly
some pus globules, the seeds of disease, may be arrested in their
course through the capillaries of these organs, and thus a foundation
be laid for mischief. A very satisfactory explanation of these
phenomena cannot readily be given.

It has already been noticed, that the softening of coagulated fibrin
must not be confounded with suppuration. The fibrinous pulp has
commonly been called pus, though erroneously; and when occurring
in the veins, as it frequently does, has been generally described
as inflammation and suppuration of the vessel. The distinction is
important; first, because many of the so-called cases of phlebitis are
shown to be of a different nature, and secondly, as to the theory of
suppuration, on which subject many writers in this country have been
engaged in making commentaries on, and compilations of, the French
doctrines, which are not deserving of much regard.

There exists without doubt a capillary phlebitis, and the vast
importance of inflammation, and its consequence in these vessels, will
be estimated when their great extent and functions are recollected. It
is probably in this class of cases especially that the blood becomes
contaminated with pus.

[Illustration]

Veins frequently become dilated or _varicose_; they assume a tortuous
course, appear much enlarged, and present an elastic, soft feel,
except in the situation of the valves, where they are more hard and
incompressible: occasionally the tortuous windings form a bluish tumour
of considerable size. The dilatation of the superficial branches is
increased by heat, the skin being thus relaxed, so as to give less
support. The limb is swollen and œdematous. The dilatation is generally
supposed to be confined to the vessels near the surface, but it appears
that the deep-seated ramifications are not exempt from the affection.
When a dilated vein becomes inflamed, great pain is felt in the part;
the vessel feels like a firm chord, its coats are much thickened, and
its cavity proportionally contracted; lymph is effused, and by it the
canal may be obliterated to a greater or less extent; a spontaneous
cure is thus accomplished. In the lower limbs, the disease is often
complicated with ulcers; and as long as the veins remain varicose, the
ulcers are almost incurable, or if they are brought to cicatrise, the
skin soon ulcerates again, and the disease is reëstablished. The coats
of the vessel not unfrequently ulcerate, and blood is discharged in
appalling profusion: such an occurrence may even prove rapidly fatal.
Sometimes, though rarely, skin thinned by pressure from within gives
way without previous ulceration, and profuse bleeding ensues.

The cause of this affection is obstruction to a free return of the
blood; as by tumours, either natural or adventitious, from pregnancy,
constipation, &c.; or by the tight application of a ligature round the
limb, as of a garter. It often occurs in those who have been in the
habit of great muscular exertion, the blood being thereby forced from
the deep-seated veins into the superficial. This even occurs, though
very rarely, in the upper extremity, and I have witnessed more than
one instance of it. Here it is more readily got rid of. Dilatation of
venous branches is met with in the scrotum, labium pudendi, lower part
of the abdomen, in the neighbourhood of the anus, and at the lower part
of the neck. The lower limb is, however, the most common seat of the
disease: when the veins in this situation are dilated, the valves are
insufficient to obstruct the calibre of the vessels, and consequently
the lower and smaller ramifications have to sustain the column of
blood in the superficial veins of the whole limb, its weight not being
diminished by the support which, in the natural state of parts, is
afforded by the valves; the disease is thus more and more aggravated.
The left limb is generally the one affected; and this circumstance may
probably be explained by the pressure of the sigmoid flexure of the
colon on the left iliac vein.

In the majority of cases, the palliative treatment can only be adopted.
The limb must be used as little as possible, and, if practicable, be
kept in a state of complete rest; the veins must also be supported by
the application of a bandage, or the wearing of a laced stocking. The
Indian rubber bandage worn over the stocking or drawers answers fully
as well as any other method. In some instances, the application of cold
has been of advantage, by promoting the contraction of the dilated
vessels. When pregnancy is the cause, it is needless to commence any
method of cure, until the cause be removed; and the same remark is
applicable when the affection arises from habitual constipation. The
varices occasionally become inflamed, painful, and much swollen, with
considerable œdema of the whole limb. Their contents become coagulated,
and their coats thickened; in the end, the swelling abates and the
vessels are closed. In certain cases, this spontaneous cure, a radical
one, may be imitated by the surgeon; an escharotic being applied over
the trunk of the vein at a healthy point, whereby inflammation is
produced in the coats of the vessel, and obliteration of its cavity
accomplished: the caustic which will be found most convenient and
effectual, is the potassa fusa. The caustic may be made into a paste
with soap; or a solid piece, of the size of a split pea, is placed over
the vein, and there retained for a few hours by plaster or bandage. The
vessel being obliterated, the lower venous branches necessarily pour
their contents into those deeply seated; as they freely communicate
with these, they readily empty themselves of their accumulated
contents, and soon regain their calibre under the employment of
bandaging. When the varicose veins are numerous, as is generally the
case, the potass is to be applied to the healthy point of the larger
trunk in which they terminate. But the practice is not unattended with
danger, for the coats of the vessel may ulcerate in consequence of the
application, and violent hemorrhage ensue; the degree of inflammation
excited may be greater than that intended, and extend so as to give
rise to suppuration in the vessel and the most alarming constitutional
disturbance. These unfavourable results, however, must be of rare
occurrence. Success has, however, followed the practice in innumerable
instances.

A much preferable method, as being less painful and unattended with
risk, is that of passing needles under the vessel, and twisting a piece
of thick and strong silk round them. Two needles should be applied
together, at an interval of about half an inch, at whatever points it
is thought right to close the vein. Coagulation takes place in the
included part, and also frequently for some distance below it; the
coats of the vessel are thickened, and its canal closed. The needles
are withdrawn before they begin to cut their way out by ulceration,—say
at the end of from three to five days,—according as the parts become
condensed. The needles suited to the purpose are soft, but tempered
at the point, which is spear-shaped; the ends are cut off with pliers
after the thread is fixed. Other operations have been performed on the
veins, to procure a radical cure of varix; one or more ligatures have
been passed round the vessel, as in the operation for aneurism; and the
vessel has been divided, or a portion of it dissected out, and its cut
extremities afterwards either compressed or secured. Such proceedings
are now almost entirely abandoned.


OF TUMOURS.

A tumour is a swelling or new production, and not a part of the
original composition of the body. Blood may have been effused, and the
coagulated part, becoming organised, is increased in size by deposits
from the vessels which enter it; or perhaps the blood, the coloured
part of it at all events, is taken up and lymph is deposited, which,
if not also removed, “undergoes further changes of a secondary nature,
and remains a parasite or new structure.” Its structure and growth
are modified according to the action which its own vessels assume,
independently of the surrounding vascular system. The bloodvessels may
enter this new growth by a narrow pedicle; or it may be of such a
form as to present an extensive surface, by which it communicates with
the surrounding parts, receiving vascular ramifications from them. As
the growth of the tumour proceeds, the surrounding parts yield, are
condensed, and form an envelope for the new formation; the neighbouring
bloodvessels are excited to a greater degree of action, and more
blood is poured into the vessels of the tumour; the action of these
in turn is very vigorous, and the increase of the new growth is more
and more rapid. They become, it would appear, dilated and tortuous.
Morbid enlargement, or rather new productions, often attain an enormous
size; some have weighed, when recent, upwards of 60 or 70 lbs. Tumours
differ much in structure; and though their general appearance may not
be dissimilar, one will scarcely be found exactly resembling another.
In many cases, the external appearance proves no certain index of the
nature of the tumour; sometimes, however, its feel and general external
character lead the experienced surgeon to form a correct estimate of
its internal structure. It is impossible, by any process of reasoning,
to account for the different actions which these growths possess; and
even minute anatomical investigation, either of healthy or morbid
structures, has not as yet thrown much light upon the subject.

Tumours are divided into _Solid_ and _Encysted_. The solid are
generally enveloped by a dense cellular sheath of the surrounding
cellular substance, yielding and becoming condensed in proportion
as the tumour increases in size; this covering appears as a barrier
between the healthy and diseased parts, shutting out the latter, as
much as possible, from connection with the rest of the body, and
preventing the former from participating in the injurious tendencies
of the latter. Some tumours have no such limit, but extend in the
direction where there is the least resistance, hold a free intercourse
with the surrounding parts, and impart to them their morbid disposition
and action; others are limited in their situation and communications,
but prove dangerous or annoying from their bulk. Some grow rapidly,
and prove troublesome in a few weeks or months; others remain without
much increase for years, and produce little or no inconvenience.
Occasionally tumours partly resemble the texture in which they grow;
those of a fatty nature are frequently found to have their nidus in
the adipose tissue; cartilaginous tumours project from the surfaces
of bones or of a joint, are subsequently detached, and lie loose in
its cavity; growths of a cellular structure internally, and invested
by an apparently mucous lining, protrude from the surface of mucous
membranes. Others differ, not only from the texture in which they are
situated, and from which they derive their nutritive vessels, but
also from every other part of the healthy structure. In one instance,
a congenital tumour was found to be composed of an aggregation of
numerous materials, many of them resembling the healthy textures of the
body. But again, tumours are constantly met with, composed of matter
which in no respect resembles any of the natural tissues of the body:
those are what have been called heterologous formations.

The simple tumour is mere enlargement of a part, from the infiltration
of solid matter deposited by its bloodvessels. There can be little
doubt that the action which lays the foundation of such enlargement is
inflammatory: in consequence of inflammation of the tissue, lymph is
effused into the cellular substance during the progress of the incited
action; and after it has subsided, the dilated and debilitated vessels
probably do not regain their condition, as to size and vigour, but
remain somewhat dilated, and continue to free themselves from portions
of their contents; thus the cellular tissue is opened out in proportion
as the infiltration advances, and the process may be occasionally
accelerated by fresh attacks of subacute inflammatory action. The
patient at first feels pain, heat, &c., as in an inflammatory tumour;
these afterwards abate, and ultimately go off entirely; and during the
increase of the swelling, little or no pain is experienced, unless
when these subacute inflammatory attacks supervene, and then it is
but slight; or unless the enlargement be resisted by an unyielding
structure, and then it is acute and troublesome. The size and rapidity
of increase in such tumours will vary according to circumstances; the
vessels of the part soon regain their size and action, either by the
efforts of nature or of art, so that the tumour will have attained
no great size, and be stationary in its progress, being denied the
materials necessary for its increase. If the morbid action be thus
stopped, the absorbents will remove the newly-formed matter, and
restore the parts to their healthy condition. But when the deposition
proceeds in a superior ratio to absorption, the new matter becomes
organised, and by means of its own vessels, secretes a substance
similar to itself, whereby the increase of the tumour becomes more
rapid, and the new structure may attain an enormous bulk. Thus the
tumour is formed, not merely by dilatation of capillary vessels, and
extension of its original tissue, but by the formation of new matter,
which, becoming organised, assumes a secreting power. At first the
former circumstance is the chief cause of the enlargement; but after
the latter process has existed for some time, the tumour loses much of
its resemblance to the primary tissue, assumes a more dense structure
and a different action, and therefore cannot be designated a simple
enlargement.

This species of tumour, or rather this enlargement which precedes
the formation of a tumour, is chiefly met with in the cellular and
glandular structures. Sometimes it is described under the term of
œdema solidum. In the scrotum, where the cellular tissue is remarkably
loose and extensile, such tumours attain a very large size. They are
found in this country, though more frequently in warm climates. I
removed one from this situation successfully, which weighed upwards
of 44-1/2 lbs.; it had been of twelve years’ duration, and caused
much inconvenience to the patient. It is sketched in the _Practical
Surgery_, p. 341. It occurs in the mamma, apparently in consequence of
suppression of the menstrual discharge; the gland becomes enlarged,
there is no pain in the tumour, and it feels soft and doughy. When the
subcutaneous cellular tissue is the seat of the disease, the tumour is
often of considerable extent, but rarely forms a great protuberance.
It sometimes is situated in the coverings of the nose, which, as they
become enlarged, lose their natural colour, and assume a purple hue;
the mucous follicles also are often much enlarged, and occasionally
emit a profuse discharge of their secretions. It can be readily
understood that in this situation the tumour is a source of much
annoyance, from its partially obstructing respiration, and even vision,
interfering with the functions of the parts and the comfort of the
patient.

It has been already observed, that when simple enlargement exists for
some time the structure changes. It becomes more dense, and assumes a
peculiar action, independent of that of the surrounding parts. It has
a harder and more firm feel, and all traces of the texture in which it
was formed are destroyed. It may be considered as the next in order to
the one already mentioned, both as to the simplicity of its structure
and action; but in consequence of its action being independent of
those of the neighbouring parts, and liable to change from even slight
causes, it is very apt to degenerate into those tumours which are more
complex and injurious.


ADIPOSE TUMOURS.

[Illustration]

Another species of tumour seems to be composed almost entirely of fatty
matter insinuated amongst extended and delicate cellular substance, and
has been therefore termed adipose. It is surrounded by a cyst of dense
cellular tissue, and to this it loosely adheres; its bloodvessels are
few, and it is of an inactive and innocuous character. It is generally
lobulated, and often attains a large size. It is not only irregularly
prominent on its outer surface, but in its whole circumference, and
its lobuli often insinuate themselves to a great depth amongst nerves,
bloodvessels, and other important parts; owing to this circumstance
they frequently prove a source of the greatest inconvenience from
their bulk, for of themselves they are neither hurtful, nor possess
any disposition to involve those parts with which they are in contact.
This tumour is found only in the cellular and adipose tissues. From
its loose connection with its envelope, it admits of ready removal by
operation. A tumour of this kind is here represented, which, but for
this circumstance, owing to its awkward situation under the tongue,
could not by any possibility have been extirpated. It is fully larger
than an orange, and had caused very great suffering. It is not so much
lobulated as fatty tumours generally are. The adhesions of adipose
tumours are, however, rendered firm and more numerous by pressure or
external stimulants—in fact, by whatever induces inflammatory action
in its substance or in its surrounding connections; and from this
cause the extraction is often rendered exceedingly difficult. The skin
becomes thickened and of a red hue, and the tumour itself is much more
vascular. From this cause it is apt to assume a new mode of action,
and to change in structure and in character, invariably for the worse.
I have removed a few tumours, originally of this benign species, but
which had apparently degenerated and assumed a malignant action. In
one, distinct indurated bands radiating from a central mass of the same
kind, are discernible. In two others, as a consequence of pressure,
condensation and ultimate softening had occurred. The largest alluded
to was removed from betwixt the shoulders of a soldier, and had borne
the pressure of his knapsack for eight or ten years. It was attached by
a thickish neck, presented the common lobulated appearance of adipose
sarcoma; but its external surface, its feel, and section, were very
different.

The patient does not complain of any pain or uneasiness in the
tumour, unless inflammation be excited in it; then the pain and other
symptoms are such as attend incited action, and the sensations which
are afterwards experienced vary according to the character which the
tumour assumes. Certain changes may occur in its texture, though
not in its general character or disposition; thus osseous or earthy
matter is occasionally deposited in some part of the tumour, while
the surrounding adipose substance retains its appearance and density.
Suppuration, it is said, has followed inflammatory action, excited in
an adipose sarcoma.


OF FIBROUS TUMOURS.

[Illustration]

Fibrous tumours are not uncommon, and are formed in various textures.
In general they are composed of a substance of a dirty grey colour and
considerable density, through which minute, firm, ligamentous fibres
ramify; in some cases irregularly, in others radiating from the centre
of the tumour. The new formation is surrounded by condensed cellular
tissue, to which it intimately adheres, and does not mingle irregularly
with the surrounding parts; in this respect differing from malignant
tumours, which occasionally contain fibrous matter. It cannot be
considered of an equally innocuous nature with those already described,
but is still, in its original state, not of a malignant disposition.
After some time, the consistence and structure of such tumours vary:
some are of a loose texture, and contain cells; others are hard, and
intermixed with cartilaginous matter, or even with bone. In general,
the tumour is slow in its progress, though it may attain a very large
size, as seen in the cut on the preceding page, if allowed to remain;
occasionally its growth is rapid.

Besides those tumours which have been described, there is a number of
others not of a malignant disposition, which are so various in their
structure as to baffle all attempts to reduce them to a scientific
classification. Some are composed of a homogeneous substance of
almost cartilaginous consistence and a whitish colour; some consist
of cartilaginous matter, mixed with substance of less density and
of a different appearance; in some, fibrous matter is mixed with a
homogeneous glandular-looking substance, partially softened. Some are
almost entirely composed of osseous matter; others contain it in small
proportion. It would be endless to enter into a minute detail of the
structure of such tumours, for it may be said that their appearances
vary with their number. In almost all tumours cysts are found, and the
internal structure of some tumours consists almost entirely of cysts,
or hydatids, as they have been called; in others, these only occupy
certain parts, and compose but a minor feature in the structure. The
sacs are generally lined with a delicate and smooth membrane, which is
often vascular at various points; some contain a transparent and glairy
fluid, albuminous or gelatinous; some bloody serum; some purulent, some
curdy matter, or this mixed with a serous or purulent fluid; some pure
blood; some a fluid like printer’s ink; and not a few are occupied by a
dense elastic substance, which, on a section being made of the tumour,
rises irregular and ragged above the cut surface. Some tumours are
smooth; others lobulated or tuberculated.


OF ENCEPHALOID TUMOURS.

The tumour which comes next to be described is decidedly malignant.
It is the Encephaloid, or Medullary Sarcoma. Although these tumours
have been called encephaloid and medullary, it must not be understood
that their intimate structure has any relation to that of the brain or
marrow; for this reason the old term _fungoid_ is perhaps a preferable
one, since it leads to no false notion as to their nature, while
it expresses a condition which at one time or other is remarkably
characteristic of them. This tumour consists of a homogeneous matter,
resembling the substance of the brain in colour and consistence It
rarely has a distinct cyst; occasionally it is subdivided by membranous
bands. It is always soft, though often more so in some parts than in
others; portions of it being frequently so much softened and broken
down as to resemble thick cream in consistence, and these are generally
of a darker colour, from being mixed with a greater or less quantity
of effused blood. Partial or universal softening only occurs after
the tumour has existed for some time, for in its original state its
structure and density are uniform throughout; and, on making a section
of it, some few drops of blood may escape from vessels, the coats of
which are of a very delicate nature. Some of these vessels seem to give
way, in consequence of the process of softening, for we frequently
meet with fluid blood, or masses of fibrin, in the midst of the pulpy
matter; and, when the softening has been extensive, the blood is
diffused throughout the whole substance of the tumour, so that it will
appear to be chiefly, or entirely, composed of effused and degenerated
blood, as here represented.

[Illustration]

The mamma and testicle, and the contents of the orbit in children, are
the most frequent seats of this disease; it not unfrequently occurs
in the lymphatic glands, and few textures can be considered as exempt
from it. The part at first enlarges slowly: but afterwards the disease
advances with great rapidity, involving the adjacent parts. In general,
the affection is not attended with much pain; the part has a spongy and
elastic feel, and frequently presents an obscure sense of fluctuation,
indicating that softening is more or less begun. The skin is tense,
generally brownish, and is pervaded by large venous branches. This
venous enlargement is always observable in the advanced stage of the
disease, before or after ulceration has taken place; it is peculiarly
evident in the eyelids, when the contents of the orbit are involved,
and is to be attributed to obstruction of the circulation in the deeper
vessels. The tumour is increased by the surrounding parts assuming
a similar action, and being converted into a similar mass; and the
disease also seems to be propagated by means of the absorbent system,
and by the irritation conveyed along the vessels which emanate from
the tumour, or from its immediate vicinity. Thus, when the testicle
or mamma is affected, the lymphatic glands, both above and below the
tumour, and the course of the absorbent vessels, are converted into
an encephaloid mass, all traces of their glandular structure being
completely destroyed. The same brain-like or cancerous matter is also
found in the bloodvessels, large and small. When the disease has been
of long duration, the superincumbent integuments appear tense, assume
a purple colour, and ultimately ulcerate; a portion of the pulpy
mass then protrudes, of a fungous appearance, the resistance being
at that point removed, and the compressed matter relieving itself by
the extension of a portion of its substance; the protruded portion
afterwards becomes discoloured, and sloughs, to be speedily reproduced
either by further dilatation, or by actual increase of the tumour;
unhealthy pus is discharged, often mixed with blood, and occasionally
slight hemorrhage occurs; the integuments become further ulcerated,
assume a dull brown colour widely around, and are undermined,
presenting a boggy feel.

Along with these local symptoms, there is a complete subversion of the
system,—there being at first symptoms of constitutional irritation,
afterwards those of hectic and extreme exhaustion. When the lympathic
glands are diseased, the limb beneath is much swollen from œdematous
effusion, the return of the blood and lymph being prevented; violent
and excruciating pains are experienced in the course of the nerves
of a limb; it also frequently loses its sensation, from those organs
being either involved in the disease, or pressed on by the tumour.
The vessels in the neighbourhood of the affected parts are materially
altered, though they are seldom converted into encephaloid matter; the
arteries are often completely obstructed by coagulating lymph for a
considerable extent, and the coagulum not only occupies the principal
trunk, but extends into the minute ramifications; and this explains
why hemorrhage seldom occurs, even after ulceration of the tumour is
far advanced; the veins also are frequently obstructed in a similar
way; but in many cases they contain a soft and pulpy matter, exactly
resembling the substance of the tumour. The fungus which protrudes
after ulceration of the integuments sometimes bleeds, when it would
appear that the hemorrhage proceeds from those bloody collections
in the substance of the tumour already mentioned. According to my
experience, when bloody points, or cysts containing bloody fluid,
exist in a medullary or other tumour which has been removed, and if
the diseased matter be reproduced, a bleeding fungus will almost
certainly follow. This species of tumour occurs in all ages and in all
situations, and during its progress evinces strong proofs of inveterate
malignancy: if removed early, the disease may be arrested; but if the
operation be long delayed, a tumour of a similar nature, and more
extensive, will almost invariably be produced. In several instances
I have removed encephaloid tumours, from the situation both of the
mamma and testicle, and the disease did not return; but in the other
cases the result has been as above stated. Encephaloid disease of the
internal organs frequently supervenes on that of the external parts,
and accelerates the patient’s dissolution; when in such situations they
are beyond the reach of surgical art, and their existence is only, if
at all, ascertained, in order to enhance the unfavourable nature of the
surgeon’s prognosis.


OF MELANOID TUMORS.

The Melanoid tumour is rather of rare occurrence in the human subject;
it originates in the cellular tissue, and most frequently attacks the
internal viscera; sometimes it occurs in the eyeball, where it has been
seen with the encephaloid disease, and occasionally melanotic matter is
diffused amongst the cellular tissue throughout the whole body, even
in that of the bones. The external surface of the tumour is generally
of a shining and mottled appearance; internally it consists of a
homogeneous black matter infiltrated into the cellular tissue, which is
condensed, and in some cases distinctly increased in vascularity. The
tumour, seldom of a large size, extends chiefly in a lateral direction.
Occasionally it is pretty firm; in other instances it is soft, broken
down, and semifluid. The melanotic matter is not always so deposited
as to form a distinct tumour, but frequently seems to be sparsely
infiltrated into the cellular tissue; and occasionally it is diffused
in so minute a quantity as merely to tinge the part, or form dark
streaks. Sometimes it is infiltrated in the substance of an organ, and
sometimes it is effused on its surface; occasionally it is surrounded
by a distinct delicate sheath; usually it is confined by no envelope,
excepting the partial condensation of surrounding parts. In the skin
it sometimes presents in a tubercular form. The tumour is said to be
chiefly composed of albumen, mixed with a peculiar colouring matter.
The disease mostly occurs in the trunk, seldom in the extremities;
it is not uncommon in the orbit, and in the internal organs the
melanotic deposits are generally both numerous and extensive. There is
seldom pain, and the patient seems to suffer chiefly from lassitude
and extreme debility, which gradually increase; anasarca frequently
supervenes; the functions of the organs affected are much impeded, or
even altogether destroyed, and thereby the sinking of the powers of
life is accelerated according to the viscera affected and the extent of
the disease. Melanosis occurs most frequently in advanced life, though
it is not confined to it; whereas encephaloid attacks indiscriminately
all ages.


OF CARCINOMATOUS TUMOURS.

The most malignant and intractable of tumours is the Carcinomatous.
This term is applied to the disease in its occult state, whilst Cancer,
a term pretty indiscriminately employed, may denote its condition
after ulceration. The word scirrhus is often used synonymously with
carcinoma; but the former has been, and still is, improperly employed
to denote indurations and enlargements of structures in all situations,
and has been altogether so much abused as to warrant its being erased
from the nomenclature of diseases. Carcinoma seldom occurs before the
age of thirty, and generally not till a later period of life; there are
instances, however, of its appearance at a much earlier period. Very
frequently it is not primary, but supervenes on adventitious formations
originally of an innocuous character, and which might have long
remained so. All tumours, though at first not of a hurtful tendency,
are liable to assume malignant action, either from a constitutional
cause, from external injury, or from latent disposition. When it
occurs in newly-formed parts, the surrounding cellular substance is
frequently condensed and thickened, so as to form a cyst round the
tumour; and when it supervenes on chronic tumours, the cysts which
enveloped these remain, for some time, as entire and distinct as
formerly, though the character of their contents is remarkably changed.
Afterwards the cyst may be contaminated with the same disposition as
its contents, assume the same action, and be converted into a similar
substance. When the disease is seated in the lymphatic glands, the
cyst is at first distinct, and gradually disappears; whilst in this
affection of the conglomerate glands a cyst is at no time perceptible,
and the cancerous matter insinuates itself, and is lost, in the
surrounding substance. The carcinomatous tumour is of great density,
and communicates a peculiarly grating sensation and noise when cut. In
its section there appears a central point, or nucleus, from which dense
ligamentous bands of a white colour proceed towards the circumference,
diverging in regular succession, as rays of light from a luminous
body; or the larger bands subdivide into smaller ones, which follow
a similar course with their parent trunk, or ramify regularly; or,
from the first, follow an irregular and intricate course, uniting with
and crossing one another, so as to present a retiform appearance. In
general, the interposed substance is of a greyish colour, extremely
dense, and generally homogeneous, though sometimes granular. Often
the ligamentous bands are so numerous, and so intimately interwoven,
as to leave little or no room for any intervening substance.
Sometimes, and most frequently in the advanced state of the tumour,
the greyish matter appears to have been broken down and removed,
its situation being occupied by a glairy or turbid fluid, by a soft
pulpy substance, or by blood; the parietes of such cysts are formed
by the whitish bands, which sometimes appear to be much thickened,
and coated with a membranous lining. The term gelatiniform cancer has
been applied to that kind in which the reticulated texture is filled
with glairy-looking fluid. Frequently, as has been already observed,
the external cyst or covering becomes assimilated to the substance
of the tumour, and the ligamentous bands then shoot forward into
the surrounding tissues, more especially the cellular and adipose,
establish a new footing for the disease, and thereby gradually enlarge
the boundaries of the original tumour. All parts in its immediate
neighbourhood become affected, and none withstand its morbid and
destructive influence; bone, muscle, ligament, skin, and membrane, are
successively or simultaneously involved; and even the bloodvessels and
nerves. From what has been already said, it is almost superfluous to
add that the tumour is most malignant, incessantly encroaching on the
neighbouring parts, and imparting to them its own disposition; and this
too frequently continues to exist after the removal of the primary
source of the evil. The disease, in its commencement, occupies a
minute and limited space, composed, it has been said, of enlarged and
varicose capillaries, interspersed with the peculiar matter of cancer.
It would even seem that these dilated aneurismal or varicose vessels,
in morbid growths, are from the first gorged with what has been called
heterologous matter. Judging from the imperfect account which has
yet been given of them, it would appear, from the observations of
Mr. Kiernan, that cancerous growths are entirely vascular in their
early stages,—composed, in fact, of capillaries filled with cancerous
matter, which shoot from the free surfaces of membranes in a flocculent
or villous form, having no albuminous matrix, as has been commonly
imagined in regard to adventitious growths generally; the progress
of the cancerous tumour appearing to depend on the multiplication of
the capillaries, their becoming remarkably varicose, tortuous, and
dilated, the dilatation being accompanied by thinning, by more or less
absorption of their coats, so as to allow of the escape partially of
the accumulated matter from their cavities. Thus may be formed a tumour
of unlimited extent. As the secerning vessels are excited to undue
action in all cases where they have to form and supply preternatural
growths, it is to be expected that they will in such cases become
enlarged. Accordingly, the enlargement both of the smaller arteries
and veins in tumours, generally, is a fact with which surgeons who
have been in the habit of operating on such parts must be familiar.
Farther, the enlargement of the capillaries in inflammation has been
shown by the experiments of Hastings, and Thompson; and Mr. Gulliver,
who informs me that he has seen pus in the capillaries of a suppurating
surface, remarks, in regard to the observation of Professor Müller, as
to the capillaries having only the diameter of a blood corpuscle, that
these vessels become during suppuration sufficiently dilated to admit
of rows of pus globules. Thus, during the formation of an ordinary
product of inflammation, the capillary vessels are enlarged; and if
excited to still further activity, and for a more protracted period, in
the nutrition and formation of tumours, the minute vessels will become
still more dilated, and filled with other materials than purulent
matter. In a melanotic eye, which I lately examined with Mr. Dalrymple,
there was a part in which the black matter seemed to be contained
within the capillary vessels.

The cancerous tumour afterwards presents a stony hardness, is generally
of a globular form, and irregular and unequal in its surface. At a
still later period it gradually enlarges, in the way already mentioned,
remains moveable for some time, but ultimately becomes fixed by the
increased extent of its connections. By these circumstances it may,
in general, be distinguished from the tumours which, from the first,
occupy a wide space, and are firmly fixed by intimate connections
with the surrounding parts. When the tumour has once been developed,
its progress is slow and steady, being arrested, or made to recede,
neither by the efforts of nature nor by the interference of art. Pain
is generally complained of in the region of the tumour, and is of a
lancinating kind, compared by the patient to the passing of sharp
instruments through the part; occasionally, however, there is no pain
in the new formation, and little inconvenience is caused by it. When
the disease is left to itself ulceration occurs, frequently at an
early period; but sometimes only after the tumour has been of long
duration. The superimposed integuments appear stretched, change their
natural colour, assume a dusky or livid hue, become attenuated, and
ultimately give way; the breach of surface not being caused by tension
and pressure, but by the parts having assumed an action similar to that
of the tumour. The ulcerated point slowly enlarges, a thin ichorous
fluid is discharged, the surrounding integuments are of a dusky red,
and the margins of the ulcer are thickened, callous, everted. Whilst
the destructive action proceeds in a lateral direction, it at the
same time advances towards the more deeply-seated parts, the cavity
becomes excavated, irregular, and ragged; and the parts seem to be
destroyed partly by ulceration and partly by sloughing. The exposed
surface seldom aims at reparation; and when it does, the granulations
are greyish, hard, warty, and endowed with but little vitality; never
investing the whole surface, but protruding from certain points,
and presenting somewhat of a fungous character. The thin unhealthy
discharge becomes profuse, and exhales a peculiarly fetid odour, highly
offensive to the patient and attendants. By these means the ulcerated
cavity may attain an enormous size, presenting a most disgusting
and lamentable spectacle. If the patient bear up under the profuse
discharge, the greater part of the original tumour may be destroyed by
the ulceration, and some attempts may be made at cicatrisation; that is
to say, the cavity may contract, and granulations be formed: but these
are always unhealthy, and, in fact, carcinomatous, and often bleed
profusely. New skin is seldom formed, the remaining parts resume their
virulency, and the process of destruction again advances, surpassing
the former both in extent and rapidity.

[Illustration]

Along with these local symptoms and appearances, it can be readily
understood that the constitution is, from the first, materially
affected. The alimentary organs are deranged in function, the patient
has a wan and sallow countenance, and is in general weak and much
emaciated. After ulceration, the system is still more reduced by the
discharge, the patient becomes hectic, and is often afflicted with
diarrhœa; along with the other symptoms of extreme debility, the
patient may become anasarcous, is affected with cough and dyspnœa, or
by other symptoms indicating disease of some internal organ, and is
ultimately carried off in a state of exhaustion.

The disease attacks various textures, but perhaps most frequently the
mammary gland. The mamma generally diminishes in size from absorption
of the fatty matter; the nipple is retracted, often to a great
degree, and the surrounding integuments are of a purplish hue, and
exude a sanious fluid; at length the nipple is completely destroyed
by ulceration. In other instances the tumour is large, and there is
a hard œdema of the integuments; the skin is thick, coarse, and of a
dark red colour. The tumour soon adheres immoveably to the subjacent
muscles and ribs, converting the contiguous portion of the former into
a substance similar to itself. There may be other varieties in the
appearances and symptoms of carcinoma; but the above are those which
are most frequently observed, and are sufficient to denote the general
character of this species of tumour, and to show its peculiar and
inveterate malignancy.

Ulcers or swellings, at first simple, may assume a malignant action,
either carcinomatous or of another kind; thus, in one instance,
a simple ulcer, produced by a burn, assumed a foul and unhealthy
aspect; and ultimately degenerated into a most malignant sore. Various
malignant actions commence in glands of the conglobate or conglomerate
kind, at first simply enlarged from irritation or injury. The female
breast often becomes indurated from a blow, or from milk abscess, and
remains for a series of years, half a lifetime perhaps, without any
perceptible change in the enlargement and induration; but the tumour
frequently is roused into activity at the critical time of life, and
malignant action ultimately commences. The menstrual period ought to be
particularly attended to in affections of the mamma more especially,
but also in all tumours and ulcers; for both during and before it
tumours become larger and more painful, the whole system appears to be
excited, then relaxed, and all morbid actions seem to possess increased
activity.

In this disease, as in soft cancer, as it has been called, (and
they occasionally pass into each other,) the bloody masses, or sacs
containing bloody fluid, are to be dreaded, and when they exist are
to be considered as very unfavourable; for if, on the removal of a
carcinomatous tumour, such appearances be found, the disease will
certainly return; a new tumour, of even a worse character than the
preceding, will be formed; a fungus will be protruded, and from this
hemorrhage will occur.

The lymphatic glands, both above and below the tumour, generally
enlarge early in the disease, become hard, and cut like cartilage,
and with a grating noise. Frequently they become converted into a
dense and fibrous substance, resembling carcinoma; sometimes they are
softened and broken down at several points, and contain a purulent or
bloody fluid. They enlarge, coalesce, and form irregular masses, which
rise more and more above the surface; the superimposed integuments
give way, and then occur those destructive ravages by ulceration and
sloughing already described. The lymphatic vessels entering these
tumours and emerging from them feel hard and wiry, as if thickened.
The integuments in the neighbourhood of the tumours, and in the course
of these absorbents, are of a blue colour, and the veins enlarged and
tortuous; the limb below the enlargement swells and is œdematous. The
absorbents often become affected months or even years after the removal
of the original and exciting tumour; the immediate cause being taken
away, yet the inherent disposition to malignant action is too often
left, not to be eradicated. In fact, the disease generally returns,
either in the original integuments, in the form of tubercles or buds,
in the cicatrix, or in the glands; very frequently all are affected. It
seems also to spring not unfrequently from fascia. Such enlargements
of the glands have been said to arise, in the first instance, from
irritation, and not from any participation in malignant action; and on
this supposition, though in general extremely incorrect, cruel, bloody,
and unnecessary operations have been performed.

Cancer seizes either the mucous or the cutaneous surface, with hardness
and a warty excrescence; this ulcerates, and is surrounded by a
hardened base. The process of destruction advances, and the ulcerated
part presents the same appearances as those of a sore arising from a
similar action in a deeply-seated carcinomatous tumour. The glands also
enlarge, and assume the same aspect as if they had been the original
seat of the disease. Some pathologists seem disposed to deny this, but
apparently on no very sufficient grounds.


FUNGUS HÆMATODES

Has been much confounded with medullary sarcoma, but the two diseases
are materially different. Fungus hæmatodes almost always supervenes on
other morbid formations, when they have been ulcerated and exposed;
and the particular formation which most frequently precedes is the
medullo-sarcomatous; a bleeding fungus, however, occasionally protrudes
from tumours of a different character, which, though they may have been
at first simple, have degenerated, ulcerated, and assumed a malignant
action. The disease certainly does not occur so frequently as some have
asserted; for many, instead of limiting the application of the term
to those fungous protrusions which bleed, honour with the appellation
of fungus hæmatodes every growth which protrudes after the ulceration
of a tumour, and every tumour which is unusually prominent, of soft
consistence, and of a somewhat fungous appearance, although such have
never shown any disposition to bleed, either spontaneously, or from
irritation. But fungus hæmatodes, as the name implies, is truly a
fungus which resembles blood; and as bloody or blood-like tumours are
formed from the rupture of some vessel of rather a large size, and
as they almost invariably evince a tendency to profuse hemorrhage,
as a necessary consequence of the mode of their formation, the term
is correctly applied only to those fungous growths which either have
at one time emitted a discharge of blood, and exhibit symptoms of a
recurrence of the hemorrhage, or which frequently pour out a quantity
of blood, sometimes inconsiderable, but often profuse, and generally
altogether uncontrollable. In short, the circumstances necessary to
entitle a morbid formation to the appellation of fungus hæmatodes are
a fungous structure and appearance, and hemorrhage proceeding from it
to a greater or less degree, and with more or less frequency. Fungi are
frequently met with, but there are certainly few hæmatoid fungi.

The excrescence is generally of a dark colour, resembling a mass of
coagulated blood, but of more soft consistence, and its extremity has
often a sloughy appearance. It is evidently organised; for, on being
injured even in a very slight degree, hemorrhage ensues from the part
which has been broken or contused, and frequently the growth bleeds
spontaneously. At first the hemorrhage is in general slight, but is
often repeated, becomes very profuse, and in most instances cannot be
arrested. The vessels in the substance of the morbid mass are diseased
in their coats, and have altogether lost their power of contraction;
they give way either spontaneously or by laceration, and by their
non-contraction they appear to serve merely as passive tubes, through
which the blood is poured out by the active vessels which supply them;
the latter are not exposed to any of the causes which tend to produce
speedy obstruction of their canals, therefore continue to transmit
their contained fluid through their subservient branches, and from this
the uncontrollable nature of the hemorrhage can be accounted for; from
the number of vessels which supply the new structure, and which are
thus employed, it can be readily imagined that the hemorrhage will be
profuse. In many instances, the application of firm pressure on the
limb above the seat of the disease is even insufficient to arrest the
flow of blood; and though this may, in some degree, be explained by
supposing the continued stream to be venous, still it must be confessed
that the disease appears connected with a peculiar hemorrhagic
tendency. Frequently the fungus is found to communicate with, or rather
to arise from, numerous cysts of a glossy appearance, from which also
blood is copiously effused. The surrounding tissues are completely
disorganised in the immediate neighbourhood, and also much altered in
structure for a considerable extent around; the muscles, besides their
disorganisation, have acquired a peculiar brown hue. Sometimes the
hemorrhage does not seem to proceed so much from the fungus as from
the subjacent cysts; for when a superficial incision or puncture is
made into it, the bleeding is often inconsiderable, and only becomes
alarming after masses of coagulated blood have been removed, and the
cysts thereby exposed. Occasionally the fungus communicates with a
cavity of enormous size, filled with blood, partly coagulated and
partly fluid, and from the parietes of which the hemorrhage proceeds.
When the disease has supervened on a medullo-sarcomatous tumour,
the coagulated blood is mixed with a substance resembling the brain
in a state of putrescence. It may supervene on polypous tumours,
particularly of the antrum; and of this I have seen several instances.
Sometimes it is produced after the removal of a tumour apparently
not of malignant character, and in this case it frequently does not
appear till the wound has almost cicatrised. When once established, it
proceeds with all its virulency. The diseased parts may be removed as
frequently as they appear; but they will be reproduced, and the disease
will assume a still more frightful aspect, both in extent and malignity.

In consequence of the repeated and profuse loss of blood, the patient
is gradually worn out, becomes hectic, is affected with nausea,
vomiting, and indistinct articulation, with all the symptoms of extreme
debility, and he generally sinks exhausted, or may be suddenly carried
off by profuse hemorrhage.

The size of the bleeding fungus is extremely various, but it is rarely
large; in fact, we frequently find that the most violent hemorrhage
occurs from those of a small size; and in illustration of this, I
shall briefly relate the following case. A man, aged forty, had been
afflicted for some time with ulceration in the ham, and exfoliation
of the posterior part of the femur. The sore healed; but about two
years afterwards the cicatrix became ulcerated, and produced a very
small fungus, resembling, in fact, a minute cluster of exuberant
granulations: from this blood was effused in small quantity, and was
easily restrained by the application of a bandage; but the hemorrhage
returned at various intervals for upwards of a week, became extremely
profuse and altogether uncontrollable. By this the patient was
greatly exhausted, and amputation was rendered absolutely necessary.
On examining the limb, the lower portion of the femur was found
somewhat enlarged, its internal structure completely destroyed, and
the periosteum on the inner side much thickened. On the posterior and
inner part of the bone, about three inches above its articulation,
there was a small fungous tumour of an irregular surface, and of soft
consistence, resembling congealed tallow. From this excrescence the
blood had been effused into a cyst formed amongst the muscles, and
afterwards discharged externally. He recovered from the amputation, and
remained well.


THE PAINFUL TUBERCLE.

Though of small size, and not possessed of malignant action or
disposition, is a tumour of very great interest, on account of the
excruciating pain with which it is accompanied. It is mostly situated
in the subcutaneous cellular tissue, but not unfrequently in the
intermuscular cellular substance; one tumour of this species which I
have removed was so deep as to be in immediate contact with the sheath
of the posterior tibial nerve. The tumour, generally of the size of a
garden pea, rarely exceeds that of a cherry. It is invested by a dense
ligamentous cyst, to which it intimately adheres; but occasionally
the capsule is thin and cellular: in many instances its surface is
perfectly smooth, in others it is slightly nodulated. It is not
connected with any large nervous trunk; but minute nervous fibrillæ
can occasionally be traced expanding on its surface, and apparently
entering its substance. Internally it is composed of numerous whitish
fibres, of considerable density, ramifying irregularly throughout
its structure; and betwixt these is insinuated a firm substance,
generally of a grey colour, and frequently of an almost cartilaginous
consistence. Such is the structure most frequently observed; but in
this morbid formation, as in all others, the appearances may be said
to vary in almost every instance. Sometimes the fibres are indistinct,
and of a yellowish or dirty grey colour; and the interfibrous matter
is often found to vary in density and colour in different tumours,
being at one time dense and almost transparent, at another opaque and
cartilaginous, and sometimes rather soft, brownish, and occasionally
tinged with blood. From attentive examination, it appears extremely
probable that the enlargement is at first produced by infiltration of
lymph betwixt the fibrillæ of a nervous twig, which becomes separated
and inclosed by the deposit—that they afterwards increase in size—that
the interfibrous matter is deposited in greater quantity, and is
farther condensed—and that thereby the nervous filaments are still more
separated and extenuated. In short, it would appear that the fibrous
matter is nervous, though altered, and that the interposed substance
is organised and condensed lymph. The tumour, at first extremely
minute, enlarges slowly; when deep, it can only be obscurely felt,
and its existence is with difficulty discovered by manipulation; but
the attending symptoms are so peculiar, and so forcibly developed,
as to lead the surgeon at once to an accurate diagnosis. When it is
subcutaneous, the skin is rendered slightly prominent, and the size,
density, and loose connections of the growth, are readily ascertained.
The slightest pressure causes the most excruciating torments, and
totally unmans the patient, even though induced by the most trifling
movement of the adjoining muscles. From a fearful and well-grounded
knowledge of this circumstance, the patient is extremely anxious to
preserve the limb in a state of complete rest, and, in fact, he is
often wholly unable to use it; although the part is completely set
at rest, still he frequently suffers from paroxysms of severe pain,
commencing in the tumour and shooting through the limb. The painful
sensations are sometimes very much alleviated by gentle friction with
the hand. The disease is most frequent in the extremities, and in the
inferior more than in the superior.

The larger nervous trunks sometimes become diseased, being affected
with an enlargement resembling the structure and appearance of the
preceding tumour, and such enlargements are termed _Neuromata_.
Occasionally a portion of a nervous trunk is thus enlarged, from a
blow or wound; and sometimes there can be no cause assigned. Nerves
when divided, become bulbous on that extremity towards their centre.
In stumps this is well seen; whilst all the tissues entering into it,
after a time shrink, and become more or less atrophied (bone, muscles,
vessels, &c.), the extremities of the nerves swell out and present
a bulbous appearance. When these tumours are connected to, and only
covered by, integument, or when they are adherent to the ligamentous
substance covering the bone, and become exposed to pressure, as in
badly made stumps, the patient often suffers excruciating agony. The
nervous trunk above is, in general, slightly enlarged, sometimes has a
tortuous course; and in some instances the neurilemmal bloodvessels are
considerably increased in size. The same symptoms exist, though in a
less acute form, as in the painful tubercle.


OF POLYPUS.

A common species of tumour is that which is attached to a mucous
surface, and is called POLYPUS. Polypi vary in structure and
disposition; some are simple and benign, others are most malignant.
The simple mucous polypus has a shining appearance, being invested
by an extremely delicate membrane, in some degree resembling the
mucous, and moistened by a fluid similar to the mucous secretion; it
is of soft consistence and homogeneous structure. They are generally
light brown, sometimes greyish, and in some degree diaphanous. They
are connected to the mucous membrane by a narrow pedicle; generally
occur in clusters, and are of pyriform shape; one or more are often
suspended from one narrow base, and they seldom attain a large size.
They possess but little vascularity, though occasionally minute
vessels are seen ramifying pretty freely on their surface, and may be
considered as almost devoid of sensibility. The malignant polypus,
on the contrary, is always attached to the mucous membrane, and also
to the subjacent parts, by means of a broad base; and its form and
structure vary according to the particular action which it has assumed.
Most frequently it is encephaloid, of an irregular form, and often
presenting a cauliflower appearance, its surface being studded with
numerous excrescences of medullary consistence and colour. Such tumours
will be afterwards treated of, as occurring in different situations.


OF ENCYSTED TUMOURS.

Along with these have been classed the enlargements of bursæ, sheaths
of tendons, &c., but with equal propriety might we include hydrocele
and other collections in natural cavities. Encysted tumours are
almost always situated superficially. The skin is distended, seldom
inflamed, and often contains enlarged bloodvessels, which give it a
streaked appearance. They consist of an external cyst, which is in some
instances extremely thin and delicate, in others dense, of considerable
thickness, and composed of fibrous looking substance, occasionally
it is almost cartilaginous; the internal structure may be said to be
almost always more or less fluid, but varies much in consistence. The
tumour is surrounded with condensed cellular substance, which is of
greater or less thickness and strength according to the size of the
tumour. Some of these tumours are supposed, and on good grounds, to be
mere enlargements of the natural mucous follicles, in consequence of
obstruction in their ducts, by hardened and vitiated secretion; the
cyst, therefore, will be at first thin and delicate; its contents will
resemble the natural secretion of the follicle, and in many cases may
be readily squeezed out. There is a black point on the most prominent
part, marking the obstructed orifice of the follicle, and the sac is
found at this point to adhere firmly to the skin. Even after all other
marks of its original formation have disappeared, the situation of the
orifice is sometimes indicated by small dark spots, by depression, or
by a minute ulcer.

Encysted tumours, or wens, as they have been called, often appear
to be hereditary; seldom occur single, and are met with under the
surface of all parts of the body. They have been divided into different
classes, according to the nature of their contents: _Atheromatous_;
containing curdy matter; _Meliceritous_, containing a substance like
honey; and _Steatomatous_, containing fatty matter, generally in
a semifluid condition. But such terms are not adequate to express
the nature of all encysted tumours; they are extremely various in
their actions, and their contents vary according to the particular
secretory action which the lining membrane of the cyst assumes; for
the same reason, also, the contents of a tumour will differ in the
different stages of its progress. Some contain a thin, fetid, brown
fluid, mixed with solid particles, resembling half-dissolved fibrinous
matter; in some the contents are serous, or seropurulent,—in others
they are gelatinous; whilst in those which have become inflamed from
external irritation, the contents are altogether purulent, or contain
a very considerable proportion of that fluid; not unfrequently the
cyst is covered internally by a layer of calcareous matter, to which
similar particles are loosely attached. Sometimes, in consequence of
irritation, organisable matter is poured out on the inner surface of
the cyst, adheres firmly to its inner surface, and is often disposed in
concentric laminæ.

[Illustration]

Sometimes, though rarely, the most prominent parts of the tumour
ulcerate, and on the exposed surface is deposited a substance of
semifluid consistence and gelatinous appearance, which afterwards
increases in density, and ultimately assumes all the characters of
horn. This hard excrescence in some instances increases only to a
slight degree, and afterwards remains stationary; in others it attains
a large size, and occasionally assumes a curved or tortuous form,
like that of the horns of inferior animals. Horns are generally met
with on the forehead, and the scalp may be said to be their seat. The
largest which I have seen, measured seven inches in length, and two in
circumference; but others have been removed still larger.

In many encysted tumours, hairs grow from the internal membrane of the
cyst, often numerous, and are generally found in those situated on the
eyelids; in some the hairs are destitute of bulbs, lie loose within
the tumour, and are often rolled into a globular form. The adhesions
of these tumours are in general very slight and easily broken up, but
when seated amongst tendons, or in unyielding parts, they are often
extremely firm. Violent inflammatory action may follow injuries of the
tumours, or the making of even minute openings into them; suppuration
occurs, the discharge is thin, fetid, and often bloody; there is much
pain, and frequently severe constitutional irritation. Occasionally
a fungus, bleeding or not, is protruded through the aperture; more
frequently, however, the opening heals, and the tumour remains as
before. External injuries sometimes appear to check the secreting
action, and to excite the absorbents to remove the morbid growths,
and this with or without rupture of the cyst. Thus, in the case of
an encysted tumour the size of a hen’s egg, on the external lateral
ligament of the knee joint, free and pretty rough manipulation was
necessary to ascertain its nature and exact situation; in consequence
of which, the tumour gradually disappeared, and no traces of it
remained twelve days afterwards. Others of less size, I have known to
disappear in a much shorter period.


OF TUMOURS OF BONES.

The vascular action of bones, in their healthy state, is feeble, but,
as in other feeble parts, it is easily excited, and disease of an
obstinate and unyielding nature is apt to follow.

The morbid growths vary much in texture. The most frequent are the
osseous, or those of the same structure with the original bone;
but even these differ much in the density and arrangement of their
particles: they have been termed _exostoses_. They may be of great
density, and are then called the hard, or ivory; these never attain a
large size, seldom exceed that of a bean, have a smooth and polished
surface, and are of a flattened and hemispheroidal form, their greatest
circumference being at the base; they occur in many of the bones, but
generally in those of the cranium and face.

Others, being of a more loose and spongy texture, have been called
cancellated. These are commonly formed by the bones of the extremities,
and often attain a very considerable size; they grow from the
periosteum, or from the outer surface of the bone, and are then
covered by an expansion of this membrane. Sometimes they adhere by a
narrow neck, and expand into a bulbous form, so that they can be very
readily removed by operation, and are very apt to be broken off by
external injury. Others have a broad and firmer attachment, and are of
an irregular shape, often projecting in the form of a large spicula,
and at other times assuming a somewhat stalactical appearance. Such
frequently prove the source of much inconvenience, by impeding the
motions of the muscles, or disturbing the functions of any adjoining
organ. They possess no malignant disposition, but are under the same
laws, though perhaps in a less degree, with their parent trunk.

On making sections of exostoses, and of the bones from which they
arise, some appear to be mere enlargements or processes of the
parent bone, the cancellated tissue extending itself so as to form
the interior of the exostoses, whilst the exterior resembles a
proportionate extension of the outer lamina. Others are evidently
formed by the deposition of osseous matter externally to the outer
lamina, many being dense and compact throughout, others containing an
internal cancellated structure, but which is not continuous with that
of the bone, as it is separated by the natural outer lamina. Their
formation appears similar to that of the fœtal bones: a glutinous
matter is effused, becomes dense, and is converted into cartilage;
bloodvessels shoot into it, ramify throughout its whole structure in a
radiated form, and deposit osseous matter. This deposit increases, and
extends from a central nucleus towards the circumference; the cartilage
is in part absorbed, and the new structure becomes osseous, and similar
to the original tissue by the vessels of which it was formed. These
tumours, even when they have attained a large size, contain a mixture
of bone and cartilage, covered by a dense fibrous investment. The bony
matter is arranged in spicula, adhering to the surface of the shaft or
head of the bone, and projecting into the morbid mass: the spaces are
filled up by a cartilaginous substance. The growth is sometimes rapid,
and the tumour soon becomes troublesome from its immense size.

Frequently a bone is much enlarged throughout its whole extent, or the
greater part of it, and presents a cancellated texture: sometimes,
also, it is much thickened, and, at the same time, of great solidity;
but such enlargements cannot be considered as tumours of bones, or
exostoses, any more than those nodules of new osseous matter, which
are effused in consequence of inflammation of the osseous tissue. The
most frequent cause of exostoses appears to be external injury; their
progress is slow, attended with slight dull pain, and often accompanied
with no inconvenience; their existence can be readily ascertained,
a hard and immoveable body being felt where no bone exists in the
natural state of parts; but when the tumour projects into an internal
cavity, the diagnosis is rendered obscure. Most frequently, they remain
stationary, after having attained a certain size, and are productive
of little inconvenience, the surrounding parts having accommodated
themselves to the new formation. Occasionally, suppuration occurs in
the soft parts, the matter comes to the surface, and a troublesome
abscess is formed.

To this class of tumours would I confine the term exostosis, not
including those consisting of softer materials, and possessed of a less
benign action.


OF OSTEOSARCOMA.

[Illustration]

By this term is meant, an enlargement and alteration in the structure
of a bone, accompanied with the deposition of a morbid sarcomatous
substance internally. This morbid change appears to be the consequence
of inflammation, and its origin is frequently attributed to some
mechanical injury or local irritation. In the commencement of the
disease, the bone is slightly enlarged, perhaps somewhat thickened
in its outer laminæ; and on a section of it being made, is found to
contain a brown fleshy substance instead of its cancelli. This appears
to be formed in consequence of a morbid action, perhaps inflammatory,
of its internal structure. By the pressure of the new formation, the
parietes of the bone are pushed outwards, in some cases attenuated,
in others thickened by deposition of new osseous matter, inflammatory
action having been induced by the pressure. As the internal formation
increases, the parietes are extended, and are generally much
attenuated, becoming in some places thin as paper, and diaphanous; they
also would seem to lose a portion of their earthy matter, for they are
flexible, somewhat elastic, and not of their usual density. Frequently
they are in several places deficient, and their situation occupied
by a membranous expansion, sometimes thin and delicate, but mostly
thick and ligamentous; in some cases, the external lamina appears to
be converted into a substance resembling the internal growth, with
which it is continuous. The investing periosteum is much thickened,
and its bloodvessels are enlarged. Occasionally, the deficiency of
the bone is not supplied by any membranous expansion, and the morbid
growth protrudes, fungous. The internal structure varies much in
appearance; generally it is brown and soft, in some places broken down
and mixed with a dark-coloured fluid, or with gelatiniform matter;
sometimes it is much more dense, and resembles cartilage; in others,
the cavity contains an ichorous fluid, mixed with small portions of
more solid matter; in the advanced stage of the disease, the contents
are often of the encephaloid nature, either in its homogeneous and
solid form, or softened, broken down, and mixed with blood, or with
a lard-like substance. Sometimes the cancelli of the bone are not
destroyed, but extended, forming numerous cavities of considerable
size, in which the morbid matter is deposited; in other instances,
there is no appearance of cancellated structure, and the diseased mass
contains rough osseous spicula, some detached, some loosely connected
with each other, and others projecting from the inner surface of the
bony parietes of the tumour. At the commencement of the disease, the
patient feels acute pain in the part, the constitution is disturbed;
afterwards, the pain becomes more dull, and there is a considerable
swelling externally, which feels hard, and slightly elastic; in the
advanced stage, the pain again becomes severe, and is of a lancinating
kind, and the system is much deranged, the tumour is softer, often
presents a sense of distinct fluctuation, and on being freely handled,
is found to crepitate, in consequence of the loose spicula of bone
rubbing upon each other. Ultimately, the integuments become tense,
livid, or dark-red, ulcerate, and allow a portion of the softened
tumour to protrude, in the form of a frightful fungus; there is profuse
discharge, thin, and sometimes bloody; there is much constitutional
irritation, and the patient is greatly exhausted. Not unfrequently,
during the progress of the disease, especially in the long bones,
fracture occurs at the diseased part, either from external injury, or
sudden muscular exertion. This occurred in the case from which the
specimen here delineated was obtained some months before the patient
submitted to amputation. The morbid structure had not broken through
its periosteal investment. The muscles and their interfilamentous
tissue were sound. The patient remained free from any return of the
local disease. Bones so affected, when broken, do not unite, the
movement of the loose and rough ends is a cause of much irritation:
inflammatory action is kindled in the morbid structure, suppuration
occurs, the integuments give way, and ulcerate to a greater or less
extent, and the advancement of the disease is thus much hastened. The
tumour may be safely pronounced malignant; it is true, that for some
time it shows no tendency to involve the adjoining soft parts, further
than by the effects of inflammation induced by its pressure; but then
it is limited by the external lamina of the bones, which confines
it to the tissue in which it originated; but after this barrier has
given way, the tumour projects through the aperture, contaminating the
adjacent soft parts, imparting to them a morbid action, and extending
also in the cancellated tissue of the shaft of the bone. In some cases,
the integuments are tense and discoloured, with large vessels running
on their surface; the tumour feels soft and fluctuating, though the
skin may not ulcerate till long afterwards. Perhaps the most common
seat of this disease is the under-jaw, but it may occur in any of the
bones; when it has been of chronic duration, not one bone but several
are affected; and in one case which I saw, the disease commenced in the
under-jaw, which it deformed to a frightful degree; almost every bone
in the body was similarly, though less extensively diseased; this could
be readily observed during the life of the patient, and was confirmed
by dissection. From this, it appears, that the affection is not only
dependent on local causes, but connected with a morbid state of the
constitution, predisposing to it, and cooperating with its exciting
cause.


There are other tumours of bones in some degree resembling, which
do not strictly come under the term Osteosarcoma. Some are wholly
cartilaginous, the disease commencing in their centre, and involving
their entire substance, emitting a gelatinous fluid when cut, but
containing no cells; others are not uncommon, partly osseous, and
partly cartilaginous, containing cells filled with a glairy fluid;
others are composed of cartilage, intersected with dense fibrous
matter, in a greater or less proportion. In fact, the individual
tumours of bones vary as much from one another as those of the
softer tissues; scarcely two are alike in their progress, action,
or anatomical characters. Irregular spicula of bone are found in
many parts of their structure; in the same way that portions of bone
often exist in tumours having no connection with the bones; in many
places they are softened and broken down, the partitions between
the cells are destroyed, and these contain a pulpy mass of a dark
sanious appearance. On making a section, they are observed to be
continuous with the interior of the bone, which is converted into a
substance similar to themselves, or is of a more soft and medullary
character. The external surface becomes tuberculated, the integuments
are painful, and changed in appearance; they ulcerate, the tubercles
burst, the discharge is thin and bloody, the ulceration extends; not
unfrequently a fungus protrudes, and occasionally bleeds; this may
slough, the tumour becomes farther exposed, portions of it die, and
are discharged, unhealthy fungous granulations project from amongst
the cancelli of the tumour, and emit a sanious putrid discharge, often
bloody; severe constitutional irritation accompanies this state, the
patient becomes hectic, is much exhausted, and sinks, unless the morbid
parts be removed. There are also tumours of bones, composed partly of
cartilaginous or fleshy, or partly of osseous matter, arising from the
periosteum and outer shell of the bone, and these often acquire a great
magnitude before the diseased mass reaches the interior or medullary
part of the bone.


SPINA VENTOSA.

By this term is understood a mere expansion of a bone from a collection
of matter in its substance. The disease may be produced by external
injury, exciting inflammation, and consequent suppuration, in the
cancellated tissue; or in a weakened and unhealthy constitution, the
action may be of a chronic nature. The fluid accumulates, the cancelli
are broken down, and the much-attenuated parietes of the bone are
pressed outwards. Occasionally inflammatory action is excited on
the external surface, from the pressure of the contained fluid, and
minute nodules of bony matter are effused, as if nature endeavoured
to strengthen those walls which are daily becoming thinner, and
more incapable of supporting the weight of those parts which they
encircle. The disease differs from Osteosarcoma in the contents being
uniformly fluid, generally purulent, though often mixed with more
liquid and dark-coloured matter, or with a curdy substance—in the
gradual extension of the bone—in no fungus protruding after a portion
of the attenuated bone has given way, matter being discharged as
from a common abscess; and in the tumour not possessing a malignant
disposition. At first there is considerable pain in the part whilst
the matter is forming, but afterwards it becomes much less acute, and
in many instances there is no inconvenience, except from the bulk of
the tumour. Often after having reached no very large size, it becomes
stationary, neither recedes or enlarges, and all painful sensations
cease; in other cases it enlarges gradually, attains an enormous
size, and produces much disturbance of the constitution; but in such
instances the patient is generally weak and cachectic. The largest
tumour of this species which I have seen, occurred in the lower part of
the femur. It measured, in breadth, seven inches, in length, seven and
one-fourth. The parietes were composed of an extremely thin lamina of
bone, and in this there were numerous deficiencies supplied by delicate
ligamentous matter; its cavity was divided into several compartments by
thin septa, partly osseous and partly membranous. A representation of
the femur so affected is given in the _Practical Surgery_, p. 350. The
patient was a boy of twelve years of age; amputation of the limb was
earnestly advised, the friends objected, he died hectic.


ANEURISMAL TUMOURS.

Besides these tumours a species of an anomalous character is sometimes
met with, appearing to arise from an aneurismal or varicose state
of the venous radicles or capillaries, and partaking somewhat also
of the nature of fungus hæmatodes.[21] I shall detail shortly the
more important circumstances of one case. The patient, a lad aged
sixteen, was admitted into a public hospital on the 7th of November,
1819, on account of a tumour over the left scapula. It was there
deemed imprudent and inadvisable to attempt operation; and, after the
application of leeches, he was dismissed, at the end of eight days.
He then applied to me. The tumour was very large, hard, inelastic,
firmly attached to the left scapula, and extending from its spine over
all its lower surface. It also stretched into the axilla to within
half an inch of the nervous and vascular plexus, and a large arterial
trunk could be felt along its under surface. The arm hung useless,
and, from the wasting of its muscles, was hardly half the size of the
other. According to his own account, the uneasiness produced by the
tumour was trifling when compared to the lancinating and excruciating
pains in the limb. On attempting to move the tumour independently of
the scapula, crepitation was distinctly perceived, as if from fracture
of osseous spicula. A tumour was first perceived about three months
previous, situated immediately below the spine of the scapula, about
the size of a filbert, of a flat form, and attended with distinct
pulsation; it had subsequently increased with great rapidity. About ten
days before his admission into the hospital, it had been punctured;
nothing but blood escaped. It was evident, from the rapid growth of
the tumour, and the severity of the symptoms, that the patient would
soon be destroyed if no operation were attempted. There were no signs
of evil in the thoracic viscera, the ribs and intercostal muscles were
unaffected; though the tumour was firmly fixed to the scapula, yet that
bone was moveable as the one on the opposite side, and the vessels and
nerves in the axilla were quite unconnected with the swelling. The
operation was commenced by making an incision from the axilla to the
lower and posterior part of the tumour. The latissimus dorsi was then
cut across at about two inches from its insertion, so as to expose the
inner edge of the tumour, with a view to tie the subscapular artery
in the first instance; in this, however, I was foiled, owing to its
depth. The dissection was proceeded with to where the branches from
the supra-scapular were expected to enter. In detaching the tumour from
the spine of the scapula, the knife and fingers suddenly dipped into
its substance. This was attended with a profuse gush of florid blood,
with coagula; by a sponge thrust into the cavity, the hemorrhage was in
a great degree arrested; at the same time an attempt made to compress
the subclavian failed, on account of the arm being much raised to
facilitate the dissection in the axilla. The patient, exhausted, made
some efforts to vomit, and dropped his head from the pillow, pale,
cold, and almost lifeless. Then only the nature of the case became
apparent. The sponge being withdrawn, one rapid incision completely
separated the upper edge of the tumour, so as to expose its cavity;
and, directed by the warm gush of blood, a large vessel in the upper
corner, which with open mouth was pouring its contents into the sac,
was immediately secured. The coagula being removed, by dissecting
under the finger, the subscapular artery was then separated, so that
an aneurism needle could be passed under it at its origin from the
axillary, and about an inch from the sac. After securing this and two
other large vessels which supplied the cavity, the tumour was dissected
from the ribs without further hemorrhage, cutting the diseased scapula
and the under part of the sac. It was then found necessary to saw
off the ragged and spongy part of the scapula, leaving only about a
fourth part of that bone, containing the glenoid cavity, processes,
and half of its spine. The edges of the wound were brought together,
and the patient lifted cautiously to bed. At this time he was pale,
almost insensible, and without any pulsation perceptible through the
integuments in the greater arteries, though the ends of the vessels
in the wound beat very forcibly. Stimuli were employed externally and
internally; in the evening his pulse at the wrist was ninety, and soft.

The sac of the tumour was composed of bony matter, containing little
earth, and arranged in strata of short fibres pointing to the cavity.
Its outer surface was smooth, and covered by a dense membrane; whereas
the inner, to which so equable a resistance was not afforded, was
studded with projecting spicula. The lower part of the scapula,
partially absorbed, lay in the middle of the sac, covered by the
remains of its muscles and coagula. Very large vessels were perceived
ramifying on the surface of the tumour.

The patient made a rapid recovery, and the wound all but healed.
A fungus, however, began to appear in about six weeks, which grew
rapidly. This was removed, and the bone cauterized with little good
effect. The tumour was soon reproduced. It was proposed to remove
the remainder of the scapula with the extremity, as the only chance,
though perhaps a slight one. This was objected to, and he died about
five months after the operation, worn out by hemorrhage and profuse
discharge.

The diseased parts presented the following appearances. Portions of
the acromion process, superior costa, and spine of the scapula, were
of their natural appearance. But the coracoid process, the glenoid
cavity, and the cervix, were entirely destroyed, and their situation
occupied by an irregular broken-down tumour, consisting of osseous
spiculæ, and cancelli, irregularly disposed, and forming cavities which
were filled with blood, partly fluid and partly coagulated. The head
of the humerus was extensively absorbed. The articulating cartilage
was almost entirely destroyed, particularly on the inner side, where a
large portion of the bony matter had also been removed. The ulcerated
surfaces were of a dark, bloody colour.


[HYDATIC TUMORS.

Another disease of the bones which ought to be introduced here is the
development of hydatids, which I described twelve years ago under the
name of _osteo-hydatidic_ tumours. The seat of this affection is not
confined to any particular class of bones; though the long are perhaps
most prone to it. Its precise nature and origin have not yet been
determined; nor are its symptoms such as to enable us, in the present
state of our knowledge, to distinguish it from exostosis, osteosarcoma,
and other maladies. Its progress is commonly slow, the surface of the
tumour is smooth and regular, the skin exhibits no unusual appearance,
and the adjacent textures rarely participate in the morbid action.
The hydatids, usually of a globular figure, vary greatly in size and
number, and are generally filled with a thin, limpid fluid. They appear
to be of the nature of acephalocysts. The prognosis unfavourable, owing
to the difficulty of destroying these parasites, and their constant
tendency, when interfered with, to reappear.

As soon as the true nature of this tumour is ascertained it should be
laid freely open, its contents turned out, and the sac destroyed. For
this purpose the sides of the cavity should be seared with the actual
cautery, or touched with some of the more powerful escharotics, as the
nitrate of silver, or the caustic potash. If these measures fail, and
the disease involve the whole circumference of the bone, nothing short
of amputation will suffice. This was successfully resorted to in one of
the cases which came under the observation of Mr. Lucas of London.]


TREATMENT OF TUMOURS.

It may be observed generally, that no benefit can be derived from
external applications to tumours, such as friction with liniments or
ointments containing iodine, mercury, &c.; and that, therefore, it is
injudicious to employ such temporising measures; for though a tumour
at its commencement appear to be of a very harmless nature, yet it
may soon assume a most malignant character. If an apparently simple
tumour increase, and exhibit symptoms of inflammation, it will perhaps
be advantageous to apply leeches, to arrest that incited action which
affords the accession of new materials; this, however, cannot check
the morbid activity inherent in the new formation, though it may
hold the growth in check a little. If a tumour is to be removed by
external applications, it is evident that these must be such as shall
prevent the deposit of new matter, and allow the absorbents to remove
that which already exists; for absorption is always going on in a
tumour, though it leaves no evidence of its progress, on account of
the deposition of new matter exceeding the removal of the old. I must
say that I am unacquainted with any remedies capable of performing
the above indication. The removal of a swelled gland may occasionally
be accelerated by such means when stationary, or on the decline,
and before cheesy tubercular unorganized matter is infiltrated into
its texture; but to trifle so with a new and independent growth is
altogether absurd. The knife only is to be depended on.

Many of the tumours first described have no malignant disposition
originally, and only require surgical interference when they produce
deformity or inconvenience from their bulk. Yet even these ought not
to be allowed to attain any great size, however indolent they may
appear at first, and however little pain they may produce; for there
is always a danger of their assuming a malignant tendency, or forming
connections with important parts, so as to render their removal either
altogether impracticable, or at least attended with much difficulty.
Tumours of every kind, when seated near important organs, must be early
removed. Glandular tumours, however, even when of great size and long
continuance, are not to be rashly interfered with, when they arise from
irritation in the neighbourhood.

Those in which it is feared that malignant action has commenced cannot
be trifled with; and the only means which afford a chance of the
patient’s being effectually delivered from them is an operation. With
a view to their complete extirpation, the external incisions ought
always to be free, so as to admit of the after-dissection being easily
and rapidly performed: they ought also to be made in the direction of
the muscular fibres, whether these lie above or beneath the tumour. In
this way the margins of the wound are easily brought into apposition,
and there retained; whereas, if the fibres be divided transversely,
the wound will gape, and union by the first intention be rendered
absolutely impossible. If there is no reason to suppose that the tumour
is malignant, little or no integument ought to be removed, unless the
growth is of a large size; but, when malignity is dreaded, all the
discoloured, tense, and adherent integument, all that is permeated
by dilated and tortuous vessels, ought to be taken away, and the
incisions made at a distance from the disease. In all cases they ought
to commence at the point where the principal vessels enter; these are
thus divided at the outset, can be readily secured by ligature, or
by the fingers of an assistant, and the dissection is proceeded in
without risk or interruption from farther hemorrhage. If the opposite
course be pursued, the vessels will be divided two or more times during
the operation, and thus the performance of it will either be delayed
by the application of numerous ligatures, or will be attended with
a considerable loss of blood. After the tumour has been exposed it
ought to be principally detached in one direction, as in this way its
removal will be sooner accomplished, and not first cut on one side and
then on another. If malignant, great care should be taken that all the
diseased mass be removed, for a minute portion remaining will form a
nucleus in which similar diseased actions are certain to arise; in most
instances, it will be prudent not only to remove the parts actually
diseased, but those also which are in immediate connection with the
tumour, though at the time they appear healthy. All important parts
must be carefully avoided. After removal of the mass, and the complete
cessation of bleeding, the edges of the wound must be approximated, so
as to favour union by the first intention; if this fail, granulation
must be promoted, and the wound dressed according to the particular
circumstances of the case. All operations on malignant tumours, in
their advanced stages, are unwarrantable; they are necessarily painful
and severe, and cruel because unavailing; they often, indeed, expedite
the dissolution of the patient. If the integuments over the tumour have
ulcerated, and if the lymphatics in the neighbourhood are diseased, the
disease if removed will certainly be reproduced, and the succeeding
tumour will be still more malignant. The operation ought, if at all, to
be performed when the disease is in its incipient state, for then only
can success be expected.

Exostoses need not to be interfered with, unless they are the source
of much inconvenience, either from their size and form, or from their
having been detached, and lodged amongst the adjacent soft parts. If
loose, they can be removed in the same way as any other extraneous
body; if firm, their attachment must be divided by a saw, or by cutting
pliers, close to the bone from which they spring. Sometimes, as in the
scapula or other flat bone, a portion of the original bony tissue can
be cut out along with the new growth, and this renders the chance of
any return of disease much less likely.

Osteo-sarcomatous tumours are to be taken away, along with the part
of the bone in which they are imbedded, and, if possible, before the
integuments have ulcerated. The incisions must be made, and the bone
sawn, at a healthy part. The removal of the entire bone in which the
disease has commenced, when practicable, will afford a still better
chance of immunity from farther disease.

In spina ventosa more is seldom required than to lay open the
cavity, give vent to the matter, and then treat the case on the same
principles as in abscess of the soft parts. The cellular tumours,
partly cartilaginous, partly osseous, ought not to be permitted to
remain; the operation can generally be done without much difficulty;
and thus the danger of their degenerating avoided. Frequently, however,
a considerable part of the bone must be removed along with the tumour,
since the neighbouring tissue is generally softened, and intimately
adherent to the diseased part, which it somewhat resembles in structure.

In general, regular dissection is unnecessary in the removal of
encysted tumours. An incision is made, or an elliptical portion cut
out; the contents escape, and the cysts, being then laid hold of by
dissecting forceps, is readily separated. In some situations, as on
the eyelids, under the tongue, or amongst tendons, the sac, which is
thin, is not so easy of extraction; it is then inseparable, either
naturally, or from previous inflammation. Caustic is used with safety
to destroy those parts which cannot be detached, and for this purpose
the potass is to be preferred. When, however, the tumour is large, a
part of the integuments covering it must be removed, otherwise a large
cavity will be left, in which pus might accumulate. In this case, the
base of the tumour is to be surrounded by two elliptical incisions,
and the cyst dissected out entire, leaving only integument sufficient
to cover the exposed surface. In the smaller tumours, it is vain to
attempt regular dissection; a portion of the cyst will be left, and the
disease reproduced: whereas, by using the potass, the operation is
much more speedy, and always successful. The making a minute aperture,
and squeezing out the contents, is at best but a palliative measure,
and is often followed by severe constitutional disturbance.


OF WOUNDS.

These vary in extent and nature. The instrument by which they are
inflicted, the violence attending the injury, and the nature and
importance of the parts divided, or in the neighbourhood of the
wound, must all be attended to, for, from an accurate knowledge of
these circumstances, the treatment of the case comes to be conducted
accordingly. Wounds are divided into incised, punctured, bruised,
and lacerated; that is, into such as are inflicted by a sharp-edged,
sharp-pointed, or an obtuse body. In the first kind, there is greater
or less effusion of blood, according to the size and number of the
vessels divided. Some extend but a little way beyond the subcutaneous
cellular tissue, and are consequently attended with but slight
bleeding; others penetrate to a greater depth, and occasion hemorrhage
from a large vessel, or other alarming symptoms, by having reached
some important organ; others, though not of so great a depth as the
former, may still, on account of their mere extent, be accompanied with
very considerable loss of blood from a number of small branches. It
is seldom that fatal effects immediately follow external wounds; but
they may and do occur when bloodvessels of the first class only are
cut. They are most likely to prove suddenly fatal when the arteries
are only partially divided, and when the large veins accompanying them
are also involved. When the artery is cut through, its extremities
retract, effusion takes place into the sheath and compresses the
orifice; the formation of a coagulum within the vessel is thus
promoted, and the hemorrhage arrested. But, when a portion only of
the circumference is divided, the blood continues to flow through the
aperture and onwards, as if into a smaller ramification of itself, no
retraction or contraction of the vessel can occur, coagulation is slow,
and the bleeding profuse. I have seen a wound of so small a vessel
as the internal mammary prove almost instantaneously fatal. Wounds
of the large internal vessels for the most part prove immediately
fatal; as wounds of the heart, or the large vessels passing to and
from its cavities, at the root of the lungs, or at the upper part of
the liver. When the heart, or the vessels within the pericardium,
have been divided, it can be readily understood how life should be
immediately destroyed, since the blood effused into the cavity of the
pericardium by its pressure completely arrests the action of the heart.
But occasionally punctured wounds, in such situations, have not been
followed by instant death. In such cases, alarming symptoms occur at
the time, but subside, and the patient may for some time suffer no
uneasiness, but afterwards expires suddenly during muscular exertion,
or perhaps in a fit of violent passion. Blood must have been effused
into the pericardium at the first, causing symptoms of, or actual,
syncope; but then the aperture in the vessel had become obstructed
by coagulum before blood had been poured out in such quantity as to
effectually prevent the actions of the heart; at a future period the
coagulum gives way, and the subsequent effusion is limited only by
the pericardial cavity being completely filled. In wounds, hemorrhage
is the symptom which most alarms the bystanders, and which demands
immediate attention; but, to operate successfully, the surgeon must
divest himself of all fear, and learn to look boldly on the open and
bleeding mouths of arteries. Effusion of blood ceases spontaneously,
even from considerable vessels, on faintness supervening, and thus many
lives are saved; but as soon as reaction commences it generally recurs,
and may prove fatal, unless proper measures be resorted to.

When an artery is divided, its extremity retracts within the sheath, it
also contracts, and coagulation occurs; thus the orifice is obstructed,
and a temporary barrier formed to further hemorrhage. The tube,
however, is permanently closed by effusion of lymph from its orifice,
and consolidation of the surrounding parts.

The circumstances which follow division of an artery are these:—The
immediate effect is retraction of its ends within the investing sheath,
and a simultaneous contraction of the coats, so as to diminish the
calibre. From the superior orifice there is necessarily a profuse flow
of blood, which is discharged through the sheath that formerly enclosed
that part of the vessel which has retracted. After considerable
effusion of blood, the flow becomes slower and less profuse; particles
of blood adhere to those filaments which previously connected the
artery to the sheath, but which were lacerated by the sudden retraction
of the divided extremity; these particles coagulate, and lessen the
canal through which the blood is discharged, whilst they present an
irregular surface, on which the blood continues to be deposited and to
coagulate; and thus the aperture in the sheath is ultimately closed.
This external coagulum is found to commence at the extremity of the
artery, where it is of a cylindrical form, and shuts up the mouth of
the vessel; it then extends along the canal in the sheath, frequently
assuming a conical form; and, if a free discharge has been allowed for
the blood, it will terminate at the cut margin of the sheath, otherwise
it will be found continuous with the coagulum blocking up the external
wound. Also, when hemorrhage has been resisted by the shutting of the
external wound, blood is infiltrated into the cellular tissue around
the bleeding point, and there coagulates; but this circumstance can
be productive of little or no pressure on the parietes of the vessel,
so as to assist those other natural means which obstruct it. The flow
of blood through the divided vessel being prevented, the circulating
fluid necessarily passes through the nearest collateral branches,
leaving the blood in the extremity of the larger trunk in a state of
comparative rest; consequently, coagulation occurs in this situation.
The internal coagulum, however, is small, and not sufficient to occupy
completely the cavity of the vessel; it is of a conical form, its apex
being towards the heart, and opposite to the first collateral branch,
and its base resting on the external coagulum, and there adhering to
the internal surface of the artery. But, whilst this latter process
is advancing, the capillary vessels supplying the cut margins of
the artery have begun to act; they throw out coagulating lymph, and
continue to do so until their secretion has completely filled the
vessel immediately opposite to its divided margins; thus a third and
more effectual coagulum is formed,—one of plastic matter, situated
between the external and internal coagula of blood, and in general
closely adherent to them. Lymph is also effused externally to the
artery and its sheath, forming a dense stratum, which separates the
extremity of the vessel from the external wound; it becomes organised,
forms granulations, and thus the parts are consolidated, and the wound
cicatrised. When the artery is permanently obstructed by the adhesion
of its cut margins, the external coagulum can be dispensed with, and
is gradually absorbed. Afterwards all the newly formed parts are
condensed, and diminish in size; the artery contracts, its internal
surface finally embraces the coagulated blood which lay loose in its
canal; its coats appear to be thickened, and it is firm and hard.
Ultimately, in consequence of the continuance of absorption, it becomes
much more attenuated, so as scarcely to differ from the surrounding
cellular tissue. Similar changes occur in the lower extremity of the
divided artery; in general it retracts farther, its orifice is more
contracted, and, the flow of blood being much less profuse than in
the superior, the natural means for its temporary closure are sooner
accomplished. When an artery has been divided close to the origin of
a collateral branch, no bloody coagulum can form internally, for the
blood in that situation is necessarily in a state of constant motion.

If the hemorrhage is suppressed artificially, either by ligature, or by
otherwise well-applied pressure, no external coagulum is formed; there
appears only the internal bloody coagulum, the lymphatic effusion,
and consolidation of the compressed part. The natural contraction and
retraction cannot occur in vessels partially divided; hemorrhage,
therefore, is more violent and dangerous from a partial than from a
complete section. Again, transverse wounds are more dangerous than
longitudinal; in the latter, the edges of the wound are spontaneously
approximated on account of the structure of the vessels, whilst, from
the same cause, the margins of the latter continue separate, and, in
fact, the aperture is a complete circle; the lips of an oblique wound
will be more or less apart, in proportion as it approaches to the
transverse direction. When an artery has been punctured, the wound in
the sheath perhaps does not correspond with that in the vessel; blood,
therefore, accumulates between the vessel and its sheath, and there
coagulates. The wound is thus compressed, its edges kept in contact,
and the farther escape of blood prevented; the lips of the incision are
then agglutinated by effused lymph, and cicatrisation occurs. This,
however, cannot be expected to take place unless methodical pressure
has been applied from the first. Even from small punctures blood is
effused under the sheath and into the neighbouring cellular tissue,
rapidly, and in such quantity as to prevent adhesion. The effusion
continues, and a false aneurism is formed. If a considerable part of
the circumference has been divided, the lymph may be, and generally
is, superabundant, and often to such an extent as to close up the
canal of the artery at that point; but, if the aperture is minute and
in a longitudinal direction, lymph will seldom be effused in greater
quantity than is sufficient for the cicatrisation; and, though it
should be superabundant, it is afterwards removed by the absorbents.
In all cases, the cellular tissue round the wounded point is much
thickened and condensed by the deposition of lymph, but this gradually
disappears after cicatrisation has been completed. Sometimes, and
generally when the wound has been transverse and large, the process of
adhesion is disturbed, and suppuration occurs; in this case the wound
in the vessel communicates with the fistulous track in the externally
effused lymph, and may be the source of troublesome hemorrhage.
In other instances of extensive transverse wounds, the undivided
slip ulcerates, and the artery becomes obliterated, by means of the
same natural processes that occur in complete division. In cases of
laceration of an artery, when its coats have been forcibly torn rather
than divided, little or no bleeding takes place. The vessel retracts;
the lacerated margins of its inner coat become puckered up, so as to
contract greatly the orifice of the vessel; the lacerated sheath is
pulled out to a point, and closed at a little distance from the divided
inner coats. If a large artery is torn asunder in the dead body, this
stretching out and contraction of the sheath will prevent injection
passing; in short, the immediate effects of the injury are such as to
favour the instant formation of coagula, by which the hemorrhage is
arrested until the orifices of the vessel be permanently closed by the
adhesive process. Thus, in instances where the whole of an extremity
has been torn off, the patients have generally lost but a very small
quantity of blood.

From wounds of veins the blood flows, not in a sub-saltatory but in a
uniform stream: its colour is dark, and the flow is easily suppressed.
The common opinion is, that to place a ligature on a vein is dangerous,
and to be scrupulously avoided. The process of reparation, besides,
in a wounded vein, is different from that in an artery. Veins are
less disposed to the secreting action by which adhesion is perfected;
and, when inflamed, the inflammation is extremely apt to extend along
the coats of the vessel; which latter circumstance has been ascribed
to the great proportion of cellular tissue in their coats. When
punctured longitudinally, the lips of the wound remain in contact,
and cicatrisation, by means of effused lymph, is soon effected; in
fact, the wound heals by the first intention. But if opened obliquely
or transversely, not to a great extent, the immediate result is
discharge of blood, and, when this has ceased, a coagulum forms in
the wound, the margins of which remain separate; and this coagulum
generally communicates with blood effused into the sheath of the
vessel. After some time, the lips of the wound, encircling the coagulum
which occupies the aperture, and which has temporarily averted the
hemorrhage, become somewhat turgid, and increased in vascularity;
they then appear to assume a secreting action, by which a membranous
substance, of extreme delicacy, is produced; and the extent of this
membrane is increased until it form an expansion, investing the outer
surface of the clot; it then becomes thickened, by addition of matter,
similar to itself, from the recent vessels which ramify in it. At the
same time it forms adhesions to the surrounding cellular tissue, and
resembles the original tunics of the vein. After being consolidated,
so as to prevent the flow of blood through that part, the coagulum,
formed to arrest the hemorrhage until a more complete barrier should
be furnished, is gradually absorbed. But the membrane long remains
smooth, thin, and diaphanous, and can be thereby readily distinguished
from the original coats. This reparative process is much longer in
being finished than the corresponding one in arteries; and, from what
has been stated, it is evident that the two actions differ in other
respects than the time requisite to complete them. When a vein has been
completely divided, the extremities are closed by means similar to
those which have been already detailed in regard to arteries.

In many, nay in most, instances of hemorrhage from a wounded artery,
the surgeon cannot wait for the natural processes by which the flow
of blood is arrested, but must have recourse to immediate and certain
means. In division of the smaller arteries, or in minute wounds of the
larger, pressure, well applied, will often be sufficient. In both cases
it immediately stops the flow: in the former, it prevents the blood
from penetrating into that portion of the sheath which has been vacated
by the retracted artery; and it being thereby confined, and kept in
a state of rest, coagulation soon takes place. At the same time,
the compression brings the divided margins of the vessel into close
apposition, and thereby permanent closure, by adhesion, is quickly
accomplished. In the latter, the mere circumstance of the escape of
blood being prevented, naturally hastens the closure of the minute
aperture by the natural process; and, if the compression be accurate
and very firm, the opposite surfaces of the vessel, being brought in
contact, may adhere, and the canal be obliterated at the wounded point.
It is obvious that, in this latter class, pressure can only be of
advantage immediately after the infliction of the wound, and not when
blood is extravasated to a great extent.

Pressure may be used along with styptics, or along with escharotics,
actual or potential. They may be often employed when pressure ought
not; styptics promote the contraction and retraction of the divided
extremities, and thereby expedite the formation of a coagulum.
Escharotics form a slough, which, adhering to the extremity of the
vessel, stops the flow of blood, and the cut margins of the vessel,
being stimulated by the application, soon cohere. Active stimulating
applications merely cause effusion quickly of coagulated lymph, and
thus often arrest hemorrhage from very vascular surfaces better than
the so-called styptics. Not unfrequently, after the separation of the
slough, it is found that union has not taken place, and hemorrhage
is renewed; from this circumstance, the remedy cannot be trusted to,
except when the divided vessels or vessel are of small size. It may
be stated, generally, that these means are of little avail without
methodical pressure. In oozing from small vessels, pressure may be
applied by means of agaric, sponge, or lint. In bleeding from small
vessels, where there is general oozing from the surface, and pressure
cannot readily be made, applications tending to produce effusion of
lymph—stimulants, such as turpentine or creosote, are often remarkably
efficacious, and very speedily so; but in wounds of the larger vessels,
the most efficient mean is a graduated compress of lint placed
immediately on the external wound, and supported by a firmly-applied
bandage. The bandage ought to encircle not only the wounded part, but
every part of the limb with a uniform tightness, not so great as to
arrest the general circulation; the parts are thereby supported, and
engorgement prevented. This method, when employed previously to the
effusion of much blood into the cellular tissue, has proved effectual
in wounds even of the brachial, femoral, and carotid arteries. When
blood has been extensively injected into the limb, when the aperture in
the vessel has remained pervious, and when a large diffused aneurism
exists, bandaging is worse than useless. By its application in such a
case the limb becomes discoloured and swells extensively; there is a
risk of mortification from impeded circulation. If a small quantity
only of blood has escaped, its diffusion and increase may be prevented
by the bandage: but a cyst will nevertheless be formed in the cellular
tissue; its parietes will communicate with the margins of the aperture
in the artery, its cavity with the canal of the vessel; an aneurism
of the false kind will be established, and will run the course of one
arising spontaneously.

A ligature, well applied, is the only means that can be relied on. The
immediate effect of a tightly-drawn ligature is to avert the flow of
blood, to divide the internal and middle coats at the deligated point,
the cellular coat remaining entire, and to narrow the canal for some
extent above the point at which it is applied. Coagulation then occurs
within the vessel above the ligature, provided there is no collateral
branch in the immediate vicinity. The ruptured margins of the internal
coat effuse lymph and cohere; lymph is effused also in the cellular
tissue, exterior to the artery and to the ligature; by the compression
of the ligature, ulceration occurs in those parts which it envelopes,
and the foreign body is discharged; but before this occurs the canal
of the vessel has been obliterated by an internal coagulum, and by the
effused lymph. Afterwards, the same absorption and consolidation occur
as in a divided artery, the orifice of which has closed permanently and
spontaneously.

When from a punctured wound profuse hemorrhage ensues, there is reason
to suspect that an important vessel has been hurt, and the bleeding
point must be sought for. After the artery giving out the blood has
been discovered, the external wound must be enlarged, so as to expose
the vessel, and admit of the convenient application of a ligature. It
will not be sufficient to include the vessel above the wounded point,
for the lower part will, after some time, be supplied with blood
by the collateral branches almost as freely as by the large trunk,
and, consequently, bleeding will be renewed. Two ligatures are to be
employed, one above, the other below, the wound. The wounded vessel
must be exposed, as already stated, but not detached more than is
sufficient for the application of the ligature; and at the same time
the ligatures ought to enclose nothing but the vessel. Neither ought
the ligatures to be placed at any considerable distance, but as close
to the wounded point as possible; otherwise circulation in the included
part may be restored. The ligature, round, narrow, and firm, ought to
be tightly applied. Cases of hemorrhage have occurred in which the
tying of the vessel immediately above the wound has been successful;
but these are few, and by no means afford any authority for the general
adoption of such a measure. If the vessel is merely punctured, it is
necessary to apply the ligature by means of a blunt pointed needle, and
the parts are to be disturbed as little as possible. If, however, the
artery is completely divided, its cut extremities are to be drawn out
of their sheath by a hook or forceps, and the ligatures applied close
to the connections of the vessel; the vasa vasorum, in the immediate
vicinity of the deligated point, being left to carry on those processes
by which obliteration is accomplished. In punctured or partial wounds
of arteries, it deserves consideration whether the hemorrhage may not
be restrained by the application of slight pressure, so regulated as
to prevent the flow of blood laterally through the wound, but not so
forcibly applied as to stop the onward current of the blood along the
vessel, from the part of the tube above to that below the puncture.
Some experiments made by Dr. Davy seem favourable to this view; as
bleeding from the carotid arteries, partially divided transversely, in
dogs was easily arrested by the means above-mentioned, the wound of the
vessel readily healing, so as to preserve its tube entire; whereas,
when the pressure was increased, the hemorrhage became violent.
The subject is mentioned as one worthy of a further experimental
investigation. The instrument which will generally be found most useful
for laying hold of the vessel is the common dissecting forceps, but a
tenaculum will, in certain circumstances, be more convenient. By far
the most convenient machine is that here represented.

[Illustration]

When no assistant is at hand, and in cases of emergency, the surgeon
provided with this little instrument can tie vessels without the least
difficulty; and in operation, when many vessels spring, several of
these forceps can be applied; there is besides this great advantage
in their employment, that a clumsy assistant can scarcely include the
point of the instrument with the vessel. Hemorrhage from the smaller
vessels soon ceases; and, before reaction occurs, their orifices have
generally become so obstructed as to resist the effusion of blood.

The effects of ligature on a vein are somewhat different from those
on an artery. The inner coat of the former is more dense and elastic,
and remains entire, whilst the external and middle are divided. It
is puckered by the ligature, and its opposite surfaces are placed in
immediate contact; but there is no breach of surface, and adhesion
does not occur till the tunic has been divided by ulceration; then
the opposite margins cohere, the vessel is obliterated, and undergoes
changes resembling those in an artery similarly circumstanced. The
coagulum between the ligature and extremity is of considerable extent,
dense, and completely filling the canal of the vein, and consequently,
of a cylindrical form.

The edges of the wound, in the soft parts, ought not to be approximated
till the bleeding has entirely ceased, and the surface become glazed,
for the interposition of the slightest quantity of blood prevents union
by the first intention. When bleeding has ceased, the divided edges
are to be brought together as accurately as possible, and adhesion
promoted. The minute vessels assume an action greater than in the
healthy state, though not equal to inflammatory action; they effuse
coagulating lymph, by which the opposed surfaces are agglutinated,
though the union is at first feeble and easily broken up. Soon the
lymph is firmly attached, by newly-formed vessels, to the surface from
which it was secreted; in effect, it becomes organised, and rendered
capable of undergoing, through its inherent powers, the changes
necessary for its perfection and stability. Similar processes go on
in it as in any sound part of the body; new matter is deposited, and
the superfluous is absorbed. The process of nutrition, however, is
not the same in all parts of its substance, that is, the new matter
deposited is not exactly similar at all points; but, according as the
new secreting vessels proceed from the different tissues of which the
margins of the recent wound are composed, so, in various parts of the
new formation, these vessels assume peculiar modes of action, one set
forming muscular, another cellular tissue, and a third a substitute for
skin, formations corresponding to the primary tissues from which the
secreting vessels proceed.

Thus the vasa vasorum, ramifying on the divided ends of the minute
vessels, secrete a substance which is transformed into a set of minute
capillaries, and these also, assuming a secretive action, produce an
arterial or venous tube, similar to that nourished by the original
vasa vasorum. By this process the lymph becomes well supplied with
bloodvessels, those from the opposite surfaces meeting, and freely
inosculating with each other. These bloodvessels, as already stated,
have been produced from arteries possessing different powers, and hence
the newly-formed assume actions similar to those of the primary, and
thereby interstitial matter is deposited of its proper kind and in
its proper place, a cuticular membrane superficially, then cellular
tissue, afterwards muscular, and so on according to the primary tissues
which had been divided; these parts do not at first resemble exactly
the corresponding natural tissues, but, by the continued action of
the new vessels and capillaries, they are moulded and prepared for
the due performance of their respective functions. If the degree of
action necessary for the accomplishment of these processes increase to
inflammation, adhesion is interrupted till the action be lowered to its
previous standard.

From this view it is evident, that, besides a certain excitement of
the bloodvessels, it is necessary that the raw margins be in close
apposition, and carefully retained so, for, by ever so slight movement
of the parts, the recent and delicate bond of union will be ruptured;
and, if this motion be allowed to continue, adhesion may be at divers
times begun, but can never be perfected. Whereas, if the necessary
precautions are adopted, union is often completed in thirty or forty
hours, sometimes sooner, seldom later. From a knowledge of the
astonishing powers of nature in repairing injuries, many and important
improvements have of late years been made in the practice of surgery.
In the majority of instances it is also requisite that the parts be
brought in contact soon after division, otherwise granulation will have
commenced in the different parts of the wound, and the surfaces then
approximated will not so readily adhere: pus is formed, and, having
lodged between the surfaces, acts as an extraneous substance, keeping
them apart, and separating them still farther by its accumulation.
All foreign bodies in the wound must be removed before adhesion can
occur; and, on the same principle, care ought to be taken that no
effused blood be interposed. In many cases the margins of the wound
can be accurately adjusted by careful attention to the position of
the part, or by the application of a few strips of adhesive plaster;
but the latter, from indiscriminate use, often prove the source of
much irritation, and totally frustrate the end for which they are
designed. When employed, they ought to be narrow and few. If such means
be considered insufficient, recourse must be had to a few points of
interrupted suture, and these are not productive of bad consequences
which have been by some attributed to them. When neatly applied, they
can produce but little irritation, more especially if removed as soon
as their presence is unnecessary, that is, as soon as adhesion has
fairly commenced, and the natural bond of union is of such strength
as to need no artificial assistance. By these the edges of the wound
are more neatly and suitably placed than by any other means; they meet
easily, without the puckering or overlapping of each other; and, from
the circumstance of sutures obtaining a more just coaptation, they can
be sooner discontinued. In most wounds no other dressing is required;
but in some a combination of sutures, adhesive plaster, and compress,
is necessary.

Of late, I have greatly dispensed with stitches and the common adhesive
plaster, using, instead of the latter, slips of glazed riband smeared
with a saturated solution of isinglass in brandy, which is much less
irritating and more tenacious than the common adhesive compost. The
parts are fixed temporarily with a single stitch, or two at most, and
cloths dipped in cold water are placed over the wound; the ribands are
not applied till the adhesive substance has partly congealed, and the
oozing of blood ceased. The divided margins being approximated by the
fingers of an assistant, the ribands are laid gently over, and held for
a few seconds. Soon after a sufficient number have been applied the
stitches are withdrawn, being no longer necessary. No other dressing
is required unless suppuration occur; the ribands will adhere firmly
till the completion of the cure, and thus the pain and irritation
caused by frequent dressing is avoided. Even the largest wounds, as
after amputation, are treated in this manner with the most satisfactory
results. Of late years a plaster, made by coating oiled silk with a
solution of isinglass, has been used instead; the glazed surface of
the slips is moistened, and applied as here directed.

If at any part adhesion fail, suppuration and granulation must follow.
The adhesion may be prevented by any of the circumstances already
mentioned, or by an unfavourable state of the constitution, the nature
of the wound, exposure to bad air, the occurrence of fever, or of a
flux natural or not. The wound may contain foreign matter; blood or the
contents of canals may be effused into it, and many other obstacles
may exist to retard, or prevent adhesion. Notwithstanding, in all
cases, though the chance of union be but small, the parts should be
approximated. A great point is gained if certain parts only are brought
to adhere, for by their natural attachments the opposite surfaces are
preserved in more direct contact than they could otherwise be, and
thereby but little space remains to be filled up with granulations.
If, on the contrary, the surfaces are not approximated, the flap is
diminished in size, and when afterwards placed in contact with the
surface from which it was detached, it is found not to correspond,
leaving considerable deficiency to be repaired by the comparatively
slow process of granulation. Whereas, if it had been early replaced,
partial attachments would probably have been formed by adhesion, the
flap thereby retained in situ, and prevented from shrinking, so that
but little new matter would be required.

Sometimes union does occur, and that speedily, after the flap has
remained separate for a considerable time; and in such cases it may be
doubted, whether union is accomplished by adhesion, strictly so called.
Most probably it is by this process that the rapid union occurs in such
circumstances: the divided parts have assumed an excited action, and
effused lymph; during their state of separation, the lymph will become
organised when it is connected with the original parts, just as well
as if the surfaces had been in contact; and when they are at length
so placed, they will be agglutinated to each other by the outer part
of the effused lymph, which still continues soft and unorganised. If
motion be then prevented, organisation, which has already commenced
in the connecting medium, will proceed undisturbed, converting the
agglutination of soft unorganised lymph into firm and permanent union
by means of organised tissue. In these circumstances, it is not to
be wondered at if adhesion should be completed in a shorter time
than when the surfaces are brought together immediately after their
division; in each instance the process is the same, only in the one
it has to proceed from its very commencement, whilst in the other it
is previously all but perfected, and after the parts have been put
together, the last stage only requires completion. It is only in a
particular stage of a granulating surface, that adhesion will take
place speedily, when the discharge is diminished, but healthy, and the
granulations florid and firm.

When a wound is to heal by granulation, the exposed surface at first
is dry, painful, and slightly swelled, and afterwards a thin discharge
of bloody serum is poured out, with relief to the painful sensations;
the surface is at this time covered by a thin layer of coagulated
lymph, and the parts, if approximated, are in the most favourable
state for adhesion. Soon, however, the vessels assume a different mode
of action, and secrete a fluid which becomes purulent; the effused
lymph has been organised, forms a living part of the surface from which
it was deposited, and is covered and protected, in its yet delicate
condition, by the purulent fluid. This new matter is disposed in
numerous small conical projections of a florid colour; and these, by
their own power, form others similar to themselves, at the same time
discharging purulent matter; so that, in a healthy constitution, the
cavity is soon filled by the granulations, which come to the same level
as the surrounding integument. Sometimes they are exuberant, soft, and
spongy, and in this state possessed of little sensibility, and but ill
supplied with bloodvessels. At others, they are slow in approaching the
surface, and then often morbidly sensible. In all cases, the new matter
is very apt to be absorbed, either from the state of the patient’s
health, or from the nature of the applications; and foreign substances,
in a state of solution or minute division, are more readily taken into
the system from the raw surface than from the sound skin. When, then,
the granulations approach the skin, the sore contracts, the newly
formed parts being modelled into a more firm and dense condition by the
action of the absorbents. Sometimes, in superficial sores, the skin is
seen spreading from several parts near the centre; but at these points
portions of the original skin must have remained uninjured, though
the others were destroyed, and have formed cutaneous matter as soon
as they were on the same level with the surrounding granulations; for
these insulated portions of skin are not a product of granulations, as
some suppose, but of a substance similar to themselves. Skin is formed
from skin. Thus, where a part of the integuments has been completely
removed by operation, or destroyed by accident, no islands of skin are
observed during the cure, but the sore is uniformly covered by skin
proceeding from its margins. The margins of a healing sore are of a
white colour, and adherent to the subjacent parts; but in an unhealthy
one the margins are often unsupported, the subjacent granulations are
absorbed, and their place is occupied by thin purulent matter; the
new skin is unable to maintain its independent existence, continues
of a dark colour, perhaps for a long period, then wastes away or
sloughs. The recent cutaneous matter covering a sore contracts, and the
neighbouring old skin is extended; the new surface is thus diminished;
it assumes a slightly puckered appearance, and is termed cicatrix. This
is at first pretty vascular, the vessels running straight; after a time
they contract and become invisible, and scarcely admit fine injections.
Frequently the scar is so far absorbed after some time, as to leave
only a firm line, whiter and more dense than the surrounding integument.

If union by the first intention does not take place, then all the
application to procure it must be abandoned, all sutures, plasters,
compresses, &c., must be dismissed, for they now can do no good, and
may be productive of harm; the attention, on the contrary, must be
directed to effecting union by granulation; with this view, other means
are to be chosen, so that to continue those which were formerly used
to promote adhesion would be absurd, when adhesion can no longer be
expected. The stitches must then be taken out, when inflammation has
gone off, and œdema remains, the parts are to be supported; and by
attention to position, and gentle bandaging, the size of the wound
will be diminished. Inflammation must be subdued by the usual means,
and suppuration encouraged by fomentation and poulticing, or warm
water dressing. After inflammation has subsided, tension disappeared,
purulent discharge occurred, and granulations formed, the edges of the
wound are to be gently brought together, so as to render the quantity
of new matter requisite for filling up the cavity as small as possible.
Nature will then accomplish the union in her own way, and we can only
assist and minister to her; for who thinks now of healing wounds by
pure force of surgery? The dressings ought to be light, the ointment,
if any is used, scanty; in some cases the application may be dry; but
in many cases various lotions will be found of much advantage. These
latter are used of different qualities, according to the nature of the
sore; and these can be of little avail unless evaporation be prevented,
by a piece of oil-silk laid on the outer surface of the dressing. In
most granulating wounds, they require to be of a mildly stimulating
nature, and the one which I have most frequently employed is a weak
solution of the sulphate of zinc. The integuments round the wound may
be occasionally washed, to prevent excoriation, but no good can accrue
from washing the sore; its natural discharge is its best protection,
and if superabundant, it can be removed by means of dry lint or tow
from the surrounding parts.

From bruised and lacerated wounds there is little or no hemorrhage, but
in proportion to the severity of the bruise, is the bleeding slight,
and the danger great. The bloodvessels are so torn and twisted as to
permit the spontaneous and temporary suppression of hemorrhage to
occur almost immediately; and the larger arteries may escape entirely,
owing to their elasticity. Sometimes after bruised wounds, such as
those inflicted by gunshot, the large vessels bleed instantly and
violently; often, however, hemorrhage occurs only after the sloughs
separate, many days after the infliction of the injury, and then it is
generally very profuse; in some instances, limbs are torn, bruised,
or shot away, without hemorrhage occurring to any great degree, or at
any period. Frequently the vitality of the parts surrounding the wound
is much diminished; and the whole limb is apt to become gangrenous,
either immediately, on account of the extreme violence of the injury,
or consecutively, from greatly excited action going on in parts whose
power of resistance has been much impaired: it often arises also from
constitutional peculiarity. The gangrene extends often rapidly, in
consequence of the infiltration of putrid serosity into the cellular
tissue. In the treatment of bruised wounds, the position of the parts
must be carefully attended to; they must be placed in a state of
relaxation. In general, it is unnecessary to retain the margins of the
wound in contact, for adhesion cannot occur—suppuration must ensue,
and is to be desired—and the dead and dying parts must be loosened and
discharged before union can take place. Sometimes, as when a large
flap has been detached, and the parts not much injured otherwise,
approximation ought to be accomplished, for the reasons already
mentioned. In almost all cases, and most certainly in those in which
the mechanical injury has been severe, and its effects extensive,
violent inflammatory action is to be dreaded, and measures must be
taken to ward it off: notwithstanding the prophylactic treatment,
violent inflammation often comes on, and then recourse must be had to
the means proper for the subduing of it. Blood is to be taken from
the part, if necessary, and soothing applications used, in the form
of fomentation and poultice. The main indications are to prevent
extravasation into the substance of the limb, and strongly excited
action. When the sloughs begin to separate, emollient poultices promote
the suppuration and discharge of dead matter, and afterwards the
sore must be dressed, according to the nature of the case, with the
applications most fit for granulating sores in their different degrees
of action and advancement. During the after treatment, the sides of the
sore ought to be well supported, so as to prevent, as much as possible,
suppuration from extending along the neighbouring cellular tissue; but,
at the same time, the dressing must not be so tightly applied as to
cause irritation. When abscesses have formed in the neighbourhood, the
cavities should be freely exposed by incision; thus a free discharge
will be given to the matter, and the cavity brought to granulate from
the bottom. During the suppurating stage, the patient’s strength must
be maintained by generous diet.

Punctured wounds are dangerous, from the deep and internal effusion of
blood and serum which usually attends them. The effusion, which in open
wounds is poured out externally, and moderates and prevents the excited
action from exceeding what is salutary, is, in punctured wounds, poured
into the substance of the limb to its detriment. It is followed by
severe inflammatory action and profuse suppuration. In order to prevent
these untoward results, it was formerly the practice immediately to
dilate the wound; but this is hurtful, for if the wound be deep, as it
generally is, dilatation of its whole extent is a proceeding severe in
itself, and in its consequences; whilst, if the external part only of
the wound is dilated, the operation will entirely fail to effect what
is intended. The knife will be used in great good time where a foreign
body is found to be lodged in the wound, when tension has occurred, or
matter has formed. Sometimes the wound heals throughout its whole track
by adhesion, without any bad symptoms being so much as threatened.
Setons, recommended in this class of wounds, are of no service. It is
not the narrowness of the external opening, as is sometimes supposed,
that is the cause of all the mischief, but the injury and consequent
inflammation of deep-seated parts.

Poisoned wounds are rare in this country. Wounds by the stings of
certain trifling insects produce considerable swelling in some
constitutions, and when the injury has been inflicted on a loose
texture. In some parts of this country, the bite of a small adder
causes pain, swelling, and unhealthy suppuration of the part, with
some constitutional disturbance, but the results are seldom serious,
and never fatal. In warmer climates, the bites of some snakes are
followed by the most violent symptoms; in some cases proving fatal
in a few hours, in others after a day or two. Great swelling occurs
almost immediately, attended with excruciating pain, and extends upward
along the limb; vision becomes impaired, the patient lies in a state
of stupor, and ultimately succumbs under convulsions and delirium; the
symptoms vary in particular instances according to idiosyncrasies and
the state of the constitution when the injury is inflicted.[22] In this
country, the bites of rabid animals are more dangerous than those of
animals naturally poisonous. Rabies most frequently occurs in dogs,
and others of that species, such as wolves, foxes, &c. They become
dull, sluggish, and irritable; have unnatural appetites and cravings,
devouring their excrement and urine; the stomach is generally found
full of chopped straw, pieces of wood, &c. Derangement of the cerebral
functions is not complete,—they know and obey their master. They are
often not afraid of water, but lap it and go into it readily. From them
the disease is communicated to the human subject, and to the lower
animals, such as cats, sheep, cattle, and even fowls; the virus is not
communicable, except by the deposition of the saliva on an abraded
surface, or into a wound. It is not produced by eating the flesh of a
rabid animal. During the first days of the attack, pustules are, it is
said, observed under the tongue, but there is no apparent change in the
glands. The symptoms of hydrophobia in man seldom appear before the
twentieth day after the infliction of the wound, and in some instances
they have not presented themselves till after the lapse of months. The
most prominent are great restlessness, much irritability and anxiety,
and convulsions of the muscles concerned in deglutition, produced
either by attempts to swallow, or by fluid being presented to the
patient. Ultimately, the spasms become general, are induced by the most
trifling exertions or noises, and prove fatal in a few days. Frequently
the patient retains his senses throughout, and is fully aware of his
lamentable situation; in other instances, he soon becomes delirious,
raves, and threatens his attendants. For this horrible disease we
are unacquainted with any cure. In general, profuse bleedings are
employed, and large quantities of opium given internally; every
powerful antispasmodic, as well as every violent medicine, has been
made trial of, but in vain: some certainly mitigate the symptoms, but
none cure the patient. It has been even proposed to suspend or destroy
the function of the nervous system for a time, by the employment
of the Wourali poison, keeping up at the same time respiration by
artificial means, under the expectation that thus the impression
on the system might be got over. The morbid appearances usually
observed after death are marks of inflammation of the pharynx and
air-passages, and of the mucous surface of the stomach and intestines.
It is evident that the disease ought to be prevented if possible, and
for its prevention the most efficient measure is timely excision of
the affected parts; and they should be cut out a long period before
the constitutional affection comes on: when excision is dangerous,
or wholly impracticable, and when the patient does not apply soon
after the accident, the injured parts may be destroyed by some active
caustic, as the potassa fusa. The nitrate of silver has been strongly
recommended and extensively employed by Mr. Youatt, whose experience in
this disease is very great. This application should scarcely be trusted
to alone. The removal of parts wounded by snakes, even after violent
symptoms have appeared, has proved successful, ammonia having been
at the same time administered internally. In some instances, arsenic
has been found efficacious when given in large doses, and frequently
repeated.[23]

Wounds received during dissection occasionally have unpleasant
consequences from the absorption of animal matter. The absorbents
leading from the wounded part become swelled and painful, and in
slight cases there are shivering and general indisposition for some
days. The more violent symptoms arise from examining bodies which are
rather recent, and in which putrefaction is just commencing, and very
frequently from inspecting the bodies of females who have died of
puerperal diseases. The absorption may take place from punctures made
by scissors, the point of a knife, or spiculæ of bone, or from old
scratches, or chops by the side of the nail or on the hand. There is
little or no danger from an open and bleeding wound, as by the flow
of blood the part is completely cleaned; it is generally from slight
punctures that untoward symptoms need be apprehended. Effects similar
to those resulting from wounds in dissection often occur in nurses
and others who have pricked themselves with pins while washing foul
clothes, or from handling poultices or dressings removed from bad,
putrid, or sloughing surfaces. The symptoms already mentioned are soon
followed by others more severe: shivering continues, and the patient
is seized with vomiting; the part affected, and often the greater
part of the arm, becomes red and much swollen; the cellular tissue
is infiltrated with serum often dark and putrescent, abscesses form
at various points along the limb to the axilla, and purulent matter
is diffused throughout the unhealthy cellular tissue, which in many
instances sloughs, and gives rise to extensive sores. Typhoid symptoms
soon appear, and in the more aggravated cases speedily prove fatal.
When such local and constitutional symptoms arise, it will generally be
found that the patient was of a broken-up constitution previously to
the infliction of the wound; did they solely depend on the inoculation
of virus, they would be of very common occurrence, considering that
wounds are so frequently received during dissection; but it is seldom
comparatively that any unpleasant symptoms follow such an accident. In
all cases, however, it is prudent to adopt measures in order to prevent
absorption of the virus. With this view, the wound is made to bleed
by means of pressure or suction, and by the latter method the exposed
surface is most effectually purified; afterwards nitrate of silver
maybe applied to deaden the surface, and protect it by an eschar. If
such means be unavailing, the after symptoms must be encountered as
they appear, local inflammation subdued, tension relieved, abscesses
opened, sloughs removed, &c. General bleeding is seldom admissible, but
purgatives and antimonials will prove beneficial at the commencement;
afterwards the strength is to be supported, and, if the patient be much
reduced, stimulants are to be liberally administered.

We shall next treat briefly of gunshot wounds; under this head are
included the contused and the lacerated, caused by splinters, &c.
The vitality of the injured surface is generally destroyed at once,
whence bleeding seldom occurs, even after whole limbs have been shot
away; in some cases, however, hemorrhage is profuse, as when a large
artery has been wounded by small shot. The effects on the system are
extremely various; some persons are affected with tremors, anxiety,
and depression from slight wounds; while the most severe injuries
are often unaccompanied by any disturbance of the nerves. The shock
is generally of short duration, disappearing soon, on the patient’s
being reassured and encouraged, or after his taking a little wine or
opium. In gunshot wounds, those inflicted from a distance or close
at hand can in general be readily distinguished. In the latter, the
wound is large and lacerated, portions of the wadding are impacted,
and the skin around is marked with grains of gunpowder. In the former,
the wound is small and clean. When a ball passes through a fleshy
part, the opening at its entrance is small and depressed; whilst that
by which it escaped is open, with everted edges. When it follows a
superficial course, its track is marked by a wheal, or elevation of the
skin with discoloration. At one time, it was believed that the most
serious consequences resulted from a ball passing close past the body
without even touching it—that in this way violent concussion of the
brain, proving instantly fatal, was produced; but this notion has been
disproved by experience; part of the head accoutrements, of the hair,
of the nose, and of the ears, have been shot away by cannon-balls, and
yet no disturbance of the brain has followed either immediately or
consecutively. The opinion originated from the circumstance of soldiers
having been found dead without any evidence of injury; but bones are
often broken and comminuted by an indirect blow, or by a spent ball,
without any breach of surface or external sign remaining; internal
injuries indeed—rupture of viscera—more than sufficient to cause
instant death, are thus inflicted without any apparent external læsion.

The course of a ball in the body is often very strange, depending
on the force with which it is projected, or the resistance which is
opposed to it, and on the position of the struck part. Balls often pass
under the integument almost completely round the head or chest, having
first struck the bone at a very oblique angle. Frequently they remain,
lodged along with part of the clothing which they thrust before them.
In such cases, they may be immediately removed, their exact situation
being previously ascertained by external examination, or by means of a
probe. They can generally be extracted through the aperture by which
they entered; but if situated superficially, and at a distance from the
opening, this will be more readily accomplished through an incision
made upon them; if allowed to remain, suppuration will occur in the
neighbourhood, the surrounding cellular tissue will be condensed, an
abscess will be formed containing the foreign body, and by the process
of absorption proceeding in the parts external to the abscess, the
ball will at last reach the surface, and be discharged. The track is
often so extremely tortuous, as to render it impossible to ascertain
the situation, or even the existence of the foreign body, which greatly
impedes the operation; and, in other instances, it may be necessary to
allow the ball to remain undisturbed, on account of its being placed
near important parts, which might be injured by any attempt at removal.
Foreign bodies often remain lodged in fleshy or membranous parts for
years, having become enveloped in a dense cyst, and having ceased to
produce any great irritation. In consequence of the force with which
they have been projected, and the resistance which has been opposed
to their progress in the body, musket-balls, when extracted, either
immediately after the infliction of the injury, or after a considerable
time has elapsed, are seldom found to retain their globular form, but
are flattened and ragged, and not unfrequently completely divided by
the bones on which they have impinged. A bullet may be divided into
numerous fragments on a bone, and part may enter into the osseous
substance, whilst other portions penetrate in all directions into the
soft parts, and, though sharp and irregular, may remain long in the
dense cellular cyst which forms over them, without producing pain or
inconvenience. There will necessarily be suppuration, and generally
discharge of dead matter, from gunshot wounds, in consequence of the
bruising of the parts by the ball, which may be expected to injure
the superficial layer of parts in its tract so severely, that it must
slough more or less.

Besides, the bones are often splintered by the force with which they
are struck, and loose portions of them lodge amongst the muscles; then
they are the cause of much mischief, for, on account of their long,
sharp, and irregular form, they occasion great irritation, suppuration
ensues in various parts, sinuses form, and the cure is rendered very
tedious. In other cases, the bone is split in a longitudinal direction,
and, in the cylindrical bones, these fissures are often of great extent.

Considering the nature of the body which inflicts the injury in a
gunshot wound, and the velocity with which it is impelled, it is
evident that the cure must be in all cases tedious, in consequence of
the sloughing and suppuration which is induced, particularly at the
aperture through which the ball passed. The foreign body ought always
to be removed as early as possible, provided it can be accomplished
without much violence, or injury to the parts. Dilatation of gunshot
wounds is now had recourse to only to facilitate the removal of balls,
splinters, &c., and even with this view, it ought to be employed but
to a very slight extent, if at all; for foreign substances, when
deeply seated, can be much more easily taken out when the sloughs are
separating, and the parts relaxed by suppuration; then, too, they can
be more readily reached through a counter-opening, when their situation
renders this expedient. In short, the surgeon is not justified in
cutting for balls, unless they are easily felt, and not deeply lodged.
In order to discover the foreign body, probes will sometimes be
required; the finger often answers the purpose best, unless when the
wound is of considerable depth. If, on examination, the ball cannot be
discovered, and if there is reason to think that it has followed an
indirect course, the surgeon will, sometimes, be assisted in his search
by placing the patient in that position in which he received the wound,
and then judging of the circumstances most likely to affect the foreign
body in its passage. In many cases, extraction can be accomplished
by means of the finger alone; in others, forceps and scoops, various
in length and size, are indispensable. Afterwards, light dressings
are to be employed; and in the first instance, cold applications
may prove advantageous in keeping down the inflammatory action; but
when inflammation has commenced, and to encourage suppuration, warm
fomentations and poultices are to be preferred; they will in many
cases be both more grateful to the patient and more beneficial in
their results, when used even from the commencement. Afterwards,
it will be necessary to afford sufficient support to the parts by
bandaging, and to change the applications according to the particular
circumstances:—soothing, if the wound be irritable, stimulating, if
inert, and gently escharotic, if the granulations be exuberant.

In severe injuries of the limbs, the surgeon must be guided by the
state of the part, and of the constitution, by the circumstances in
which he is placed, as to accommodation, and mode of transportation,
&c., in deciding on the removal of the part by amputation,—or on
making an attempt to save it, by trusting to, and assisting, the
processes of nature. The question whether to amputate immediately,
and on the spot, merely allowing the shock, if any exist, to pass
away, or to delay till suppuration occur, is now scarcely a matter of
dispute. When it is evident, from the extent, violence, and nature
of the injury, that there is danger of speedy mortification, or of
extensive and severe inflammation and suppuration, amputation is to
be instantly performed,—delay is inadmissible. In comminution of the
hard, with contusion and laceration of the soft parts—where limbs have
been shattered and completely detached, or nearly so—in lacerations of
parts, including the principal bloodvessels and nerves—fractures of
the heads of bones, with openings into the joints—and in bad compound
fractures, more especially of the thigh (for all compound fractures
of the upper part of the thigh are dangerous), amputate at once.
When the limb has been retained, and gangrene arises in consequence
of the external injury, and when there is no reason to suppose that
any internal cause is also in existence; or when the violence of
inflammatory action has subsided, and the patient is become hectic,
with profuse purulent discharge, and with disunited bones, then
amputate. But, in this latter case, the chance of recovery is not
so great, and the proportion of recoveries small; whereas, in the
immediate or primary operations, the very reverse holds true. Such is
the experience of the greater number of military surgeons. In civil
practice, the results are somewhat different; a greater proportion of
primary amputations are unsuccessful, and the secondary turn out more
favourably than the statements of military surgeons would lead one to
believe. In all cases, the judgment of the surgeon must guide him in
his determination. The circumstances of the case, and the probable
contingencies, must be all duly considered, and he must not proceed
with his knife where there exists even a slight chance of preserving
the limb.

Paralysis occasionally follows wounds of the arm, forearm, face, &c.,
inflicted by accident or operation, and this arises from an important
nerve, or set of nerves, being divided. In cases of simple division,
without much separation of the parts, reunion of the nerves may take
place, and their functions be restored. If the limb remains paralysed,
after cicatrisation of the wound, tepid effusions, friction, dry
or with liniment, stimulating applications, &c., may sometimes be
advantageously employed.


TETANUS

Is a disease which occasionally follows a wound, but rarely in this
country. It is a spasmodic contraction, with rigidity, of the voluntary
muscles, in some cases involving the whole body, in others the upper
part of it only, and in some it is confined to a certain class of
muscles. When the extensors are affected, the disease is termed
opisthotonos; when the flexors, emprosthotonos. Complete tetanus is
said to exist when the flexor and extensor muscles exactly balance
each other, and the body is thereby kept straight and rigid. But when
the affection is confined to the muscles of deglutition, and chiefly
to those moving the lower jaw, it is called trismus. The disease has
besides been divided into acute and chronic, and into traumatic and
idiopathic; the one following wounds, the other arising from internal
causes, or circumstances not connected with the læsion of the surface.
The disease supervenes at various periods; sometimes, though rarely,
not long after the infliction of the injury, in other instances after
the lapse of eight or ten days, and often when the wound is healing,
or nearly cicatrized. In warm climates, where it is of very frequent
occurrence, it occasionally seems to be caused by exposure to damp
and changeable weather; in children, it supervenes on the slightest
irritation. It is often induced by the presence of splinters, or
rather bodies of an irritating nature, and by the partial division of
nerves. Not unfrequently it occurs after clean wounds, as amputation
or venesection; in the former it may perhaps arise from a nerve being
included in the same ligature with an artery, in the latter, from a
nervous twig being partially divided. The more prominent symptoms are,
stiffness of the back of the neck, and contraction of the features;
difficult deglutition supervenes, and the efforts to accomplish it
are attended with violent spasms of the muscles of the pharynx and
œsophagus. Spasms of the injured limb often precede those of the
muscular system generally; the muscles of the lower jaw become rigid
and spasmodically contracted, and by a continuance and increase of
the spasmodic action, the mouth is at last completely and immovably
shut. The muscles of the trunk and limbs become affected, and there
are violent spasms of particular sets of them, most generally of those
situated posteriorly; thus the body is bent violently backward, so
that its whole weight is supported on two points only, the heels and
the occiput. These symptoms are not constant; relaxation occurs,
and the patient enjoys a cessation of the malady: but this is only
temporary; the painful feelings and the spasms soon return. A symptom
of the most distressing nature is pain and spasmodic twitching of
the diaphragm, impeding respiration, and imparting a shock to the
whole system. Occasionally, emprosthotonos occurs, but, so far as my
experience goes, the body is much more frequently bent backward; the
muscles are sometimes ruptured by the violence of their own action.
The circulating system and sensorial functions are often not much
disturbed; but during the whole course of the disease, the bowels
are much constipated. In most cases of traumatic tetanus, after four
or five days, all the symptoms become aggravated; the countenance is
horribly distorted, the spasms of the diaphragm are more frequent and
violent, and the patient dies convulsed. Sometimes, though rarely, the
fatal termination does not take place till the eighteenth or twentieth
day. On dissection, the pharynx is found contracted, and bearing marks
of acute inflammation. In one case, which fell under my observation,
there was ultimately great difficulty in breathing and expectorating;
and on examination, the trachea, as well as the pharynx, bore evident
marks of inflammation, and were filled with a viscid mucus. In some
instances, there are evident marks of inflammation of the spinal
chord; the vessels, more especially at the lower part, are found
enlarged, tortuous, and engorged with blood; portions of lymph are seen
deposited on the arachnoid covering, and a serous fluid is effused,
not unfrequently mixed with blood. Such appearances, however, are not
observed in every case of fatal tetanus, and therefore it cannot be
asserted as a fact, that the disease is dependent on a morbid condition
of the spinal chord, though in certain cases the two affections
coexist. By some it has been supposed, that in consequence of the
distended and engorged state of the spinal arteries, the origins of
the nerves are stimulated, and that a morbid affection of them ensues,
giving rise to the tetanic symptoms; but want of uniformity in the
morbid appearances prevents such a cause from being generally set down
as the origin of tetanus.

This disease is one of the most intractable with which the surgeon
has to contend. In the acute form, time is scarcely allowed for
remedies; and in the advanced stage, it is with much difficulty that
medicine can be received internally. Of course all irritations must be
removed, both local and general, as far as that can be accomplished.
If the patient be robust, and if the tetanic symptoms be ushered in
with arterial incitement, general depletion ought certainly to be
practised; and if the symptoms be such as to render the propriety of
general bleeding dubious, blood may be abstracted locally, from the
back of the head, or along the spine; and this may be followed by such
counter-irritants as act rapidly. At the same time, powerful purgatives
must be given, so as to bring the bowels into a better state; for, as
already observed, obstinate constipation is a constant attendant on
this disease. But the most important indication is to alleviate and
prevent, if possible, the spasms; and for this purpose, opium is to be
administered in large doses, either by itself, or combined with camphor
or other antispasmodics. By such means, the disease has in some cases
been arrested, but in the majority it has proceeded unabated. Some
practitioners recommend and employ cold affusion and immersion, whilst
others prefer the warm bath; and the latter appears to be the safer
application, though neither can be considered as efficacious. Great
relief and benefit seem to have accrued from the frequently repeated
use of a warm bath, with some drachms of the tart. antimonii dissolved
in it. I have had only two opportunities of trying this practice; one a
chronic ease, where, after the division of the nerves proceeding from
the wound, this remedy, with others, seemed to allay the spasms in a
very remarkable manner: the patient recovered. In the other, a very
acute case, after the extraction of a splinter from betwixt the thumb
and forefinger, the bath was tried; the patient felt much comforted by
it; but suddenly expired in a violent convulsion, whilst being replaced
in bed. Great relaxation follows this remedy, profuse perspiration,
and subsidence of the rigidity and convulsive action of the muscles.
The practice was recommended to my notice by my excellent friend Dr.
Stevens, Professor of Surgery at New York. In some cases, it would be
worth trial to produce instant vesication by the acetic solution of
cantharides or ammonia, and then try the effect of the application
to the blistered surface of some of the alkaloids, such as morphia,
aconitine, &c., or belladonna might be applied.

Some practitioners have used mercurial frictions along the spine, or
on other parts of the surface; while others administer stimulants,
and enemata with tobacco and turpentine. When there is reason to
apprehend that the symptoms arise in consequence of laceration or
partial division of a nervous trunk, it has been recommended to
complete the division of it; and the practice is worthy of adoption,
as in some cases it appears to have been successful. Little good can
result from scarification of the wound. Amputation of the wounded
member has also been proposed, particularly in chronic cases, and
in one or two it has succeeded. I have made trial of it in but one
instance, and in that it failed. Acute tetanus had followed a lacerated
wound betwixt the thumb and forefinger; amputation of the forearm
was performed, and immediately after the operation the spasms abated;
but they soon returned, notwithstanding the free use of opium, and
other remedies, and the patient died. In this case, the branch of the
median nerve was found partially divided, and its cut extremities were
thickened and inflamed. During the operation, I wished to abstract
a considerable quantity of blood, but the arteries seemed to be so
spasmodically contracted, as to permit the flow of a small quantity
only. On examination after death, the median nerve was of its natural
appearance, excepting at the bend of the arm, where it was of a
bright-red colour. No change could be perceived in the brain or spinal
chord, though the examination was conducted with the utmost care.


OF ULCERS.

By ulcer is generally understood a breach of continuity in the soft
parts of the body, with secretion of purulent or other fluid. But as
suppuration may be independent of ulceration, so may we occasionally
see a loss of substance like an ulcer on the surface of parts,
without the production of pus, or any other morbid secretion, of
which some instances are noted in the remarks on Atrophy of Articular
Cartilage. Mr. Burns, in his excellent volume on the Principles of
Surgery, has extended the term to the reparative process, as well
as the destructive; this, if adopted, would lead to confusion and
misapprehension.

Ulcers vary much in disposition and appearance, follow wounds,
abscesses, sloughing, eruptions, &c., and often occur without any
previous læsion of the surface. Those most generally met with are
comprehended in the following classes:—1. The simple purulent ulcer,
or healthy or healing sore. 2. The weak or sluggish ulcer,—a sore
with undermined integuments and an unhealthy state of the cellular
tissue. 3. The indolent ulcer,—a sore with hard elevated edges, and
presenting little or no appearance of reparation. 4. The irritable
ulcer,—a sore with over-action, and generally affecting only the mere
surface of the true skin. Besides these, there are sores connected with
diseases of the bones, and others arising from specific action; some
are complicated with a varicose state of the veins: the former have
been already treated of; the latter are reserved for consideration.
Ulcers change their characters, as from simple to irritable, and from
indolent to inflamed; the change depends on situation, on the state of
the constitution, and on the treatment which they receive.

I. The appearances of the first class were described when the healing
of wounds by granulations was considered, p. 173. They heal more
readily on the upper extremities, on the face, neck, and trunk, than
on the lower limbs; for in the former parts the circulation is more
vigorous, the natural processes of cure proceed more easily, and are
less liable to interruption. The sore only requires rest, a clean
condition of the surrounding parts, mild and light dressings, and
moderate support; dry lint or lotions are preferable to ointments,
since the latter are apt to irritate by their rancidity. When the sore
is of considerable size, and there is a tendency in the granulations to
rise above the level of the surrounding skin or cicatrix, the edges may
be protected by very narrow slips of fine old linen or cambric, spread
with fresh spermaceti ointment or cold cream; a pledget of dry lint is
then laid on, and retained by a roller. The dressings thus arranged
do not adhere, and the tender cicatrix is not ruffled and disturbed;
or a piece of pierced linen spread thinly with unirritating ointment
may be placed over the sore, and above that dry lint. When the sore
has contracted to a small size, and some powder, as starch or calamine
stone, or a piece of dry lint, may be applied, so as to allow a scab
to form for the protection of the subjacent surface; but this will,
in most cases, be better accomplished by touching the surface lightly
with lunar caustic or blue stone; the fluids on the part are thereby
immediately coagulated, a crust is quickly formed, and by covering it
with charpie, it is retained in its situation, whilst the process of
cicatrisation proceeds beneath it: if a small quantity of matter should
be secreted, it readily escapes by the sides of the crust, without
disturbing either it or its covering; the limb should be raised above
the level of the trunk. Sores on the lower limbs are always difficult
to manage. The reparative process is tedious, on account of their
situation; the parts are at a distance from the centre of circulation,
their action is weak, the return of blood is tardy, and the same
facility is not afforded of restraining the motions of the part as in
the upper extremities. In persons of a good constitution, however,
the simple purulent sore often heals speedily, even in the lower
limbs. Before cicatrisation can take place, it is essential that the
granulating surface should be on a level with the sound surface around;
this soon takes place when a favourable position is observed, and the
part is kept at rest; but by neglect, the new matter is often absorbed.
Again, the healing process cannot advance where the granulations are
exuberant, large, and flabby, and have risen above the proper level:
they must be kept in check by due compression, and by astringent
lotions, containing salts of zinc, copper, &c. The constant meddling
with sores, the touching them with this, that, or the other caustic, is
much to be reprobated. Should it be necessary to destroy granulations,
and bring them down to the surrounding surface, one good rubbing with
the blue stone will generally suffice. If the ulcer is large, the
granulations close to the cicatrix should only be destroyed, leaving
the centre to be dealt with as the cure advances.

During the cure, the patient must be a good deal confined to the
recumbent posture; when erect, a bandage or laced stocking must be
applied to the limb; thus the return of blood is assisted, swelling
is prevented, and the affected parts placed in a state of comparative
rest. Much pressure ought to be avoided, as it is apt to produce
bad effects upon the sore, causing absorption of the granulations,
thin bloody discharge, and great tenderness of the surface. After
cicatrisation, the scars may be absorbed, and sores reproduced, by
external injuries, or an unhealthy state of the body; and so much does
the state of a sore depend upon that of the general health, that the
one is a good index of the other.

II. In the second class of sores, or those with weak action, the
granulations are flabby, of a pale colour, and possessed of little
sensibility or vascularity; the discharge is gleety, and the surface is
liable to be destroyed by ulceration or sloughing, upon the slightest
excitement of the circulation in the part. The surrounding integuments
are generally of a bluish colour, in consequence of their separation
from the subjacent parts; and in several places of the neighbourhood,
small, unhealthy, detached abscesses may exist; at some points of the
sore, glairy fluid is seen to ooze out on pressure, and a probe can
be passed pretty deeply into the cavity of an abscess in the soft
parts beneath. These sores may arise from an unhealthy condition of
the cellular tissue, taking place spontaneously, or following slight
injury; they are attributable to the state of the constitution, and
may result from an ulcer, originally of a healthy character, which
has remained long open, in consequence of its great size, or other
impediments to its contraction.

It is the business of the surgeon, in cases of this description, first
to obtain a sound foundation, by destroying the unhealthy skin and
cellular tissue; the free application of caustic potass will answer
this end most readily and effectually. Its application is attended with
considerable pain, but the practice is more successful and less severe
than the removal of the unsound parts by the knife or other means. The
small abscesses may be all freely laid open; the diseased cellular
tissue may be cut into, or cut away; in short, incisions may be made in
all directions, and in every portion of the affected part; but still
it will be found that the granulations, as they appear, become pale
and flabby, that they spring from a loose and powerless base; matter
will again collect; the surrounding skin will again be undermined; no
progress will be made towards soundness. But by attention to the state
of the constitution, and the application of potass, the neighbouring
sound parts have their actions roused, and the healing is carried
on rapidly. After its application, a poultice may be applied for a
few days, and followed by water dressing, and then stimulants, both
internally and externally employed according to circumstances, the
parts being all along well supported. The long continued use of warm
fomentations, or poultices, is prejudicial, as tending to diminish
still farther the action of the parts; ointments can be of little
service, and will generally do harm.

III. Indolent ulcers, which have long existed, are frequently met
with on the lower limbs. Their margins are thick and insensible—their
surfaces smooth, hollow, and of a pale colour—the discharge is
scanty, and adheres to the surface. A sore, having been long open and
neglected, degenerates into this state. Poultices are to be applied for
a day or two, to clean the surface, promote the discharge, and soften
the callous margins. This is the more necessary, if, as is often the
case, the sore, or the surrounding integuments, are inflamed when the
patient applies for relief. Afterwards, the applications must be of
such a nature as to moderate the discharge and keep the granulations
firm and healthy. In such cases only is adhesive plaster applicable,
and in them it produces the most beneficial results. Supposing the
ulcer to be situated on the fore and middle part of the leg, a bandage
should first be firmly applied from the toes to a little below the
sore; the ulcerated part of the limb is then encircled by narrow
strips of adhesive plaster, tightly drawn, and with the extremities
of each strip crossing immediately over the ulcer. A pledget of tow
is placed on the plasters to absorb the discharge, and the bandage is
brought over dressings, and continued for some way upward. By this
application, the margins of the sore, it is supposed, are brought
nearer to each other, and the ulcerated surface diminished; the
sluggish granulations and the subjacent parts are stimulated, and a
more vigorous action being excited, the process of reparation proceeds
speedily and effectually; the surrounding parts, previously turgid
and œdematous, are by the pressure brought to the same level with the
newly-secreted matter, and new skin is quickly formed. In the previous
state of matters, the old skin was much elevated, and an action was in
progress, causing a continuance of that elevation; by the compression,
the whole limb is properly supported, serous effusion prevented,
absorption excited, and œdema removed; the livid swelling of the lower
part of the limb, which might arise from the tightness of the adhesive
plaster, is obviated by the bandage being first applied. A feeling of
uneasiness in the limb sometimes follows such dressing, but is of short
duration; should it increase, so as to amount to pain, the elevation of
the limb and the pouring of cold water occasionally over the dressings
will soon restore the parts to comfort. Or the adhesive plaster may
be slit up behind, immediately after its application; indentation of
the limb being thereby avoided, and sufficient pressure at the same
time kept up on the sore. If possible, the dressings ought not to be
removed before the second day, as much irritation will be produced
by their frequent renewal. The benefits arising from this mode of
treatment are truly surprising; the slow and indolent ulcer is speedily
converted into the simple purulent sore; the white and recent cutaneous
substance encircles small pointed and florid granulations, which bleed
from the slightest rudeness of touch; and the space formerly occupied
by an unsightly sore is soon diminished to a small and firm cicatrix.
It is only necessary to continue this mode of dressing so long as the
granulating surface is below the level of the surrounding surface.
Then the object being attained, the deranged state of the cellular
tissue being got rid of, and the ulcer put in a state favourable for
cicatrisation, the sulphate of zinc lotion not over strong may be
resorted to; positive rest and support of the affected part being still
enjoined and observed. In the old and debilitated, however, in whom the
indolent sore most frequently occurs, the integuments remain purple
and shining, and from very slight causes the cicatrix is absorbed, and
breach of surface is reproduced.

These sores are often connected with a varicose state of the veins.
In all such cases, a degree of compression on the affected limb must
be maintained, both during the continuance of the sore, and after it
has healed. The usual situation of such sores is on the leg, and the
varicose state of the veins does not, in general, extend above the
knee; in such cases, a radical cure may be attained (provided the
patient wishes to encounter the attendant risks, rather than submit
to a continuance of the disease) by effecting an obliteration of the
saphena major vein. The manner of doing this, and its effects, were
mentioned while treating of diseased veins. In some cases, the saphena
minor is also varicose to some extent, the varices on which must also
be obliterated. Sometimes as many as eight or ten needles must be
applied, in pairs, before the circulation of a limb can be brought into
a right state.

IV. In this fourth class of sores, or the irritable from over-action,
the sore and its edges are of a jagged, irregular appearance, the
discharge is thin and bloody, and considerable pain is experienced.
This ulcer is very superficial, involving only the surface of the
corium and the more sensible part of the integument, the papillæ,
and extremities of the nervous filaments. They often succeed to
scaly eruptions, and present a remarkable character and appearance,
cicatrising in the centre, whilst they extend towards the
circumference. The sore is often covered by an ash-coloured slough;
on the removal of which, granulations arise, but these either again
slough, or are removed rapidly by the ulcerative process. In the
treatment of such sores, complete rest and soothing applications
are the means on which most reliance is to be placed. Warm and
soft poultices, such as those of arrow-root, fomentations, tepid
water dressing, solutions of opium, or of extract of poppy, and the
occasional use of a local vapour bath to the part, may be enumerated
amongst the means best fitted to allay the irritable condition of the
ulcer. When the surrounding integuments are swollen, red, painful,
in short, evince marks of inflammatory action going on in them, the
feelings of the patient will be rendered grateful, and the cure
advanced, by abstraction of blood from the parts by punctures. When the
nature of the sore is changed, and when cicatrisation has commenced,
the treatment is similar to that of a simple granulating surface—light
dressings, due support of the parts, and repression of exuberant
granulations by the sulphate of copper. The nitrate of silver, applied
in substance round and about the ragged edges, is of great service at
an earlier period. This practice must be sparingly and seldom resorted
to, but it does wonders when judiciously employed.

Ulcers are occasionally prevented from healing by the presence of dead
portions of tendon, fascia, or cellular tissue, and are accompanied in
general with a bad state of constitution; in such it is necessary to
clean the surface by a powerful escharotic, and the best is potass.
Otherwise, granulations will be produced quickly, it is true, and in
abundance, to supply the original substance; but then they are flabby
and exuberant, new skin is formed slowly, if at all, and the sore does
not contract; but by removing the dead or half-dead surface, a healthy
and firm foundation is prepared, on which is securely and gradually
raised the new matter for cicatrisation. But caustics are applied
injudiciously to firm and healthy granulations which have not yet
reached the level of the surrounding parts; they are only useful in
repressing exuberant granulations, or in destroying half-dead parts,
which interrupt or deteriorate the cure: and when employed, it should
be effectually, and once for all.

Along with the topical treatment of ulcers, internal means are, in
most cases, indispensable. Thus, in indolent ulcers, the state of
the constitution is often sluggish, and ought to be changed by the
exhibition of alteratives or stimulants; with this view, much benefit
is derived from a prudent and restrained use of mercury, from the lytta
vesicatoria, from minute and occasional doses of arsenic, from the free
exhibition of sarsaparilla, and from generous diet, porter, and wine.
It is however, altogether impossible to lay down fixed rules for the
management of sores; every one has some peculiarity in its nature and
appearance, every one requires some peculiarity in the applications
and mode of dressing, and what may suit well one day will often prove
inert or injurious on the succeeding. Again, when any one application
or internal remedy is found to agree with the sore, it ought not
to be changed for fashion’s sake, from caprice or routine. In this
department of surgery, one practitioner excels another, not by his
superior knowledge of the various applications, but by his acuteness
in selecting the remedy adapted to the particular state of the sore,
and in accommodating the various ointments, lotions, or powders, to the
different characters which the ulcer assumes during its progress. The
healing of sores is very easy in some constitutions, and very difficult
in others. Hence, it has been supposed that the long existence of a
sore is a salutary process of nature, tending to relieve or prevent
some more serious affection, and on this account some are little
solicitous to procure its cicatrisation, or at least are careful that
the cure shall not be a speedy one. If, indeed, an extensive sore,
or a series of sores, be suddenly dried up, the circumstance must be
considered as very unfortunate, and the consequences may even be fatal;
but such an occurrence is unusual, and the patient may in general be
saved by the timely insertion of an issue in the neighbourhood of
the sore, or by an active employment of what is best calculated to
insure a renewed discharge. Some sores have a disposition to extend
by sloughing, and such frequently attack the lips and pudenda of
weakly children; they are also met with, amongst the lowest class of
prostitutes, in the cleft of the nates, in the groin, &c., and in such
cases the sore closely resembles hospital gangrene.


OF HOSPITAL OR CONTAGIOUS GANGRENE, AND SLOUGHING PHAGÆDENA.

This disease has been long known, and has proved very fatal in crowded
and badly-aired hospitals. It may break out at any season, but hot,
sultry, and damp weather is most favourable to it. No breach of
surface, however small, is secure from its attack. The wound becomes
painful and swollen, and loses its healthy, florid appearance; the
granulations are flabby, and appear as if distended with air; vesicles
form, containing serum or a bloody fluid; the pain is stinging; the
secretions are suspended; and the wound is either altogether dry,
or covered with slimy, tenacious, and peculiarly offensive matter.
An ichorous discharge follows, the pain increases. The sore assumes
a circular form, and its edges are everted; erysipelas attacks the
surrounding integuments, often extending over the whole limb, and
forming a principal feature of the disease. In fact, violent erysipelas
and hospital gangrene are affections very closely allied to each other,
often arising at the same time, and from the same causes. Both are
accompanied with great constitutional disturbance; but in erysipelas,
this generally precedes, whilst in hospital gangrene, it follows, the
appearance of the malady. The lymphatic glands, in the neighbourhood of
the gangrenous part, inflame and suppurate, the skin gives way, and the
gangrene soon seizes the newly-formed sore. Fever supervenes, the pulse
is often full and strong, and the surface hot; there is great nausea
and thirst; the tongue is brown, and the bowels much disordered. The
inflammation and ichorous discharge increase. A thick slough covers the
sore, and its fetor is peculiar and intolerable. The burning pain is
excruciating. Blood oozes out, and, in the last stage, the hemorrhage
is often copious from large vessels exposed by the ravages of the
disease.

Now, extensive mortification occurs, the strength fails, the pulse
becomes tremulous and indistinct, the features collapse, the surface
is bedewed with a cold sweat, diarrhœa and hiccough come on, and death
puts an end to the patient’s suffering. Such is the progress of the
disease in those who were previously in perfect health. Often, however,
it is attended with typhoid symptoms almost from the beginning, in
people whose constitutions are wasted, who have long laboured under
disease, or who have been long confined in hospital. The important
distinction between these cases must influence the treatment; what
succeeds in the one will destroy in the other. It is not the name of
the disease which is to be combated, but each symptom as soon as it
presents itself.

Those who have been once afflicted with hospital gangrene are extremely
liable to its recurrence, and that too on the same sore; though the
secondary disease is much less acute. This form has been termed
Sloughing Phagædena, and may seize a sore not previously affected with
gangrene. The wound, recovering from the first attack, and appearing to
heal rapidly, with good discharge and healthy surface, presents, near
its edge, a small dark spot or ulceration, of the size of a small bead
or shot, of a circular form, with a ragged edge, excavated surface, and
fetid discharge. Several such points may appear; they spread rapidly,
unite, and the surface is soon destroyed. It is not uncommon to find
one part of the sore of a healthy appearance, and even cicatrising,
whilst in another part the surface is rapidly disappearing. The
patient complains of a burning sensation in the part; suppuration
occurs round the edges and beneath the slough, and the dead parts
separate; but the same process again takes place, and another slough
forms. The malady proceeds often with a rapid and alarming pace; the
sloughs are soft, pulpy, and reddish, and separate one after another,
exposing muscles, nerves, bloodvessels, and bones. Joints are opened
into, and the vessels, having been exposed, perhaps for a day or
two, give way, and fatal hemorrhage ensues, their cavities not being
obstructed with coagula as in sphacelus. The patient is sick, has no
appetite, and labours under other symptoms of deranged stomach; there
is restlessness, with a small quick pulse, and all the symptoms of a
weakened and sinking system. The ulceration becomes more rapid, the
discharge is bloody and peculiarly offensive; all the symptoms increase
in violence, and may proceed for fifteen or twenty days, or terminate
in four or five, either in convalescence or death.

Hospital gangrene is supposed to arise from a variety of causes:
from the state of the atmosphere, moist and hot—from inattention
to cleanliness, the parts around the sore being seldom wiped, the
matter collecting amongst the dressings, and becoming acrid by
putrescence—from irritating applications, as rancid ointments—from
a too stimulating diet, and from the abuse of wine and spirits—from
mechanical irritation, in moving the wounded over rough roads and in
bad conveyances, as after great engagements—from specific contagion
without immediate contact. After being once generated, it is
propagated by direct communication, by the application of morbific
matter from sponges, dressings, or instruments. It is not easy to say
how the disease originates.

In the treatment of this scourge, great attention must be paid to
cleanliness in all circumstances. Free ventilation must be constantly
preserved in the apartments of the sick, and fumigations assiduously
employed. The infected ought to be separated from the others, and but
few patients placed in the same ward. Stagnant drains and accumulations
of filth out of doors are to be removed; otherwise, during hot weather,
the atmosphere becomes much vitiated. Care must be taken, also, to
destroy all the dressings which have been used; not to employ sponges,
but to wipe the surface in the neighbourhood of the sore occasionally
with tow, which is to be burnt immediately, being an article of little
value, and easily procured. Too much attention cannot be paid to
the cleaning of those instruments with which gangrenous sores have
been treated, before they be applied to healthy wounds. As to the
constitutional treatment, the alimentary canal must first be purged
of its solid contents, and the secretions afterwards kept in as good
a condition as possible. When the wound or sore is surrounded with
intense inflammation, and when the skin is dry and the pulse strong
and full, with all the other symptoms of an inflammatory diathesis,
immediate recourse must be had to free abstraction of blood from the
system, as thus only can the progress of the disease be efficiently
arrested; and if inflammatory symptoms exist, when there is reason to
expect the occurrence of the disease, though no symptom of it has yet
appeared, then, too, venesection combined with purgatives is demanded,
as being the most powerful preventives. Emetics are also recommended.
When the affection is from its commencement accompanied with typhoid
symptoms, depleting measures must do irreparable mischief: in such
cases, the local pain and irritation will be relieved by the exhibition
of opium or camphor, and it may also be of service to preserve a
perspirable state of the surface by means of Dover’s powder, or other
diaphoretics. Preparations of Peruvian bark, the decoction with or
without the tincture and acid, or the sulphate of quina, are often
given with great advantage—opium is also usefully exhibited. Vinegar,
weak acids, the nitric and muriatic acids diluted, have been used as
external applications, and nitrate of silver, the red oxide of mercury,
and the actual cautery, have been applied with the view of removing the
diseased parts, and procuring a healthy surface. Arsenic in solution,
used so as to produce a slough, followed by hot dressings, has been
supposed to be serviceable. A much safer and more powerful application
is the strong nitric acid, which sometimes requires to be applied over
the diseased surface very freely, and repeated if need be.


THE MALIGNANT PUSTULE

Is a gangrenous inflammation of the skin, rarely extending to the
subcutaneous cellular tissue, and in this respect differs from
carbuncle, which commences and is seated in the cellular texture. It
arises from the application of the fluids of animals which have died
of putrid diseases common in some marshy and low situations. It is
communicated not only by matter from the diseased part, but also by
the blood of the animal; thus it is frequently observed in those who
handle the recent skin or flesh; and the excrements also appear to be
possessed of the poisonous principle. It spreads from one person to
another by contact. There is much reason to doubt, whether carrion
introduced into the stomach produces this disease, though by some it
is maintained that even the respiration of effluvia from putrescent
substances produces malignant fever, with fetid evacuations and
gangrenous patches on the skin. In the West of Scotland, an instance
occurred some years ago, in which several persons lost their lives
from eating the flesh of dead animals which had been washed ashore.
The occurrence of malignant pustule is rare in this country. Some time
since, I met with a well-marked case in a shoemaker, who had been
employed in killing some sickly pigs. Whilst turning over and removing
the abdominal viscera of one of them, he had scratched his finger
slightly with a pin stuck in his jacket, and he then perceived that
the contact of some putrid matter from the intestines caused great
pain. On the third or fourth day afterwards, he presented himself with
a malignant pustule formed on the hand between the fore and middle
fingers. The pain was very intense, and the disease seemed to be fast
extending. Active treatment was employed, and the patient had a speedy
recovery.

The disease generally attacks the hands, neck, face, or shoulders of
butchers and others, who carry, or in some way deal in carrion. It has
also taken place in consequence of the hand being introduced into the
rectum—a veterinary method of removing scybala—of an animal labouring
under putrescent disease. A pustule appears on the part affected,
containing a serous or a dark-coloured fluid; and the base ulcerates,
extending through the skin to the subjacent parts; at first it is
accompanied with a pricking sensation, afterwards the pustule enlarges
and becomes brown, and the pain is burning and itching. The vesicle
when opened, or when it has burst spontaneously, furnishes a few drops
of red serum, and the pain is thereby relieved for a few hours. A hard,
moveable, and circumscribed tubercle forms, without alteration of the
surrounding skin. The bottom of the sore is yellow, greenish, or livid,
and the sensation is that of acute heat and erosion. Phlyctenæ spread
around. The tubercle becomes black in the centre, and an eschar forms;
the patient becomes irritable and languid. The gangrenous point begins
to extend, and that alarmingly; great swelling takes place, elastic,
red, and shining, more emphysematous than inflammatory or œdematous.
The burning pain is aggravated; the patient has a feeling of weight
and stupor; great constitutional disturbance follows, there is slow
fever, with a small pulse, a dry and brown tongue, and unquenchable
thirst; a low muttering delirium ensues, and under these symptoms the
patient soon sinks. After death, the fetid body swells rapidly. The
disease sometimes terminates fatally in twenty-four hours or less;
but generally the patient’s sufferings are more protracted. In the
treatment, superficial scarifications are of little avail. The only
topical application which can be relied on is a powerful escharotic,
applied freely to the part, and at an early stage, before swelling
and constitutional affection have been added. By it the parts replete
with virus, being immediately deprived of vitality, are soon thrown
off. Thus the virulence of the poison is annihilated, it is rendered
inert, and is concentrated in the slough, and the surrounding parts are
stimulated, and receive vigour of action, which enables them to resist
any further inroad, and to detach quickly the mortified substance.
For this purpose, the most effectual and convenient escharotic is the
caustic potass, but the liquid muriate of ammonia may also be employed.
The vesicle is opened, and the caustic applied to the exposed surface;
and if necessary, the eschar may be afterwards divided, and the remedy
reapplied. In the absence of other escharotics, the actual cautery will
prove a valuable substitute. After the separation of the slough, the
sore is to be dressed with slightly stimulating applications. Bark,
camphor, and mineral acids, are given internally, and the patient is
enjoined a light diet, with a moderate allowance of wine.


OF ULCERS OF THE GENITAL ORGANS, AND THEIR CONSEQUENCES.

It were unprofitable to enter here upon the History of Venereal
Affections, as it is a subject of no practical utility, still involved
in uncertainty, and mystified by disputation. It will suffice to
describe the different forms of the disease, and state the treatment
applicable to each.

During the last century, and in the beginning of this, much greater
ravages were produced by the disease than at the present time; and
though this may be, perhaps, partly owing to a change in the poison
itself, it is mainly attributable to the mildness of the measures by
which it has been, and is, opposed. Every form of the affection, as
soon as it appeared, was at one time opposed by a counter poison,
mercury; and the practitioner, relying implicitly on this mineral as
a specific, and not being fully aware of its dangerous properties,
continued to gorge the system with the supposed remedy, subverting the
constitution of his patient, making, in many cases, no impression on
the disease, but still persevering in the use of a poison equal, if
not more potent, than the one which it was intended to destroy. The
change of treatment has been propitious to our science and to mankind.
But let it not be inferred that mercury now is, or ought to be,
entirely dismissed from the treatment of this disease, or from practice
generally: often no other means are effectual; but it should always be
prescribed most cautiously and sparingly.

The effects of the venereal virus are divided into primary or local,
and secondary or constitutional; and these present a great variety
in their appearances, characters, and tendencies. They are sometimes
modified by the constitution, or by the remedies ordered in the
first stage; but there can be no doubt that different poisons exist,
producing distinct kinds of ulcers, which again are succeeded by
different constitutional affections.

The most common kind of sore is the _simple ulcer_, at first excavated,
in consequence of the process of ulceration continuing; afterwards
the ulceration stops, and granulations, somewhat fungous, supply its
place, so that the surface is raised above the level of the surrounding
parts, and has a smooth, soft appearance; there is no hardness of the
edges, and there is no tendency to slough or extend by ulceration.
Sometimes it commences in the form of a pustule, which soon gives way,
discharging its contents, and leaving an exposed surface, in which
the process of ulceration quickly proceeds; but often it arises from
simple abrasion of the surface. Different forms of sores may exist on
the glans and prepuce at the same time; and it is maintained, that
one sore may produce another of a different kind, and the same is
asserted with regard to eruptions. The simple ulcer, as well as other
sores, is produced by the contact of secretions, generally morbid,
but often apparently healthy, with a susceptible surface. Sores, with
eruption and sore throat, sometimes appear in one or both individuals
immediately after marriage, and probably arise from the acrimony of
the female secretions causing tenderness and ulceration of the parts.
The application of gonorrhœal matter readily produces the simple
ulcer on the glans or prepuce, particularly if an abrasion or rawness
existed; and if the matter be allowed to remain on an unbroken surface,
a pustule will form, and ulceration follow. From this latter cause
numerous sores are produced, separated from each other by sound parts,
and not extending into one continuous ulcer; and this condition may
have been preceded, on the glans, by a rawness of the surface and a
profuse discharge, or by a herpetic eruption on the mucous lining of
the prepuce. One man may be affected with gonorrhœa, and another with
ulcer, from connection with the same female, the same day or hour; and
it is doubtful whether the effect is not similar, in both cases, viz.,
ulceration; for it is supposed, that in gonorrhœa, the discharge, in
some rare cases, proceeds from patchy ulceration of the mucous lining
of the urethra, similar to the ulceration usually met with on the
glans. In examining women who have communicated infection, very often
no sores are found, and but little unhealthy discharge. In short, the
simple elevated sore may arise from the application of secretions from
an unbroken surface, from inoculation of matter from a similar sore,
or spontaneously, from inattention to cleanliness. Sores with elevated
surface, more extensive than those of the glans and prepuce, occur
on the skin of the penis and scrotum, or in the folds of the thigh;
and in women they are often met with in the perineum, or the cleft of
the nates. Sores of different kinds arises at various periods after
the application of their cause, from a day or two to some weeks, or
longer, but the usual time may be said to be from four to eight days.
The duration of the simple elevated sore may be modified by various
circumstances—by the constitution of the patient, his mode of living,
and the attention paid to the affected part. It seldom remains open
above a few weeks, but occasionally it may be seen unhealed at the end
of several months in those who lead careless and irregular lives.
Such ulcers produce, as readily as any other sores, enlargement of the
inguinal glands; they are a source of irritation, the effects of which
may be extended along the lymphatic vessels, to the cluster of glands
through which the absorbents pass, so as to cause inflammatory action,
ending in indurated enlargement; or venereal virus from the sore may
be taken up by the lymphatics, deposited in the glandular structure,
and produce a similar affection. Buboes thus caused are situated in the
upper cluster of inguinal glands; if the lower cluster is affected, it
is to be presumed that the cause is not in the organs of generation,
but in some part of the inferior extremity. From the existence of bubo,
nothing can be deduced as to the nature of the poison, or the probable
effects to be produced on the constitution; for enlargement of glands
in the course of their lymphatics will occur from irritation, whether
connected with a mild or malignant virus, or with one totally devoid of
any poisonous quality.

From the simple ulcer there arises a constitutional affection, in all
respects resembling that which follows gonorrhœa (a disease which will
be treated of under affections of particular mucous surfaces); but
before attending to this, it will be proper to advert to another form
of ulcer, which differs but slightly from the preceding in primary and
secondary symptoms. It is a sore with a brown surface, either on a
level with, or above the surrounding parts, with defined and elevated
edges, with no cartilaginous hardness of base or margins, and with
no tendency to spread either by sloughing or by ulceration. Such may
occur in the same situation as the simple sores, but they often form
on the outer surface of the prepuce, or on the scrotum; and are not
unfrequently met with round the orifice of the prepuce, which is a most
troublesome situation, as, in healing, they generally produce phymosis.
Sores and fissures in this situation are very often kept up by the
tense and irritable state of the aperture. The bubo which follows
this differs from that caused by the simple sore, in having, after
ulceration of the integument, a greater disposition to burrow; and this
tendency is more marked where mercury has been employed. From either
of these forms of ulcer, it sometimes happens that constitutional
affections arise, either during the existence of the sore, or some
weeks after it has cicatrised.

The usual secondary symptoms are those attendant on a papular eruption.
There is fever, with pains referred to the head, to the joints, chiefly
the larger ones, and to the chest, which latter symptom is sometimes
attended with dyspnœa. This indisposition is followed by the appearance
of a papular eruption, termed lichen, on the face and trunk, the
extremities being less thickly studded. The fever subsides in a great
measure after the eruption appears and comes fully out; but fresh crops
of papulæ may appear, and, in this case, the fever continues little
abated until the eruption begins to fade. The eruption consists, in the
first instance, of simple elevations or pimples of a red colour, and
these do not appear at once, but gradually: so that some have assumed
the form of cones, with minute collections of matter in their apices,
whilst others are mere elevations of the cuticle. When they fade the
spots are of a copper tint, and become covered with thin scales, in
consequence of the cuticle desquamating; but this latter appearance
can never be confounded with the scaly eruptions following another
description of primary sore. In all cutaneous eruptions, attended with
any febrile action, there is a tendency to sore throat, with tenderness
of the eyes; and this eruption is not exempt from a similar affection:
the fauces feel raw and tender, and are pained in deglutition; on
looking into the throat, the mucous surface is found red and swollen,
and the tonsils are generally enlarged; but there is seldom any breach
of surface; and, when this does occur, it is rather entitled to the
appellation of excoriation than of ulceration. Occasionally the
surface is covered with a thin coating of lymph, and sometimes this is
confined to the situation of the mucous crypts, so as to give a false
appearance of small sores. As in similar affections, unconnected with
any discoverable cause, the lymphatic glands, at the angle of the jaw,
are not unfrequently swollen and painful.

Such is the usually mild character of this affection; but if its
progress has been interrupted by any means, more particularly by
mercury, it assumes a more complicated form, and a less tractable
nature. If that mineral is administered in the usual style, and at the
commencement, when the fever and other symptoms are high, the patient’s
sufferings are all much aggravated. After the fever has subsided, the
eruption will often be found to disappear under the use of mercury;
but it is extremely apt to recur, as soon as the system has shaken
itself free from the effects of that medicine. The mercury produces an
irritation, which supersedes the eruption, but by frequent repetition
its effects on the system diminish: it at last fails to create an
irritation more powerful than the disease to which it is opposed,
and, consequently, the eruption does not yield, but during its use
is frequently reinforced by fresh crops of papulæ. If the eruptive
fever, and advanced stage of the disease, are imprudently and suddenly
arrested by the use of mercury, by exposure to cold, or by other means,
inflammation of the iris or joints often follows, of a very violent
form, and not to be easily moderated. No one thinks of repelling
measles or other eruptive diseases, and with good reason, for such
practice would almost certainly induce serious affections of internal
organs. For the same reason, every precaution must be used to allow
this form of eruption to take its own course, while we merely regulate
the constitutional symptoms as they obtrude.

Another form of eruption, which occasionally, though much less
frequently, results from either of the above mentioned sores, is
the pustular. It is preceded by fever, and consists of rather large
pustules, separated from one another, and not very numerous. After
their apices give way, and the contained pus is discharged, a thin
scab is formed, and on its separation a small ulcer is left, which in
general soon heals from its margins, leaving a dark-coloured spot to
mark its situation. The papular and pustular eruptions are sometimes
blended; a few pustules appearing amongst numerous papulæ, or _vice
versâ_. The pustular disease is not of frequent occurrence; and in
proportion as it approaches the papular, with desquamation, it becomes
milder and more easily removed. In it, as in the papular, mercury
proves injurious.

The phagedenic form of ulcer is the most dreadful and unmanageable
of all; most uncertain in progress, and direful in event, and often
rendered still more destructive by the mode of treatment adopted.
Fortunately, it is now seldom seen, though not long ago it was well
known, as a perpetrator of dreadful havoc, under the name of black pox.

It is a corroding ulcer, without hardness of the surrounding parts,
presenting no appearance of regeneration of the tissues which have
been destroyed. It may follow either upon a pustule or an abrasion.
Sometimes it destroys the prepuce and glans in a few days, or again,
when chronic, it spreads deceitfully, healing at one part and
destroying at another. The ulceration is often deep, penetrating the
corpora cavernosa, or the corpus spongiosum urethræ: in such cases
it is followed with violent hemorrhage, which often produces a great
and sudden improvement in the sore. After slow cicatrisation it not
unfrequently happens that the scar gives way, and the ulceration
returns.

Sometimes another character is given to the sore, by the rapid
sloughing of the parts. In this modification, a small black spot is
first observable, unattended with pain: it enlarges rapidly, and, after
no long time, the mortified part separates, exposing an unhealthy
surface, which is immediately attacked and progressively destroyed
by phagedena. The part may again slough, and, by an alternation of
mortification and phagedenic ulceration, the external organs of
generation, male or female, may be wholly destroyed. In the present
day, however, its ravages are much less extensive and more easily
combated than formerly, and it seldom, if ever, proves fatal. One very
troublesome case is in my recollection, where the patient suffered
two attacks at the interval of two years. During the progress of
the disease he was seized with delirium tremens; a bubo formed and
ulcerated; a violent hemorrhage occurred from the sore; sloughing and
phagedena alternated; and both prepuce and glans were entirely lost.
An eruption followed, accompanied with ulceration of the throat and
nostrils. He recovered much mutilated. Ulcers originally of a simple
character may become affected with phagedena, or sloughing, from the
state of the constitution, from mismanagement, or from exposure to an
unhealthful atmosphere. But in such cases, after the separation of the
slough, the exposed surface is found to be of a healthy granulating
character, contrary to what is observed in the originally phagedenic
disease. Buboes, when they occur, have the same malignant action as the
primary sore: the breach of surface is extended either by sloughing
or by phagedenic ulceration, and the edges of the sore are ragged and
undermined.

The secondary eruption which follows the phagedenic form is pustular,
though differing from that which has been already noticed. The pustules
soon give way, and ulcers remain, covered with thick scales or crusts,
which sometimes increase, layer by layer, so as to become prominent,
dense, and of a conical form,—the rupia prominens. After the separation
of the crusts the ulcers are found, superficial, rather unhealthy, and
showing a disposition to extend, chiefly towards the circumference.
When healing, the process of cicatrisation frequently proceeds from
the centre of the sore, which is still enlarging at its circumference.
The reason for this unusual mode seems to be that ulceration does not
commence in the secondary sores till the crusts which cover them have
been removed: they then are very superficial, not extending through
the thickness of the true skin; and the ulceration does not go on in
the centre of the original sore, but towards its margins, so that a
portion of true skin remains in the centre of the sore, whilst it is
gradually destroyed towards the margins. Then, whilst the surrounding
skin, which usually forms the new cutaneous texture necessary for
reparation, is gradually and progressively destroyed, the remaining
old skin in the sore assumes an excited action, as in ordinary cases,
and from it the requisite new texture is formed, and gradually extends
over the surface, until it meet with a similar substance, which has
been produced by the surrounding skin after the ulceration in that
quarter has ceased. Thus the general principle that skin is formed
by skin is, even in such instances, found to be correct; the healing
from the centre not following, as some have supposed, the complete
destruction of the cutaneous tissues, but from its having remained
unaffected, or nearly so. The appearance of the eruption is preceded by
general indisposition, and occasionally by smart fever. It is sometimes
extensive, but is in general confined to the upper parts of the body.

Ulcers of the throat occur, of a very alarming kind, quickly destroying
the parts attacked, spreading chiefly towards the posterior part of the
fauces, rapidly extending to the pharynx and to the nostrils, and in
some instances also involving the larynx. The pendulous velum of the
palate and the tonsils are often wholly destroyed, the bones of the
nose, more especially the turbinated, are deprived of their coverings,
and exfoliate, the osseous and cartilaginous portions of the septum
are discharged, and the nose becomes sunk, or is supported merely by
the columna. The patient’s breath is fetid, respiration is in some
degree obstructed, a foul ichorous discharge flows from the nares,
and the surrounding parts are inflamed, swollen, and excoriated. The
countenance is greatly disfigured. On looking into the throat, nothing
is seen but an extensive ulcerated surface covered with white adherent
matter, and exhaling an offensive fetor, particularly when the bones
are affected. Respiration is nasal, and the speech indistinct. When
the larynx becomes affected, the patient may be almost considered as
lost: phthisis laryngea is established, the symptoms and treatment of
which will be afterwards mentioned. The mutilating affection of the
nose does not seem to be produced by any other form of the venereal
disease, if not in any way aggravated. Along with the eruption and
its after effects, severe pains in the articulations, particularly in
the knee-joint, often occur, and are always much increased during the
night. Nodes seem to be produced only in those cases in which mercury
is exhibited; their most usual situation is on the fore part of the
tibia; severe pain is felt in the part, which becomes slightly swollen,
and of a bright red colour; the swelling feels dense and firm, being
a simple enlargement of the bone. They often occur when the patient
is taking mercury, and when, in fact, the constitution is completely
saturated with it. This medicine may interrupt the progress of the
disease, may remove the eruption and the ulcers of the throat, but it
at the same time transfers the disease to deep unyielding parts, to the
bones and their coverings, and the fasciæ.

The last distinct form of the venereal disease is the scaly—syphilis,
or true pox. The primary sore, termed a chancre, “is somewhat of a
circular form, excavated, without granulations, with matter adhering
to the surface, and with a thickened edge and base. The hardness or
thickening is very circumscribed, not diffusing itself gradually and
imperceptibly into the surrounding parts, but terminating rather
abruptly.” Such is the appearance generally presented by the sore
when situated on the glans and prepuce. It generally commences in the
form of a pimple, without much surrounding inflammation. Sometimes
the ulcerated surface is very inconsiderable, but there is always the
abrupt and remarkably dense thickness which serves as a distinguishing
mark. The non-syphilitic ulcers may have surrounding hardness from
the first, or in consequence of the application of stimulants and
escharotics; but this is diffused into the neighbourhood, and is not,
it is said, of that remarkable solidity peculiar to chancre. It is
seldom that more than one chancre occurs: the usual situation is on
the glans and lining of the prepuce; but they occasionally form on
the outer surface of the prepuce, and on the dorsum penis. In the
latter situation the sore assumes a somewhat different appearance: it
is, in general, larger, the hardness of the base is not so great, the
excavation is less, and the surface is of a livid hue. When allowed to
proceed uninterrupted, the livid surface is alternated with that of a
light brown or tawny colour. Chancre is an indolent ulcer when compared
with the phagedenic or sloughing sore, the ulceration proceeds very
slowly, and, in proportion as it advances, the surrounding hardness
increases. It is also contumacious and obstinate in taking on any
reparative action. Phymosis occasionally takes place, in consequence of
chancre situated at the orifice of the prepuce, but not so frequently
as when that situation is occupied by superficial sores of a more
active nature. Bubo sometimes appears in both groins, or in one;
sometimes on the same side with the sore, often on the opposite, and
not unfrequently when the sore is healing, or after it has healed. It
may suppurate and give way, or may subside without having advanced to
suppuration. It differs in no respect from the swelling of the glands
from other causes, either in its swelled or open state. Neither does
the occurrence of a bubo render it more probable that constitutional
symptoms will follow. Enlargement of the glands is often caused, or
at least hastened, by the patient continuing to walk about and exert
himself during the existence of a sore, and whilst the absorbents
are in an irritable state; but a bubo may be caused by irritation
or excoriation in any way produced; and it not unfrequently occurs
without any apparent cause. In some cases of chancre or other ulcer,
the absorbents along the dorsum penis become swollen, and occasionally
suppurate. In former times, it was not uncommon for the surgeon to
insist that all swellings in the groin were venereal, though no primary
sore had ever existed: the virus was said to be absorbed from an
unbroken surface; the patient’s system was saturated with mercury; and
the use of that medicine was persevered in, with the view of opposing
those symptoms of a ruined system which itself had produced. Such
delusions have now happily passed away.

The eruption which follows the chancrous form of primary sore is scaly
from the commencement, and by this character is readily distinguished
from every other venereal affection. It is generally preceded by
an efflorescence or discoloration, rendering the skin of a mottled
appearance. The scaly eruption is a form either of lepra or of
psoriasis. The patches usually do not exceed a sixpence in size, are
distinct and separate from each other; their base is of a dark red
or coppery hue, the affected skin is not hard or rough, but soft and
pliable, and seldom covered with crusts; as they extend, the edges
are slightly elevated at the centre, which alone is covered with thin
white scales, appears flattened and somewhat depressed; when they
begin to fade, the margins shrink and become paler, and desquamation
proceeds slowly; a circular, purplish-red discoloration, with a central
depression, remains for some time after the blotches have declined: the
depression is permanent, but the discoloration disappears. The smaller
patches, which assume a variety of forms, continue for some time of a
dark colour, extend towards the circumference, become pustular, and
at length ulcerate superficially, enclosing an area of sound skin.
When depressions of the skin, as the folds of the nates, are affected,
a scaly eruption does not take place, but soft and moist elevations
arise, discharging a whitish matter, varying in form and size, and
accordingly receiving various appellations, as condylomata, fici,
or marisci. From them a secondary form of disease is occasionally
communicated. If no decided treatment is resorted to, and if the
eruption is consequently permitted to follow its own course, thick
crusts form, ulceration proceeds beneath them, the matter is confined,
and the patch becomes prominent. Another secondary symptom of chancre
is ulceration of the throat, sometimes extensive, but generally
situated in the tonsils, or their immediate neighbourhood. The ulcer is
not preceded by much pain or swelling: “it is a fair loss of substance,
(part being dug out, as it were, from the body of the tonsil,) with
a determined edge, and is commonly foul, with thick matter adhering
to it, like a slough, which cannot be washed away.” Such ulceration
may be simulated by excavated sores attending the phagedenic form of
disease; and it ought to be more especially distinguished from an
affection to which the tonsil is extremely liable, irregularity of its
surface, enlargement, and effusion of lymph, in consequence of chronic
inflammation.

A more serious part of the secondary disease is affection of the
deep-seated parts, ligaments, periosteum, and bones. The bones nearest
the surface are principally affected: a swelling gradually forms on the
tibia or ulna, without discoloration of the integuments, and without
pain occurring till after a long time. The pain is most severe during
the night. The inflammation of the periosteum is often very violent,
the subjacent bone, as in the head or extremities, becomes dead, and
exfoliates; but it remains to be seen whether this will take place
when mercury is more sparingly, if at all, administered. Ulcers betwixt
the toes, occurring along with the above symptoms, are supposed to be
venereal: they are unseemly, and peculiarly fetid.[24]

Such are the affections, local and constitutional, arising from a
venereal cause; but the latter may be simulated. Many affections of the
skin, mucous membranes, and bones, resembling the venereal disease,
may be produced by disorder of the constitution, by a decay of the
digestive organs, by unwholesome food, and exposure to inclement
weather, by inattention to cleanliness, and many other circumstances.
Morbid poisons, not venereal, but of various kinds, may exist, and
cause much mischief.

A disease resembling syphilis was produced by the cruel practice of
transplanting teeth from sound people into the jaws of persons in the
higher ranks of life, whose corresponding teeth were decayed. The
latter were the affected party, and that justly.

A very infectious disease was at one time common in the poorer parts
of Scotland, and known under the name of sibbens, or sivvens, chiefly
occurring amongst the poor, ill-fed, badly-clothed, and worse-housed
people in the Highlands. It was communicable by very slight contact
by kissing the lips of an infected person, smoking the same pipe,
drinking out of the same cup, or using the same spoon. Cases of it
are still occasionally seen. There are ulcers of the lips, mouth,
throat, and nose; ulcerated patches and warty excrescences in the
cleft of the thighs, in the axilla, and round the anus and pudenda.
A pustular eruption appears, and terminates in hardened crusts. The
same disease is known in Ireland, under the name of button-scurvy;
and a similar one, called raddesyge, has been described as occurring
on the sea-coasts of Norway and Sweden. In Canada, also, something
of a like nature was at one time prevalent. The yaws, at one time
common and destructive in the West India Islands, appear to be much of
the same nature. Some of these diseases, more particularly sivvens,
are very common amongst children. Even in these days children are
not unfrequently born with copper-coloured blotches of the skin and
desquamation of the cuticle; or they may come into the world with these
appearances, along with affections of the mucous membrane, hoarse
voice, redness round the anus, &c. These are forthwith attributed to
a syphilitic taint existing in either of the parents; and one or both
are put under mercury; but child after child comes into the world in
the same plight. Again, the disease is communicated by children to the
nurses, and _vice versâ_. All these affections are rendered much more
obstinate by full courses of mercury: the bones and ligaments become
affected in consequence; but small doses of that medicine may prove
useful towards the decline of the disease.

Some have believed mercury a certain test of syphilis; maintaining that
the disease, still checked by the specific, is never overcome by the
constitution; that it is unchangeable, and regularly and progressively
grows worse, where no mercury is employed; that, opposed by that
medicine, it is stationary, and is permanently cured by adequate
mercurial influence on the constitution. Whatever were the appearances,
if they went off under mercury, the advocates for this practice set
them down as those of syphilis, lues, or pox. If they did not yield
to that mineral, they were termed syphiloid, pseudo-syphilitic, or
mercurial; for they did admit, now and then, that their favourite
remedy produced unpleasant effects. Such theory and practice are now
very happily exploded.

As to the _treatment_ of local venereal affections, it may be, in
the first place, remarked, that prevention is better than cure. The
means employed for accomplishing this end are very various: oily
applications, alkaline and spirituous washes, &c., with the view
either of preventing the matter from coming into contact with the
genitals, or of completely removing it, when it has been but a short
time applied. There is one certain method of avoiding disease, which
it is unnecessary to mention. In all affections of the penis, it
is of the utmost importance to keep its extremity bound up to the
abdomen, in order to prevent congestion or inflammatory swelling.
Celsus knew this well; “Sursumque coles ad ventrem deligandus est,
quod in omni curatione ejus necessarium est;” rest and quiet must
be strictly observed; the patient must be confined to the recumbent
position, particularly when the sore is irritable, when swelling or
bubo has occurred or is threatened; and when the system is excited,
and the eruption has commenced, the bowels must be kept gently open,
the patient’s diet must be low, and the parts surrounding the sore are
to be kept carefully clean. Whatever the nature of the ulcer may be,
it is safe and prudent, in the first instance, to change its action
by the use of the nitrate of silver, or to destroy the surface by the
free application of escharotics, as nitric acid, or solution of nitrate
of mercury: the morbid poison is thus got rid of, and the surrounding
parts stimulated to a proper degree of action. This is absolutely
necessary in the phagedenic form of ulcer, whether of an acute or
chronic nature. But, in most cases, the patient does not apply for
medical assistance till the sore has been of so long duration as to
preclude all hope of counteracting the virus by any local application.
The simple superficial sores, and those with elevated margins, must be
treated on the same principles as if they were totally unconnected with
any specific cause; and the applications must be varied according to
the peculiarities of the part affected, and the different appearances
which the surface assumes during the progress of cure. Lotion is the
form of application found preferable in most cases, and may consist
of calomel and lime-water, with mucilage, called the black wash; of
muriate of mercury, with lime-water, called the yellow wash; of a
solution of sulphate of zinc, with spirit of a solution of nitrate of
silver, or of sulphate of copper. The linimentum æruginis or Barbadoes
naphtha, are often useful in foul sores. Ointments, if at all, ought to
be used sparingly. The application of dry lint, or the sprinkling of
a little fine powder, is often all that is requisite. Of course these
applications must be varied, according to the particular circumstances
of each case.

Buboes are to be treated in the same way as any other inflammatory
swellings; local means being taken at the commencement to subdue the
inflammatory action, and resolve the swelling. Rest is indispensable.
When they are stationary, the application of a blister will either
cause resolution or suppuration, and so the enlargement will be got rid
of, either in the one way or the other. The painting of a rubefacient
solution of iodine occasionally on the swelling is also useful, and
preferable to frictions with iodine ointment. When they have passed
into a decidedly chronic state, absorption may be promoted by pressure,
or, again, means must be taken to hasten suppuration, and the matter
which forms is to be early evacuated. If suppuration occur in the
cellular tissue, and not in the substance of the enlarged gland,
neither cicatrisation, nor a permanent cure, can be expected until
the prominent and indurated parts have been destroyed by the caustic
potass. In phagedena, bread and water poultices or tepid-water dressing
are, in the first place, to be applied, and the pain and irritation
may be soothed by solutions of opium, or extract of poppy. If bands of
skin intersect the ulcerated parts, they are to be divided, as being
a source of irritation which prevents healing. If the frænum præputii
be surrounded by ulceration and undermined, it must be incised for a
similar reason. It is often advisable, also, to divide the prepuce.
After the process of destruction has ceased, gently stimulating washes
will promote contraction of the sore.

It is an important fact, that the majority of primary ulcers can be
made to heal without mercury. Cavillers object to the mercurial washes,
supposing that they may act by affecting the constitution. The sores
with hardened edges, chancres, heal as well as others, when mercury
is not employed, but much more slowly. In some mercury is injurious:
in chancres it promotes the cure. In any case, I would never think of
ordering it, unless the progress were very tedious, the ulcer being
indolent and contumacious; then mercury may be advantageously used,
and moderately continued, until the callosity disappear. It is no
easy matter to say, judging from the appearance of the ulcer, whether
secondary syphilitic symptoms are likely to arise in consequence of it
or not, or what their nature may be should they occur: they follow upon
sores of all characters, and, again, do not appear, after what might
be set down as the genuine Hunterian chancre. Whatever the nature and
appearance of the ulcer may have been in the first instance, should it
become stationary, and show no disposition to heal under local means,
mercury may then be given cautiously, and with advantage. Considering
that very obstinate sores are now seldom met with, it would seem that
very little mercury is required in the treatment of primary venereal
ulcers. During the progress of acute inflammatory action, this medicine
should not be given for the primary affection, whatever the nature of
the ulcer. Mercury cannot prevent constitutional affections.

Constitutional symptoms do not often occur, taking place scarcely in
one case out of a hundred of all the forms of sores which present
themselves. In the _papular_ form mercury is hurtful, as already
remarked; it interferes with the natural and mild progress of the
affection, frequently gives rise to iritis, and produces pains of the
joints and bones. The powers of the constitution, aided by simple
remedies, are sufficient: the cure may be tedious, but cannot be
destructive. Whereas, if mercury be considered as the only specific,
its use will be long continued; it will frequently be resumed after it
has been dispensed with on the supposition that the virus is destroyed;
and by the effects of excessive mercurial irritation, combined with
those of the disease, tampered with and aggravated, the patient may
ultimately perish. The fever, which precedes and attends the eruption,
must be moderated by depletion, antimonial medicines, and purgatives;
but depletion ought not to be carried far, lest the eruption be thus
checked and disappear; and the patient ought to be carefully removed
from external circumstances which might produce a similar effect. After
the eruption has come fully out, and the febrile symptoms subsided,
it will be sufficient to attend to the general health, and employ the
decoction of sarsaparilla, a medicine which excites the secretions, and
more especially promotes diaphoresis. In short, the treatment may be
said to consist in allowing the disease, in a great measure, to follow
its own course, taking measures to prevent it from being interrupted,
and merely moderating such violent symptoms as may precede or accompany
it.

In the _pustular_ form of eruption the general treatment is the same
as in the papular. Mercury is hurtful, and increases the tendency to
burrow. When the surface is nearly covered with pustules and ulcers in
all stages, desquamation may be hastened by fumigations of sulphur, the
general sulphur baths, lotions of sulphuret of potass, nitro-muriatic
baths, vapour baths, or by smearing the affected surface with equal
parts of tar and sulphur ointment.

In phagedena the patient ought to be, if possible, placed in an airy
and healthful situation. In most cases free bloodletting may be
necessary at the commencement, and will be advantageously followed
by purgatives and antimonials. The patient ought to be strictly
confined to his room, and ordered low diet with diluents. Afterwards,
the internal use of nitric acid, the decoction of sarsaparilla, and
an occasional dose of Dover’s powder at night, will be beneficial,
particularly if sleep be disturbed with pain of the bones and joints.
Mercury, even in small quantities, protracts the disease, and in
large doses it hastens the ulceration and sloughing. When all febrile
symptoms have subsided, when the ulcers are nearly healed, when no
fresh pustules appear, and when desquamation is begun, alterative
doses of mercury, as a blue pill or grey powder every second night,
may sometimes be ventured upon, will tend to hasten the cure, and will
not, possibly, be followed by any unpleasant symptoms. The safe course
is to promote the secretions by some safe substitute—preparations of
sarsaparilla, ipecacuan, taraxacum, &c.

In fact, in all scaly eruptions, whether scaly from their commencement,
or having become so in their latter stages and previously to their
disappearance, mercury, prudently administered, will be useful by
expediting the cure, and not injurious by deranging the system. The
tar or citrine ointments may be applied to the eruptions and cutaneous
ulcers.

For the ulcers of the throat, unless in a sloughing state, the lunar
stone appears to be almost a specific, removing the irritability of
the sores, and protecting them from further irritation by coagulating
the discharge, which then more effectually covers and protects them.
The application requires to be repeated every second or third day, as,
by the frequent and necessary motions of the parts, the crust loosens
and separates, leaving the surface exposed and irritable. At the same
time the sore will contract very considerably under each successive
crust. The lunar stone may also be applied in solution; or a solution
of the bichloride of mercury in spirits or laudanum may be used, in
the proportion of from four to six grains to the ounce, or stronger.
The solution of the nitrate of mercury is sometimes employed with
advantage. Fumigation of the throat with the red sulphuret of mercury
has been extolled as a powerful means of checking the alternating
sloughing and ulceration which often accompany the ulcers of these
parts, but the propriety of its employment is doubtful; the system
is thereby rapidly put under the influence of the mineral, which, as
already remarked, generally aggravates the violent disturbance under
which the constitution labours. More permanent good may be expected
from means taken to remedy the constitutional evils than from such
violent remedies as are directed against the affected part, but which
also produce a baneful effect on the system. In ulcers of the nostrils,
with fetid discharge, snivelling, exfoliation of the inferior spongy
bones, affections of the palate, &c., the nitrate of silver is also
very efficacious; or the affected parts may be occasionally touched
with a hair pencil, dipped in a liniment composed of lime-water, olive
oil, and the golden ointment. They ought to be frequently washed
with tepid water, and all sources of irritation must be removed. If
the patient be in the habit of taking snuff, the practice must be
abandoned, and the powder already impacted in the nostrils removed.
If there be carious teeth or stumps in the upper jaw, the sores can
scarcely be expected to heal till these be extracted, as constant
irritation is kept up by them. When the affection proves obstinate, a
recourse to mercury is recommended by some writers; but this will make
bad worse. Sarsaparilla in these cases, with attention to diet and
air, will always prove a better alterative than any form of mercury.
It may be combined, according to circumstances, with the nitric or
nitro-muriatic acids, or with the hydriodate of potass, in which many
practical men have great faith. This medicine is employed in cachexia,
following or not the use of mercury, and is directed against eruptions,
sore throat, and pains in the limbs.

The constitutional symptoms of the _scaly_ disease, or true pox, when
they occur, which is now but seldom, are decidedly benefited by a
prudent employment of mercury. It may be administered externally or
internally, though the latter method is the one generally adopted. It
may be introduced into the system under various forms, according to the
particular circumstances of the case, or the ideas of the practitioner.
The most common form, and the simplest, is the pil. hydrargyri; but
for this may be substituted hydrargyrum cum creta, Plummer’s pill, or
calomel with antimony. In painful affections of the bones, with or
without swelling, the muriate of mercury (bichloride) is the form which
I have found most efficacious; one-eighth of a grain of the muriate
being given thrice a day in a pill; or the medicine may be given in
solution. The iodide of mercury is also a very useful medicine in some
cases. It is impossible, and would be absurd, to lay down any precise
rules as to the quantity of mercury which is necessary for the cure
of pox: in some patients the system is with difficulty put under its
influence, whilst in others a single grain will produce salivation,
constitutional disturbance, and eczema. When the mouth becomes affected
the mercury ought to be discontinued: much harm and no good resulting
from the medicine being pushed to profuse salivation; the tongue swells
hideously, the teeth loosen, and portions of the jaw die and exfoliate.
It is sufficient that the system be under the influence of mercury;
and that circumstance is marked by the tenderness of the gums. If,
after the medicine has been disused, the disease does not appear to
recede, it may be resumed in the same moderate way as before; but there
certainly can be no use in continuing mercury after the symptoms of
venereal affection have ceased. Nodes may still exist, portions of bone
may be dying, abscesses forming, and various other changes of structure
going on, but these are no reasons for a continuance of the mercury.
If they have originated from the venereal affection, that cause has
been removed, and the diseased actions will now proceed altogether
independently of their original cause. Mercury proved beneficial in
removing a disease of which they are not a part but a consequence; and,
if that medicine be now blindly persevered in, the only effect will be
to ruin the constitution, and thereby greatly retard the cure of those
affections which, if the natural powers of the system had been merely
supported, or in a great measure left to themselves, would have soon
ceased to annoy the patient or alarm the antisyphilitic mercurialist.

Slight swellings and pains of the bones often yield to local
abstraction of blood, friction, and the internal use of the compound
decoction of sarsaparilla. Nodes, however, sometimes continue to
enlarge, and occasion much pain, notwithstanding these means; and in
such circumstances much relief will be afforded by a free incision over
the affected part, from whatever cause the swelling may proceed. When
the pain has subsided, and the swelling remains stationary, a decrease
of it may be sometimes effected by a blister.[25]

Of the bad effects of mercury on the constitution much might be said.
Treatises have been written on mercurial pox, a species reported to
be much the most violent; and others have detailed an accumulation
of evils, under the title of mercurial disease. There is no doubt
that extensive, deep, and sloughy ulcers of the throat are produced
by mercury; and of this I witnessed the following unexceptionable
instance:—The fauces presented one extensive mass of ulceration,
sloughing at its margins, and the uvula was almost detached. The
patient was an old and emaciated woman, who neither had, nor could
be supposed to have, any venereal complaints. She employed herself in
coating mirrors with quicksilver, and to that she ascribed her malady.
In fact, her system had been long under the influence of mercury, in
consequence of her occupation. When I visited her, her daughter and
husband, the latter of whom was paralytic, and almost bedridden, were
affected, from the same cause, with a pustular eruption of the face,
with disease of the nostrils, and snivelling. Another old woman had
numerous and deep ulcers of the fauces, tongue, and lips, having been
kept unmercifully under mercury for nine continuous months. She had,
besides, taken it from time to time, for upwards of four years, though
her sole complaint was slight sore throat. Pains of the joints, too, I
believe, are attributable to the use of mercury. That medicine has no
power to prevent the occurrence of nodes, for these often form during
its action. Affections of the periosteum are very frequent in horses
and other lower animals, and also easily excited in some human subjects
who have neither had pox nor been put under mercury; but in no instance
of venereal disease have I observed serious affections of the bones
where mercury had not been given. Even the advocates for mercurialising
speak of mercurial nodes. It has been asserted that nodes do not occur
when mercury has been given for liver or other complaints; but they do
form under such circumstances, though not so frequently as when the
medicine has been exhibited during venereal symptoms. A cachectic state
is often induced by a continued use of mercurial preparations, or at
least by mercury and disease together, in constitutions not originally
strong. It is marked by pale lips; bloodless conjunctiva; a rough
anserine skin; a relaxed state of the mucous membranes; hemorrhages
from these, particularly from the gums, which may prove fatal, as
I have myself witnessed; exfoliations of the alveolar processes;
slimy stools; pale urine; pains of the limbs; sores, showing great
indolence, or even assuming malignant action; dropsical symptoms, and
other evils, of which a lengthened catalogue might be made out. Such
symptoms were often met with when mercury was exhibited for every
trifling or suspected sign of disease arising from carnal conjunction.
On this subject, Mr. Samuel Cooper has well remarked: “Experience has
fully convinced me, that in no forms of chancre, nor in any other
stages of the venereal disease, is it proper to exhibit mercury in
the unmerciful quantity, and for the prodigious length of time, which
custom, ignorance, and prejudice, used to sanction in former days.
Violent salivations ought, at all events, to be for ever exploded. When
I was an apprentice at St. Bartholomew’s Hospital, most of the venereal
patients in that establishment were seen with their ulcerated tongues
hanging out of their mouths, their faces prodigiously swelled, and
their saliva flowing out in streams. The wards were not sufficiently
ventilated, and the stench was so great, that the places well deserved
the appellation of _foul_. Yet, notwithstanding mercury was thus
_pushed_ (as the favourite expression was), it was then common to see
many patients suffer the most dreadful mutilations, in consequence
of sloughing ulcers of the penis; other patients, whose noses and
palates were gone; others who were covered with nodes and dreadful
phagedenic sores.” This woful picture is not exaggerated, and cannot
be too strongly impressed on the minds of young practitioners. A small
quantity of mercury will affect violently some constitutions; as of
those who have been in warm climates, or who have taken much of the
drug, even in this country.

_Eczema Rubrum_, a disease resulting from external causes, but which
may also be produced by mercury, often arises from but a very small
quantity of that medicine even applied externally. It most frequently
affects the scrotum and upper and inner parts of the thighs. It is
preceded by heat and itching in the part; a diffused redness appears,
and the affected surface is rendered rough by the eruption of numerous
minute vesicles. In a short time, these vesicles, if not ruptured,
attain the size of a pin’s head, and the included serum becomes opaque
and milky. The affection soon extends over the rest of the body in
successive large patches, and is accompanied with considerable swelling
of the integuments, tenderness of the skin, and itching. The vesicles
burst, and discharge a thin acrid fluid, which renders the surrounding
surface painful, inflamed, and excoriated. The discharge becomes
thicker, adhesive, and fetid, and by its drying, partial yellowish
incrustations are formed. The disease terminates in desquamation, and
in some cases, the hair and nails are also lost. It is preceded and
accompanied with smart fever, and general disorder of the system.

_Erethismus_ is another occasional consequence of mercury,
characterised by remarkable depression of strength; small, quick, and
often unequal pulse; anxiety, sighing, and trembling; a pale contracted
countenance, and occasional vomiting. While in this state, sudden
exertions are apt to prove fatal.


OF SCALDS AND BURNS.

Different degrees of injury are inflicted on the surface from the
application of heated solids or fluids. The term scald is generally
confined to the effects of heated fluids, whilst burn denotes the
consequences of the application of a heated solid, or of ignited
combustible matter; the latter class of accidents is, in general, the
more serious, yet the former, though not injuring the skin deeply,
gives rise to the most alarming symptoms when a large extent of surface
is affected. A slight degree of heat is productive only of redness of
the surface, with a sharp hot pain, and these symptoms may subside with
or without vesication. However, effusion of serum under the cuticle
often takes place almost immediately after the contact of the heated
body—the cuticle may be destroyed by the intensity of the injury—or the
true skin may die, either partially or throughout its whole thickness,
and the subjacent parts be at the same time injured to a greater or
less depth. But parts, not severely injured at first, may afterwards
perish, violent inflammatory action being excited, which terminates in
sloughing. The neighbouring parts have their vitality much diminished,
by the direct influence of the injury; and hence, when these parts
come to be the seat of increased action, sloughing almost inevitably
ensues, from the want of corresponding power. From the same cause,
subsequent sores are tedious in healing, being so far debilitated as
to be unable to assume full vigour; even slight ulcerations following
vesication contract very slowly; the granulations are flabby, and the
discharge profuse and thin. The inflammation is often at first very
violent, and kept within bounds with difficulty. Burns of the trunk,
particularly of the genital organs, are to be considered as attended
with much danger. And extensive burns and scalds, wherever situated,
are always to be dreaded. Violent constitutional irritation takes
place, dyspnœa is apt to occur, with effusion into the chest of serum,
or a sero-purulent fluid; and the nervous system ultimately becomes
oppressed. Great sinking of the vital powers is generally the immediate
consequence of extensive and severe burns; there is shivering, weakness
of the pulse, cold extremities, anxiety, and vomiting, requiring the
exhibition of warm drinks, and even sometimes of cordials, opium, or
strong stimulants. These must, however, be given with a sparing hand,
or the depression following the excitement is with difficulty got over.
Nor can it be matter of surprise that such serious effects occur, when
we reflect on the extreme sensibility, and highly organised state of
the affected part, and the important functions which it is intended
to perform, as well as those sympathies which it holds with internal
parts, on which life principally depends.

In trifling burns cold applications are generally used—as immersing the
part in cold or iced water. A great variety of remedies are employed,
spiritous, watery, acid, alkaline, cold or hot; some apply a coat of
cotton or flour, some of tar or pitch, and they state that when these
artificial crusts separate, the skin is found healed beneath; in fact,
every practitioner, and almost every individual, possesses a favourite
application for this very common accident. Some have recommended
holding the part to the fire, or plunging it into hot liquid; but this
practice, and all similar, are too severe ever to become general,
when milder means prove equally effectual. Perhaps the most common
applications are, a mixture of lime-water and olive oil, or the ceratum
acetatis plumbi. The vesicles, when left to themselves, burst, expose
an irritable surface, and the acrid discharge from them excoriates
the surrounding skin. Their contents ought to be evacuated by a small
puncture, and the cuticle being left carefully undisturbed, a scab
soon forms, by which the part is protected while healing. In extensive
injuries of the skin, where the cuticle has been altogether destroyed,
finely carded cotton is sometimes applied; it is of use in somewhat
the same way as the cuticle in the former instance, and being a sort
of cushion over the part, prevents it from being irritated by bed or
body clothes, or by the patient’s resting on it. It soon becomes soaked
with the discharge, and must either be frequently changed, or become a
receptacle for pus to putrefy in, and maggots to breed; on account of
these circumstances it is objectionable. Dusting the part with common
flour, starch, or hair powder, is equally advantageous, and much more
convenient; relief is afforded by its immediate application; the parts
are cooled; the flour, absorbing the discharge, is soon formed into
crusts, which effectually protect the surface; and the after-secretion
readily escapes from beneath this, no more moisture being imbibed than
is merely sufficient for the encrustation. The artificial covering
ought not to be removed until completely detached, by purulent matter
accumulating beneath it; then its presence can be of no service, and
its removal is accomplished by fomentation or poultice, and without
pain to the patient; whereas, by pulling off the crusts shortly after
their formation, as some do, whilst they are adherent to the surface,
and protecting it from injury, much pain is given to the patient, the
raw surface is irritated, and made liable to over-action; a useful
application is taken away to make room for another, and, perhaps, not
so congenial. After the spontaneous separation, fresh flour may be
again sprinkled over the suppurating surface, and, if the affected part
is small, it may heal under this application. But when, in burns of
considerable extent, suppuration is fully established, and granulations
have begun to arise, tepid-water dressing, and lotions, are to be
applied as to any other granulating sore; for the reasons already
assigned, the applications require to be of a gently stimulating nature.

In severe cases, there is first extreme depression of the powers
of life, under which patients sometimes sink; but most frequently
this state is obviated by the employment of cordials or stimulants.
But these ought to be administered with caution, for reaction soon
commences, and often increases to well-marked inflammation, requiring
for counteraction low diet, and even bleeding. In such cases gentle
laxatives are preferable to purgatives, as by the latter the patient
is obliged to make frequent movements, and those are always painful.
Stimulants have been strongly recommended, at first powerful, and
afterwards gradually weaker, so as, it was said, to restore the balance
between the affected parts and the system; and the latter is again
to be excited, in order to meet the increased action which the parts
assume. The practice is founded on fancy, and cannot become general,
being in its first part cruel, and in its second absurd. Whilst
debility exists, stimulate cautiously; when over-action ensues, adopt
those measures which are best calculated to subdue excitement; this is
common sense, and the common practice.

During the process of healing, position of the parts ought to be
carefully attended to; contraction of the cicatrices, and cohesion of
opposed surfaces often causing unseemly deformities. Surfaces opposed
to each other, and naturally separate, may be prevented from uniting
by dressing interposed; and contraction of joints is to be guarded
against by keeping the limb extended by splints and bandages. Where
deformity has occurred, the hardened cicatrix which is in fault may
be either divided or excised, and by paying attention to position in
the after-treatment, the evil may be greatly lessened. In the case of
contracted joints, it is not necessary to excise the whole or greater
part of the callous web; simple division is sufficient, if carried deep
enough, through the altered and condensed cutaneous tissue. A horrid
case of deformity is sketched on the next page, and from a very horrid
and atrocious scoundrel, the companion and assistant of Messrs. Burke,
Hare, and Co., the Thugs of the Modern Athens. In such a deformity
the art of surgery could not avail. In others, however, the cicatrix
is not so extensive; it is separated into bands, by the division of
which the position of the head and lip is improved, and the comfort
of the patient much enhanced. In one case, in which I operated with
success very lately, the scar, though extensive, was remarkably soft
and pliable, as much so as the finest kid leather.

[Illustration]



PART SECOND.

OF PARTICULAR SURGICAL SUBJECTS.


INJURIES OF THE HEAD.

_Wounds of the Scalp_ are attended and followed by more dangerous
symptoms than wounds of the integuments on any other part of the
body. This is in a great measure attributable to the nature and
connections of the parts. The subcutaneous fatty matter is condensed,
and closely attached to a firm and unyielding tendinous expansion; and
betwixt these tissues and the pericranium, a loose cellular tissue
is interposed, so as to allow of free motion of the parts. They are
highly vascular, with the exception of the occipito-frontalis fascia,
and between them and the internal parts, as is well known, a free
communication exists. Injuries of these coverings, though at first
apparently trifling, and consequently looked upon as of no importance,
and unattended with danger, often assume a very alarming character.
No injury of the head, in fact, is too slight to be despised, or too
severe to be despaired of.

Punctured and lacerated wounds, more especially those penetrating
all the layers of covering, are frequently followed by violent and
extensive inflammation of all the tissues, with severe constitutional
disturbance, and with delirium and other symptoms denoting functional
derangement of the brain. The swelling is often extensive, involving
the whole scalp, together with the integuments of the face, and
completely shutting the eyelids. In some cases resolution may
be accomplished, but the most frequent termination is extensive
infiltration of purulent matter into the cellular, or even into the
more deep structures, with sloughing of the tendinous expansion.
Collections of matter frequently form in the loose cellular tissue of
the eyelids, when the parts are affected with inflammation, whether
superficial or deeply seated.

As to treatment, after the infliction of an injury, the scalp ought to
be shaved, and the wound cleansed of coagula and foreign substances.
If a large flap of integument is detached, it should be replaced,
and retained as nearly as possible in its natural situation; and
if, for this latter purpose, slips of uninitiating adhesive plaster
and methodical compression prove insufficient, it will be necessary
to employ a very few points of interrupted suture: these, however,
must be removed at an early period, that is, when either adhesion or
suppuration has commenced, and ought, if possible, to be altogether
dispensed with, being apt in this situation to produce injurious
effects by their irritation. Light dressing is afterwards applied.
On the accession of swelling, heat, and pain, the parts are to be
well fomented with a hot decoction of chamomile flowers, or hops, and
afterwards covered with a warm and soft poultice; and should these
symptoms continue, the fomentation ought to be frequently repeated.
Fomentation and poultice are also the best applications when a
day or two has elapsed between the receipt of the injury and the
patient’s application for cure. The constitutional symptoms are to be
moderated, and may in many instances be averted, by the exhibition of
antimonials and purgatives; and by general bloodletting, when demanded
and authorised by the symptoms, and the state of the constitution.
Punctures or incisions are to be employed according to circumstances,
in order to lessen the vascular congestion of the part, and prevent
the formation of matter, to evacuate it if already secreted, or to
relieve inflammatory tension and promote the formation of pus at the
incised parts, where erysipelatous inflammation is threatened, healthy
suppuration in such circumstances often appearing to be critical. In
many unpromising cases of lacerated scalp, when a great part of the
cranium has been exposed, and partially deprived of its periosteum, a
rapid cure has taken place without the formation of much matter. The
detached scalp, though much torn and bruised, ought not at first to be
removed, it being more prudent to leave nature to determine how much
must be destroyed. After the sloughs, if any, have separated, and
granulation has commenced, the loss of substance is rapidly repaired
in this region, more especially when the patient is young and healthy.
General or partial support, by bandaging, is required in many cases, as
by a handkerchief, split cloths, or a roller applied in various forms.

_Wounds of the Temporal Artery_ are either the result of accident, or
made intentionally for the purpose of abstracting blood; and it may be
here proper to make a few remarks regarding this latter circumstance.
When it is wished to take away blood from the head, no one thinks
of opening the trunk of the temporal artery; its anterior branch is
generally chosen. By some the vessel is first exposed by means of a
scalpel, and then opened with a lancet. But preliminary incisions
are altogether unnecessary. The vessel ought not to be cut entirely
through, and the incision should extend obliquely across its course;
and care is to be taken that the external aperture shall be larger than
that in the cellular tissue involving the artery, as thus the blood
escapes freely, and no risk is incurred of its becoming infiltrated
into the surrounding parts. When the branch is of the ordinary size,
a sufficient quantity of blood is readily obtained from it; but if,
from its small size, or a faulty form of incision, blood does not flow
freely and quickly, a cupping-glass may be applied, and its lower
edge slightly raised. This latter precaution is absolutely necessary,
for if neglected, little or no blood can escape, the artery being
firmly compressed against the cranium by the edge of the exhausted
glass. No other mode of cupping ought to be practised on the temples,
for the cupping by scarification is here both unwarrantable and
unnecessary—unwarrantable, because the cicatrised scarifications
leave an unseemly and permanent mark on a prominent part of the
countenance,—and unnecessary, since there can be no occasion for six
or eight incisions when one is fully sufficient. The bleeding may be
readily stopped, after the requisite quantity has flowed, by a small
graduated compress placed over the wound, and retained by bandages,
which surround the head, and are afterwards twisted and brought
under the chin in order to increase the security. If by these means
the bleeding is not readily restrained, the vessel may be divided
throughout its whole circumference, by entering the lancet at the
original wound, and moving its point laterally. Then compression is to
be again employed, by the assistance of which the natural processes for
closing the divided extremities are speedily accomplished.

When this artery has been injured by external violence, the wound of
the integuments is generally large, and the bleeding profuse. In such
cases, both ends of the vessel must be pulled out by means of forceps,
and tied separately; afterwards the integuments are to be approximated
and supported.

Unpleasant consequences sometimes result from the simple operation of
opening the temporal artery, and occasionally also from accidental
wounds of that vessel. The integuments unite, and may soon heal; but,
from the compression not being sufficient, a small quantity of blood
is insinuated into the cellular tissue, which becomes condensed for a
considerable extent around the wound, and ultimately a sac is formed,
which communicates with the ununited opening in the artery, and is
consequently filled with sanguineous clots; in short, an aneurismal
tumour is formed. For the cure of this untoward occurrence, the artery
may be tied between the heart and tumour, as in the case of spontaneous
aneurism; but in consequence of the free inosculation which exists
between the numerous ramifications of the artery, this measure may
not prove successful, and it will be found necessary, either then
or afterwards, to secure the vessel beyond the tumour. But there is
another mode of procedure. From the tumour being generally small and
circumscribed, excision of the whole of it can be effected easily,
and so as to leave but a slight scar: this operation is not liable to
failure, and is not more severe than the first mentioned. After the
removal of the diseased part by elliptical incisions, the two ends of
the artery are to be included in separate ligatures, and the edges of
the wound kept together.

A more troublesome accident sometimes takes place,—ulceration of, and
over, the vessel, with effusion of serous and purulent fluids into the
surrounding cellular tissue, often to a great extent. A profuse flow of
blood bursts from the ulcerated surface, perhaps twelve, fifteen, or
twenty days after the vessel had been opened, and, if active means are
not speedily adopted, the hemorrhage by its recurrence may prove very
dangerous. In such cases compression is of no avail; the bleeding may
be staid for a time by this means, but upon the circulation becoming
again active, fresh hemorrhage must and does take place; the parts
around are separated and engorged more and more, the blood escapes in
alarming quantities, and the patient is saved only by the occurrence of
syncope. To search for, and make a clean dissection of the wounded part
of the vessel in such cases, is impossible. A long and deep incision
must be made through the swollen and diseased parts in the course of
the arterial branch, and a ligature passed under it, on each side of
the ulcerated point, by means of the common curved suture-needle, or
of one in a fixed handle. The ligatures should be at a considerable
distance from each other, in order that they may surround healthy parts
of the vessel; after they have been firmly tied, all risk of further
hemorrhage is gone. Of course the ligatures should enclose as little
as possible of the parts surrounding the artery. A poultice is perhaps
the best application for a few days, and under its soothing influence
the effects of the continued compression, which had been previously
employed, soon subside. The after applications must be varied according
to the appearances which the part presents.

Laceration of a large or small bloodvessel is a frequent consequence
of _bruise_ of the scalp.—Blood is effused, and the surrounding parts
are thereby separated to a greater or less extent; and thus a tumour
is formed, either rapidly or slowly, according to the size of the
injured vessel. The swelling is in general large, soft in the centre,
and hard towards its circumference; the blood in the latter situation
being coagulated, and firmly impacted in the condensed cellular
tissue; whilst in the centre it is fluid, or at least partially so,
and occupies a free cavity. These characters of the tumour are apt
to mislead a careless or inexperienced examiner, the feel being in
some degree similar to that attending fracture with depression, but
still easily distinguishable from it by attentive and experienced
manipulation. By pressing the finger or thumb firmly on the centre
of the tumour, the blood is displaced, and the bone felt distinctly.
In slight cases of this affection, no treatment is required, as the
tumour is of no importance, and soon disappears, by the effused blood
being absorbed. When, however, the swelling is accompanied with
unpleasant symptoms, cold applications are to be made to the part,
and low diet, with occasional purgatives, enjoined. If inflammatory
symptoms occur, local abstraction of blood may be necessary, followed
by hot fomentations to the part. When the pain has ceased, and the
swelling is not speedily removed, absorption is promoted by stimulating
applications, such as fomentation with a solution of the muriate of
ammonia in a decoction of the anthemis nobilis, in the proportions
of ℥ss. to ℔ii.; a    spirit lotion containing the tincture of
arnica montana, in the proportion of one part to fifteen or twenty of
water, will be found a good application in many such cases.

Such tumours may ultimately require to be laid open, in consequence
of the blood putrefying and becoming mixed with purulent secretion.
Under no other circumstances is incision warrantable, as unhealthy,
troublesome, and tedious suppurations are sure to follow.

_Of Concussion._—Concussion, in a greater or less degree, attends
most injuries of the head. The functions of the brain are either
disturbed or suspended; there is loss of sensibility, of volition,
and frequently of the power of motion. The confusion of intellect
or stunning may disappear in a short time, or may continue, though
diminished in intensity, for many days, and even for weeks; it is
seldom, however, that the functional disorder exceeds in duration two
or three days, and in general it disappears before that length of time
has elapsed. The stupor is seldom complete; the patient can perhaps
be roused, though with difficulty, so as to answer questions by a
hurried monosyllable, or make signs in regard to the seat of pain, or
for such things as he may suppose himself to be in need of. At first
the circulation is weak; the pulse is fluttering, often intermitting,
and scarcely to be felt in the extremities; the countenance is pale,
and the surface cold; there is occasional vomiting, a symptom which
seldom occurs when compression of the brain exists, and the breathing
is difficult, though scarcely ever stertorous. The pupils are generally
contracted, but not uniformly so; one pupil may be contracted and the
other dilated; at first, they are insensible to light, neither dilating
when in darkness, nor contracting further when the light is suddenly
increased; not unfrequently a considerable degree of squinting exists.
The muscles are neither much relaxed, nor spasmodically contracted.
After a time, the circulation is restored, and the heat of the surface
returns, with more or less of regained sensibility. The pulse either
becomes altogether natural, or else more slow or more rapid than in
health. The circulation is then easily excited; by even raising the
patient in bed, the pulsations of the carotids are increased, in some
cases, by fifteen or twenty beats. Sensibility returns, always very
gradually, and in some cases more slowly than in others; frequently the
patient becomes quite collected after the lapse of some hours or a few
days, but in other instances a degree of mental confusion remains for
many weeks; occasionally the intellect continues weak for a lengthened
period, and sometimes even for the remainder of life.

When the insensibility has begun to diminish, the patient can be roused
with less difficulty; if pinched, he complains of it by uttering some
inarticulate sounds, or by attempting to move himself further from the
quarter whence he supposes the injury to come; he answers, though with
unwillingness, loud questions regarding the pain which he suffers, and
points to the part where it is chiefly felt. As the stupor goes off,
symptoms of inflammatory action, or a threatening of it in a greater
or less degree, manifest themselves. The pulse becomes more rapid and
sharp, the skin is hot and dry, the face is flushed, the conjunctiva
is redder than usual, and the pupils are often much contracted: the
patient is restless, and tosses about in bed; mutters confusedly to
himself; often attempts to enact a part in some fanciful scene which he
supposes to be passing around him, or talks rapidly and incoherently
concerning circumstances which have formerly occurred. His flitting
ideas are often of an alarming nature; he endeavours to get out of bed,
and struggles violently if opposed. He frequently puts his hand towards
his head, and gives other indications of suffering acute pain in that
region, much increased by any movement of the part.

Such symptoms are often followed by vomiting and rigors, and too
frequently by convulsions, more furious delirium, and coma. On
examination after death, an increased vascularity of the cerebral
membranes is observed; there is an effusion of gelatinous-looking
matter on the surface of the membranes, and in the cellular tissue
beneath the arachnoid. In more advanced cases, thin patches of lymph,
or more extensive strata of it, cover the arachnoid and the inner
surface of the dura mater; a puriform fluid is found effused between
these membranes, and sometimes blood and matter are deposited in
some part of the cerebral substance; bloody serum is effused into
the cavities, and at the base of the brain. The above symptoms and
appearances sometimes follow injuries not at first thought severe, but
are most frequently the result of such as are attended with læsion of
the bone, or of the internal parts.

It is not at all improbable that concussion is produced after a manner
somewhat resembling the following. The brain has a natural tendency to
remain at rest, but is liable to be brought into a state of commotion
by impulses on the cranium being communicated to it. When a slight
blow is inflicted on the skull, only a slight commotion of the brain
is induced, the cranial contents are, as it were, slightly jumbled,
and a temporary and trifling confusion of its functions follows. When,
however, the stroke is more severe, the brain is separated from its
cranial attachments, both at the point struck and at the part directly
opposite,—it is thrown upon itself towards its centre; its substance
is thereby condensed, its diameter in the direction of the impulse is
diminished, and a separation between the brain and cranium is formed at
each extremity of that diameter. By post mortem examinations, it has
been ascertained that condensation of the substance of the brain does
exist in cases of severe concussion. Such commotion may be sufficient
to cause instant extinction of life, or the brain may gradually resume
its former condition, or with only such slight incited action as may
be required to reunite the dura mater with the inner table of the
skull. Extravasation of blood or serum is extremely liable to occur
in such cases, the vessels being either compressed, stretched, or
otherwise thrown out of their natural relations along with the other
cranial contents, reparation can only take place by absorption of the
extravasated fluid, and gradual deposition of plastic matter. When
extravasation takes place to a greater extent, compression is the
consequence, as will be more fully explained further on. Perhaps the
brain does not recover itself gradually, but suddenly; the impulse,
which was at first directed from the circumference towards the centre,
now acting from the centre towards the circumference; and then the
propulsions and recoilings may be repeated, though gradually lessening
in their intensity, until the effect of the original impulse is lost,
and all vibration consequently ceases. But concussion may be caused by
an impulse received not immediately on the cranium, but on some other
part of the body, as when a person falls from a considerable height and
alights on the feet or buttocks; and in such a case also its effects
may be indirectly communicated to it through the brain, and may produce
equally violent effects, without there ever being any appreciable
lesion of the cerebral matter.

The circulation may be merely disturbed, or laceration of the brain may
occur with extravasation of blood into its substance. It may present
the appearance of having been bruised, or the tear of its substance may
be extensive. A multitude of minute vessels may be torn without the
substance of the brain being much broken, in which case bloody specks
will be observed over a large surface of the interior of the organ.
In many fatal cases no change in the state, either of the vessels or
of the cerebral substance, is perceptible on minute examinations. The
organ in these cases has been merely disturbed and shaken, without
visible rupture or hurt having occurred. Again, many patients are
supposed to labour under concussion only, in whom fracture of the base
of the cranium, or extravasation of blood on the surface, or into
the substance of the brain, are discovered after death. It is always
difficult to distinguish between the effects of mere concussion and
those of compression of the brain by extravasated fluid; for, in the
greater number of cases, the symptoms of both affections are blended
together. In both there is insensibility from the first; but if an
interval of sensibility occur, diagnosis is rendered more easy and
certain, it being a fact well verified by experience, that the state
of stupor which precedes the return of correct intellectual function
is the effect of concussion, and that there is every reason to believe
that the insensibility into which the patient subsequently sinks, is
caused by compression of the brain; if compression existed from the
first, the stupor might not be of longer duration than if it were
the effect of concussion, but its stillness would not be interrupted
by any restoration of mental exercise, however short. Remarkable
effects sometimes result from commotion of the brain; the patient may
suffer loss of vision or of hearing, either partial or complete; or
partial paralysis may occur; of the muscles, for instance, supplied
by the portio dura. In many cases such affections may be supposed
to arise from compression of nerves, or other læsion subsequent to
and caused by the effects of concussion, and probably connected with
fracture of the base of the cranium. Again, it occasionally happens
that the senses are rendered more acute than previously, and of this
I shall mention an example which came under my own observation. An
old nurse sustained fracture of the vertex, with slight depression of
the broken part, in consequence of some rubbish having fallen on her
from a considerable height. Stupor, along with the other symptoms of
concussion, was the immediate effect of the injury, but disappeared in
two or three days. Her hearing, which previously to the accident had
been long so obtuse as to render it necessary for her to discontinue
her employment, became so intensely acute, that the most trifling
noise became a source of pain. She gave immediate orders for the clock
to be stopped, the ticking of which annoyed her greatly. Her hearing
gradually became of the natural intensity, and continued perfect. In
this case there can be little doubt that restoration of a sense which
had long remained dormant arose entirely from cerebral commotion, for
no discharge of blood or other fluid occurred from the ears, by which
cerumen accumulated in these organs might have been displaced. People
sometimes forget languages from hurts of the brain, whilst they retain
memory in other respects; or, rather, the memory on certain things
becomes injured, but remains quite perfect on others.

_Treatment._—Whilst the circulation remains depressed after injuries
of the head, or of other parts of the body, it is a common practice to
abstract blood; but it is one which cannot be too much reprobated, for
it is attended with great risk, and can be productive of no benefit;
the feeble remains of vital power, whilst struggling as it were against
the depressing cause, may by depletion be quickly annihilated, when
the vigour which they still retained might have been sufficient, if
encouraged and supported, to overcome those effects of external injury
which had so far reduced them.

When a patient is seen insensible, it is highly proper and necessary
to examine carefully the trunk, head, and limbs, in order to ascertain
whether either fractures or displacements have occurred; for it is by
no means creditable to the care or science of a surgeon to be made
aware of such accidents when the patient regains his senses, after the
lapse perhaps of weeks, and when they can be remedied, if at all, with
much difficulty.

In the first stage of concussion, as was already observed, the
circulation is much weakened, and it is therefore necessary to adopt
means for sustaining and strengthening it; and with this view, warmth
is to be applied to the surface, more especially to the extremities and
epigastrium.

When the powers of life appear to be failing, stimulants must be
administered internally. Perhaps the most convenient stimulus is ardent
spirit, the only objection to its use being, that when imprudently
given in large quantities, its effects, though at first stimulant,
become sedative; it ought to be given in small quantities, and at short
intervals. Other stimuli, as preparations of ammonia, may be given
by the mouth; and much advantage will often be found to follow the
employment of a turpentine enema, free motion of the bowels, as well as
excitement of the system, being thereby procured.

Stimuli, however, should always be used with much caution and prudence,
and never unless fully warranted by the train of symptoms under which
the patient is labouring at the time; when the circulation is restored
in the limbs, and is becoming throughout steady and more natural, all
sources of excitement must be abandoned and carefully avoided, as there
is considerable risk of reaction proceeding to too great a height.
The patient is to be kept quiet in a darkened room, cold applications
made to the head, previously shaved, and free motion of the bowels
procured by neutral salts with antimony, or by other purgatives not of
an irritating nature, and not given in such doses as to prove violently
cathartic. Enemata are in some cases preferable, and are always a
valuable adjunct, to the employment of purgatives by the mouth; they
procure evacuation from the larger intestines, in which feculent matter
chiefly accumulates; they ought to contain asafœtida and turpentine;
with these additions more salutary effects are produced than from mere
evacuants. The latter ingredient would seem, by its local stimulus, to
impart energy to the bowels sufficient for the correct performances of
their functions, while the former tends to allay spasm and irritation,
both locally and generally.

If the circulation becomes unduly excited, abstraction of blood
from the system, in sufficient quantities and at proper intervals,
is absolutely necessary; and the depletion must be regulated by the
symptoms and circumstances of each case. The action will in general
be more speedily and effectually moderated by one copious bleeding
at the commencement, than by repeated bleedings to a less extent. An
easy and open state of the bowels is of much importance in the excited
stage. Mercurial preparations are sometimes useful, as they are known
to possess the power of causing the absorption of coagulated lymph and
serum, and probably of preventing their effusion.

In cases where insensibility continues after the arterial excitement
has been subdued, counter-irritation on the head or the back of the
neck is often useful, as the application of blisters, or the rubbing in
of antimonial ointment. These are supposed to act by causing an unusual
influx of blood to the surface, producing a change in that fluid by the
copious purulent, serous, and lymphatic secretions from the irritated
part, and thereby diminishing the distended and engorged state of the
internal vessels, which might produce considerable compression of the
brain.

If, at a late period in the case, the powers of life begin to flag,
stimulants must be again had recourse to, and may now be pushed pretty
freely, there being less risk of inordinate action ensuing, and much
reason to fear that life can be prolonged only by the continued use of
powerful means for the excitement of the system. Nor ought the surgeon
to cease stimulating though the vital powers continue to diminish in
spite of the treatment, and though the circumstances of the case may
be so hopeless as to lead him to suppose that death cannot be further
delayed; for many patients, who would otherwise have necessarily
perished, have, by the continued use of stimuli, recovered under my
care their sensibility, and been ultimately restored to health.

Separation of the dura mater from the cranium, with more or less
extravasation of blood between, sometimes takes place as a consequence
of blows on the head, even though not severe. The blood may be
absorbed, or an unhealthy abscess may form between the bone and
membrane, attended with violent, dangerous, and, if neglected, fatal
results. The internal mischief is not without external marks of its
occurrence. If the scalp is undivided, a puffy tumour forms; and, when
it has been injured, the wound degenerates, its surface is pale, and
the discharge gleety; the exposed bone appears white and dry. It is
also preceded by general disorder of the system, by restlessness and
fever; there is sickness, occasional vomiting, shivering, pain of the
forehead and back of the neck; in some cases, delirium and convulsions,
and perhaps partial paralysis, and ultimately coma. All these symptoms,
however, may exist without indicating precisely either the existence or
the site of abscess, as I experienced in the following cases.

A middle-aged man was brought intoxicated into the Royal Infirmary with
a lacerated wound of the scalp, over the upper part of the occipital
bone, on the _right_ side of the mesial line. For thirteen days after
the accident he did well, walking about the wards in good health, with
the wound healing kindly; but on the fourteenth he became affected with
hot skin, restlessness, slight incoherency, severe pain in the head,
and intolerance of light, with a full but not quick pulse. A vein was
opened, but after three ounces of blood had flowed, he was seized with
rigors, vomiting, and violent convulsions; and these symptoms again
occurred after the application of leeches to the head. Rigors returned
at various intervals; stupor supervened and gradually increased. He
became delirious on the eighteenth. A considerable part of the bone
was exposed and dead, and there was a puffy swelling of the scalp
around the wound. On the nineteenth he lay insensible. A portion of the
dead bone was removed by the trephine, and the dura mater was found
covered with lymph, but no appearance of effused blood or pus could
be perceived. He seemed to suffer nothing from the operation, but
continued insensible, passing his urine and feces in bed, with dilated
pupils, quick breathing, and subsultus tendinum; his pulse, which had
previously never been above 80, now rose to 100. He died on the morning
after the operation. On dissection, the right hemisphere of the brain
was found of the healthy appearance; but four ounces of pus lay over
the _left_ hemisphere, between the dura mater and arachnoid, which
latter membrane was of a granular appearance; there was also a small
sloughy spot of the dura mater over the left anterior lobe.—A woman,
aged 40, fell down and sustained a wound of the scalp on the upper part
of the occipital bone on the left side; she suffered but little from
the accident, and continued to live freely and irregularly. Seven days
after the injury she was seized with shivering: and on the ninth day
she lay comatose, voiding her feces and urine involuntarily. The wound
was pale and gleety, and the surrounding scalp puffy; the bone was bare
and white; pupils dilated; pulse slow. The trephine was applied, and
fluctuation felt beneath the exposed dura mater, which was otherwise
unchanged in appearance; the membrane was divided by a trifling crucial
incision, but only a small quantity of bloody serum escaped. Shortly
after the operation she became quite sensible, but again sunk into a
state of stupor, with slightly stertorous breathing and contracted
pupils. However, all traces of coma disappeared next day, and she
recovered soon and perfectly, apparently without having received either
benefit or injury from the operation of trephine.

Purulent collections under the cranium, between the bone and dura
mater, are not of very frequent occurrence, when symptoms are well
watched and treatment properly conducted. But these collections
certainly may and do occur, and usually at a considerable period after
the accident: many such cases are related by the older authors. Their
attendant symptoms are materially different from those of extravasated
blood; in the latter case, all the symptoms of compression ensue
immediately after the effusion has occurred, and that is generally
very shortly after the injury. But matter is not formed till after a
considerable period has elapsed; it is not attended with symptoms of
compression suddenly supervening, but is preceded by restlessness
or febrile excitement; and in the later stages only of the affection
do the symptoms of cerebral compression manifest themselves. By the
external injury, those bloodvessels by which the dura mater is attached
to the skull, and by which it communicates with the pericranium and
more external parts, are lacerated, or otherwise materially injured,
inflammatory action is excited in the connecting medium, unhealthy
suppuration ensues, and by the accumulation of matter, the membrane
is completely separated from the cranium, and generally participates
in the morbid action. It may ultimately slough and give way, and the
matter will then be effused internally. A similar process goes on in
regard to the bone and its pericranium, a tumour forms externally, and
the bone, being deprived of its supply of blood, necessarily dies,
either in part, or throughout its whole thickness. When an external
wound exists, the altered appearance of the bone, with the sloughy
state of the detached pericranium, gives evident warning of the
mischief which is proceeding internally.

The general symptoms of suppuration are the same, whether the
collection forms in the substance of the brain, or on its surface.
Perhaps the symptoms are not so severe, nor the collection so speedily
fatal, when in the substance of the brain, as when situated immediately
under the bone, or at the base of the cranium. The external marks
already mentioned, are generally indicative of the site of such
internal collection, but not uniformly.

Formation of matter in the diploe of the skull, in consequence of
external injury, is of rare occurrence; and when it does occur,
somewhat similar symptoms and appearances ultimately ensue as when the
suppuration commences between the bone and dura mater.

Sometimes the abscess under the bone is of a chronic nature, as in
the following case:—The patient, a boy, æt. 11, received a blow on
the vertex, after which a puffy tumour formed in the injured scalp,
and was freely incised. He afterwards became subject to epileptic
fits, which were relieved by copious evacuation of matter from the
wound. Exfoliation of the cranium occurred; one small sequestrum
was separated, which involved the whole thickness of the bone, and
a collection of matter between the dura mater and skull-cap was
thereby exposed. The contained matter was evacuated, and the wound was
carefully dressed, with the view of procuring adhesion between the
membrane and bone, but without effect. The dura mater was ascertained
to be extensively detached around the opening; it was found necessary
to remove a large portion of bone by means of the trephine and cutting
pliers, and then the dura mater soon became united with the integuments
of the head. Many months afterwards, the patient complained of severe
pain in the back of the neck; an abscess formed in that situation, and,
pointing under the right scapula, was opened. Weakness of the right
arm and of the inferior extremity suddenly supervened, and the patient
gradually sunk. On examination after death, the cervical portion of the
spinal chord was found much softened, with infiltration of purulent
matter into its substance. The deficiency in the cranium was supplied
by a ligamentous expansion, to which the dura mater and scalp adhered
intimately.

_Of Compression of the Brain._—Compression is produced by extravasation
within the cranium of blood or other fluid, by the lodgement of a
foreign body on the surface of the brain, or in its substance, or
by displacement inwards of portions of the cranial bones; and these
causes are usually the effects of external injury. It may either
follow the injury instantaneously, or supervene some time thereafter.
Many examples have occurred of a patient, at first insensible, with
symptoms of concussion, having had the functions of the brain restored
almost entirely, and again having relapsed very quickly into a
comatose state, in consequence of extravasation of blood. The whole
circulation is at first lowered by the shock of the commotion, and the
blood scarcely flows in the cerebral vessels; but on its restoration,
blood is poured out from the lacerated vessels, or from those which
have been so injured in their coats as to be unable to withstand the
increasing impulse of their contents. As was already observed, the
symptoms of compression are often mixed up with those of commotion,
but, when an interval of sensibility has occurred, mistake in diagnosis
can scarcely occur. Compression is attended with slow, stertorous
breathing; a distinct slow pulse; a relaxed state of the limbs,
features, and sphincters; and dilated pupil. Total insensibility to
external impressions attends compression of the brain, whatever the
cause of it may be. These symptoms may, and do sometimes, gradually
disappear after a time. But they may continue unabated, and the patient
may gradually sink under them. Or, again, his dissolution may be
preceded by excited circulation and furious delirium, the vital powers
recovering from their first depression, only to become roused into
violent and destructive action, again to sink to a still lower ebb,
and be ultimately annihilated. Extravasation is most commonly met with
on the lateral parts of the brain in the situation here indicated; the
coagulum is perhaps extensive, reaching to the base of the skull, in
consequence of rupture of the middle meningeal artery, with or without
fracture of the parietal bone.

[Illustration]

Little or nothing can be done in cases of compressed brain from
extravasation. We possess no means of preventing the effusion, and
though we did, the mischief has generally taken place before the
patient can receive assistance. Again, the site of the extravasation
can seldom be ascertained; and, should that objection to the propriety
of surgical interference not exist, still the coagulated blood cannot
be evacuated even after extensive removal of the bone. If the coagulum
is small, it may be gradually and wholly absorbed, or the brain may
become accustomed to the pressure of what remains. It is the surgeon’s
duty to take means for averting inflammatory action, and to subdue
or moderate it when it has been excited. The symptoms arising from
displaced bone may be relieved by surgical operation; but we must
premise some observations on fracture, before speaking of the treatment
necessary in such cases.


FRACTURES OF THE CRANIAL BONES.

At an early period of life the bones are soft and elastic; they yield
readily under external violence, and it requires a great and direct
force to produce fracture of them. Late in life, when the diploe
disappears, the external and internal tables come in contact; the bone
is brittle, and solution of continuity in it is easily effected. And
it is wisely so arranged, for thus in the recklessness of childhood
and youth, severe blows on the cranium, which are then of so frequent
occurrence, are seldom attended or followed with danger; whilst the
aged are taught by experience to avoid the unfortunate consequences so
apt to result from even a slight blow on the then brittle cranium, by
cautiously preserving themselves from exposure to violence.

Solutions of continuity in the cranium, caused by external force,
are either attended with depression or not. Fissures, mere capillary
rents in the bone, may take place at the part of the cranium which is
struck, or on the side opposite to that to which the force is applied.
They will be found either short and limited by sutures, or extending
in different directions through several sutures, as from the vertex to
the base of the skull, and terminating perhaps in the foramen magnum.
Fissures in the upper part of the cranium are of themselves attended
with comparatively little danger; they produce of themselves no claim
to attention, and really require none. But the force which gave rise
to the injury of the bone may have disturbed the internal parts; and
though the patient may have recovered from the first shock and the
immediate effects of the violence, severe and dangerous consequences
often result, and at a late period from the infliction of the injury.

Fractures of the base of the skull are the result of great force
applied to the lateral parts of the head, to the vertex, or to the base
itself through the spinal column. A blow inflicted by an obtuse body
on the top of the head, whilst it is at rest and fixed—by producing
expansion of the lateral parietes, and forcing the base down upon the
upper part of the spinal column—may have the effect of breaking up the
connections of the bones at the base, which is the weakest part of the
cranium, and splintering them to a greater or less extent. Again, if
a person falls from a height, he perhaps alights on some part of his
trunk, as the buttocks, and this coming to a state of rest, whilst
the head is still in projectile motion, the spinal column is driven
towards the cavity of the cranium, and the same effects are thereby
produced as in the preceding instance. Or the patient alights on his
head, and the base of the cranium is then impinged upon by the weight
of the whole trunk, as well as by the force of the projecting power,
and in this case also the base is frequently broken up. In the sketch
here given, showing extensive fracture of the occipital and sphenoid
bones into the foramen magnum, the patient, a brick-layer, fell from
a ladder on the vertex. He lay comatose for some days before death:
there was found extensive extravasation over the middle lobes and
cerebellum. Concussion has resulted from falls when the person has
alighted on his nates or feet; but the symptoms attendant on fracture
of the base are more generally those of compression of the brain. In
this accident the bones are seldom displaced to any great extent; the
dura mater is generally lacerated, its bloodvessels, and frequently its
sinuses, are wounded, and blood is consequently effused at the base
of the brain, where injury is most fatal. The upper part of the brain
may bear pressure to a considerable degree without bad consequences
ensuing, but compression at the origins of the nerves is always highly
dangerous and generally fatal. Bleeding from the nose, mouth, and ears,
when attended with other circumstances and symptoms evincing a violent
injury and consequent cerebral disturbance, has been considered as
decisive of fracture at the base having occurred. But we find that such
bleeding happens in slight injuries unattended with any circumstances
or consequences to induce a belief that so serious an injury has taken
place: and again, in cases where dissection has shown most extensive
fracture in the temporal, sphenoid, and æthmoid bones, no blood had
issued from their external openings. Fracture of the base of the skull
generally proves fatal, but many cases are met with in which there is
reason to believe that it had taken place, and yet the patients have
recovered with perhaps partial paralysis. Of this I lately met with
a good example in the case of a girl seven years of age, whose head
had been squeezed between a wall and the back of a cart, and thereby
considerably flattened. She lay insensible for several days, with all
the symptoms of compression, and with blood flowing in small quantity
from the nose, mouth, and right ear. An extensive abscess formed
over the right temporal bone. She ultimately recovered, but remained
affected with paralysis of the right side of the face and amaurosis of
the left eye; sensation in the paralysed parts being quite perfect.

[Illustration]

Fractures of the upper part of the cranium are generally attended
with displacement to a greater or less extent, and with wound of the
cranial coverings. The size of the depressed portion, the depth to
which it is displaced, and the extent of wound, will depend upon the
nature and intensity of the force applied. When both tables are broken,
the fracture of the inner is almost always more extensive than that of
the outer one, as fissures will extend furthest in the most brittle
part. A broken fragment, comprehending the entire thickness of the
skull, presents generally a much larger portion of the inner than of
the outer table, so much so that the piece would sometimes not admit of
removal, though perfectly detached, without enlarging the opening in
the outer table. Fractures, with depression of a considerable portion
of one of the flat bones, are sometimes unattended with any alarming
symptoms. The effects of the injury soon disappear, and even in cases
where the depression has been very considerable, and where, from the
escape of brain, it was evident that both this organ and its membranes
had been seriously injured, no bad symptoms have occurred to retard
the patient’s recovery. Symptoms of compressed brain, however, may
generally be expected to attend depression of any considerable portion
of bone below its natural level. Still the brain may become accustomed
to the pressure, and the symptoms may gradually subside without
surgical interference. And if the indications of compression are not
very alarming, the coma not very profound, a little delay is allowable,
means being taken to avert inflammatory action: for danger is not
imminent, the cure may not be expedited by operative aid, and there is
chance of injury resulting from rash interference.

But it is in general necessary to remove the cause of the symptoms, to
elevate the depressed bone, and take away those portions which may be
detached.

It has been said that we must be regulated in our proceedings very much
by the existence or not of external wound; that we must be cautious in
cutting down upon fractures of the cranium where there is no wound, and
so converting a simple into a compound fracture. In fact, so much is
the danger increased, it is alleged, by the existence of wound, that
the symptoms must be very urgent indeed which would demand division
of the integuments in order to admit of examination of the fracture,
the application of the trephine, or the elevation of the bone; whilst,
on the contrary, if the fracture is exposed by the accident, very
slight symptoms will fully warrant performance of the operation of
trephine. In other words, it is said that simple fractures should be
left to nature, unless under very urgent and alarming circumstances,
and that compound ones ought almost always to be interfered with. But
the facts are otherwise. The greatest danger of compound fractures of
the cranium does not arise from the admission of air. It is not the
wound of the scalp, but the mechanical irritation of the brain and its
membranes that proves dangerous. Injuries of the cranium inflicted by
sharp bodies, such as divide the scalp and cause compound fractures,
are generally attended with splintering of the internal table, and
require the trephine. The existence of this sort of fracture of itself,
without a single bad symptom, without any present disturbance of the
sensorial functions, is a sufficient warrant for the application of
the trephine, so as to permit the removal of the detached portions of
the inner table: and this should be done before inflammatory symptoms
have shown themselves. The brittleness of the internal layer of the
skull is well known. In fractures inflicted with sharp and pointed
instruments, as a bayonet or pike, the corner of a sharp stone, or
the heel of a horse’s shoe, the external opening is often very small,
it is a mere puncture; in the bone there is a central depression,
from which fissures proceed around in a radiated form, and hence the
injury has been termed punctured, or starlike fracture. But though
the external wound is apparently insignificant, the vitreous table is
extensively separated, and, perhaps, broken into innumerable minute
and sharp spicula. These sharp portions are driven down upon the
dura mater, and by them the membrane is often severely lacerated. If
these be not removed soon after the accident, inflammatory action
is almost invariably lighted up on the surface of the brain; and we
cannot expect to allay or avert such action by general antiphlogistic
means, however energetically applied, so long as their exciting
cause remains. It is in such cases, I repeat, that the operation of
trephining is imperiously called for. Sometimes, however, patients
are found to recover from punctured fracture of the cranium, without
the operation having been performed, as in the following case, the
only one so terminating with which I have met:—On the 4th September,
I was consulted by a gentleman, aged 35, who had received a punctured
fracture of the cranium, on the 29th of August; a heavy dung fork had
fallen from the top of a haystack, and struck him on the upper part of
the head. Immediately after the accident he became confused, but not
insensible; he lost the power of motion in the right lower extremity,
but almost instantly regained it. Next day the right arm became weak,
and when I saw him, he was almost wholly unable to move it: he could
not bend his fingers, nor raise the arm, and he retained the power of
exercising but very slight motion in the elbow-joint. There was a small
wound of the scalp, nearly healed, over the posterior part of the left
parietal bone, close to the sagittal suture, and nearly midway between
its two extremities. A probe passed down to, and through, the bone;
and there was slight swelling of the scalp around the wound. He had
felt pain in the right ear, and in the forehead, whilst stooping, for
some days after the accident. No blood had ever escaped from the ear. A
fit of shivering occurred on the night following the injury, but never
returned. He soon recovered completely.

I subjoin a case of an opposite description. A coachman was knocked
down, late on a Saturday night, and fell with his head on the corner
of a stone on which masons had been recently working. After being
carried to his lodgings, he recovered from the stupor produced by the
combined causes of liquor and blows; and next morning he went to have
his head dressed by an apothecary, who with difficulty extracted a
fragment of the stone from the wound of the head. The patient then
drove a party to church, and probably drank some more whiskey during
the day. He afterwards felt indisposed, and was seized with sickness
and shivering in the afternoon. On Monday he was in a violent fever,
and I saw him in the evening. He had been delirious, but was now lying
in a state of stupor. There was a hole in the right parietal bone,
capable of admitting the point of the little finger, and many loose
fragments of bone were felt lying on the dura mater; a trephine was
applied, and numerous spicula were removed. Afterwards, the circulation
became much excited, he was bled copiously, and antimony was exhibited
in nauseating doses; but he died early on Wednesday morning. On
dissection, there were found marks of violent inflammatory action on
the surface of the hemispheres. The vessels were unusually numerous
and highly engorged, and lymph and pus were effused in considerable
quantity, the arachnoid was opaque, and the cerebral substance was
somewhat softened. Had the operation been performed at an earlier
period, there is every probability that the inflammation, which proved
fatal, would have been averted, as in the following instance:—A
quarryman received a blow from a sharp stone of considerable size,
which rolled down a precipitous bank, and struck him on the vertex.
He lay insensible for half an hour, but recovered, and followed his
occupation during the rest of the day. In the evening he came for
advice. There was a small wound in the scalp, and the subjacent bone
was fractured exactly in the same manner as in the former instance, but
he felt no uneasy symptoms whatever. The consequences likely to result
from such an injury, and the necessity for trephining, were represented
to him; he agreed, and the operation was performed on the spot. Many
sharp fragments of the inner table were extracted; he proceeded home,
never had a bad symptom afterwards, and consequently required no
treatment save dressing of the wound.

The operation, if undertaken early, will, in all probability succeed in
averting future evil, more especially if the dura mater be not wounded.
As a proof of the unfavourable nature of this latter circumstance,
I give the following case:—A young man, aged 18, received a kick
on the forehead from a horse, September 9th. He remained perfectly
sensible, and did not fall to the ground. Shortly after, he was seized
with vomiting, which recurred at intervals; his pulse was regular,
but feeble; pupils dilated. On the centre of the forehead, there was
an irregular wound, which extended to the root of the nose; and on
introducing the finger, the os frontis was found fractured, and a small
portion of it comminuted and depressed. The trephine was applied, and
several detached portions were removed, with some difficulty, from
beneath the undepressed portion of the bone. A spiculum had lacerated
the dura mater, and penetrated the substance of the brain, to the
depth of half an inch; on removing it, a small portion of cerebral
matter escaped. The fracture extended apparently in the direction
of the right orbit. In the afternoon, the pulse was sixty-four, of
good strength, and the pain in the wound had slightly increased. He
was bled to fourteen ounces, and ordered an antimonial solution.
Afterwards, the pain of the head increased, the pulse rose, the scalp
around the wound became the seat of puffy swelling, and several small
abscesses formed: the antiphlogistic regimen was rigorously followed,
and the abscesses were freely opened as soon as they began to form.
On the 21st, a portion of the brain had sloughed, and there was some
appearance of fungus cerebri; an incision was made into a swelling over
the right temporal muscle, and ℥viii. of blood allowed to flow.
On the 22d, several portions of brain were discharged, the pulse was
100, and intermitting. Next day, he was delirious, and a hernia cerebri
protruded, of sloughy appearance, and considerable size; pulse 142.
Soon afterwards he became comatose; and died early in the morning of
the 23d. On dissection, the integuments and pericranium surrounding
the aperture, in the frontal bone, were found much thickened, and
infiltrated with pus and serum. The dura mater at the wound had a
sloughy appearance. There was great effusion of purulent matter, under
the dura mater, investing the right hemisphere of the brain; the
corresponding tunica arachnoidea was thickened and opaque; and between
it and the pia mater there was considerable deposition of lymph and
pus. The fungus was collapsed, of a dark colour, soft consistence, and
connected with the anterior lobes; the surrounding cerebral matter was
much softened, and mixed with pus. The fracture extended through the
orbitar plate of the right os frontis, over which lay two small spicula
of bone; and a similar fragment was situated over the right optic nerve.

Many cases illustrating the danger of punctured fracture might be
related, but are unnecessary, inasmuch as they would lead to the mere
repetition of such facts as have been already stated.

Fracture of the external table alone must be rare, but we occasionally
see in museums specimens exhibiting a small portion of the outer table
driven into the subjacent cancelli, without any fracture of the inner
table. This kind of injury belongs entirely to that period of life in
which the diploe is of considerable thickness. The treatment would of
course be simply that adapted to contusion or concussion.

It is also possible for a blow on the head to produce fracture of the
brittle inner table, the outer table remaining entire. However uncommon
such a form of injury may be, as its effects may possibly be very
serious, it is right to bear it in mind. A splinter of the inner table
thus driven into the dura mater might cause violent symptoms and even
death.

_Wounds of the Brain._—Laceration of this organ to a slight extent,
with more or less extravasation of blood, often takes place, without
external wound, and when the patient has symptoms of concussion only.
In such cases, the blood may be absorbed, and the læsion repaired,
without permanent impairment of the sensorial functions. Wounds of
it, along with fracture of the skull, are often very extensive; and
portions of its substance may be either severely injured, or entirely
separated. Loss of substance, even to a considerable extent, in the
upper part of the hemispheres, may occur, without bad symptoms or
consequences ensuing. The exposed surface of the brain granulates,
and is healed as other parts of soft structure. Generally, however,
untoward symptoms result sooner or later in such cases. Hemorrhage
occurs from the injured part, and a clot protrudes from the external
wound. Or the cerebral substance in the neighbourhood of the wound
softens, and becomes converted into a semifluid mass, often mixed
with pus; and a fungous growth, connected with the disorganised
matter, gradually protrudes through the aperture in the cranium, and
is repressed with difficulty. If removed by knife or ligature, it is
rapidly reproduced. Pressure is the only means left by which to attempt
its retardation; and this, too, is generally ineffectual; for if not
very moderate, the effects of compression extend from the fungus to
the whole of the brain, and an impairment of the sensorial functions
in a greater or less degree necessarily results. The formation of such
a growth is generally attended with shivering, sickness, and fever, by
a weak, rapid, and irregular pulse; the strength declines, convulsions
and delirium supervene, and coma terminates the symptoms.[26]

_Perforation of the Cranium_ is not often resorted to since the
treatment of injuries of the head has become better understood. In
former times, the operation of trepan was performed frequently,
and many seemed to rate the dexterity and science of a surgeon by
the number of holes which he was able to bore in the skull of an
unfortunate patient. It ought never to be performed, unless the
necessity for, and the propriety of, the proceeding be clearly
indicated. It used to be practised in a most unlimited manner for
fissure: cracks were sought for with the greatest care, rules were
propounded to enable the surgeon to distinguish fissures from the
cranial sutures, and from furrow made in the bone by periosteal
vessels; and the trepan was frequently applied over each part of the
fissure, however extensive it might be, the only apparent end of the
operation being to widen very materially the solution of continuity in
the cranium. It was also resorted to in cases of compression without
fracture, with the view of discovering the effused fluid, and removing
it; but, as was already stated, it is unwarrantable in such cases; and
much more so in concussion, for which latter accident, however, it
has been occasionally performed. I met with a case some years since,
in which the patient was certainly not much benefited by such active
practice. The operation is of itself attended with danger, and likely,
under many circumstances, to aggravate the patient’s symptoms, and
diminish his chance of recovery.

The cranium must be perforated, however, when the existence and site
of abscess under the bone is distinctly marked: and in such cases
the practitioner is much to blame if he does not give his patient a
chance of recovery by the operation: many are lost by its not being
performed, and the following case is a striking example of such
negligent practice. A young female fell from a great height amongst
some rubbish, and sustained a severe blow on the left side of the os
frontis, a considerable portion of which was thereby denuded. She
seemed to be doing well for some time; but about the eighth day after
the accident, pain in the head, with vertigo, rigors, and sickness,
febrile excitement, and a white and dry state of the bare portion of
the bone, supervened. She was depleted copiously, but notwithstanding
all the symptoms indicating formation of matter under the exposed
bone were present, the operation of trephine was deemed inadvisable.
Severe rigors continued; she became affected with spasmodic twitchings
of the muscles of the face, and stiffness of the jaw, neck, back,
and breast, and was, in short, allowed to die. On the dissection,
the dura mater below the diseased bone was found separated to a very
considerable extent, and the cavity was filled with thin purulent
matter; the abscess extended along the superior longitudinal sinus, and
communicated with this vessel through an ulcerated aperture; the canal
was filled with pus, as far as its junction with the transverse sinus,
near which point its cavity was obstructed, and the abscess limited by
a firm plug of lymph. A small abscess had formed between the bone and
pericranium, above the extensive collection within; the internal table
of the diseased bone was fractured and slightly depressed, and its
fractured edge was rough, sharp, and projecting.

But the operation may sometimes fail to prove beneficial; the brain may
have become diseased, as well as its membranes, or the patient may not
recover from the irritation caused by the abscess, and the depressing
tendency of the antiphlogistic treatment which may have been put in
force, previously to the formation of matter. But still there is a
probable chance, after the collected matter has been evacuated by the
operation, of the dura mater granulating, the cavity filling up, the
membrane becoming adherent to the cranium around the aperture, and the
patient regaining his former health and vigour.

If, after removing a portion of bone on account of symptoms of
suppuration in that situation, the dura mater be found adherent, and of
a healthy appearance, the surgeon is scarcely justified in going deeper
in search of effused fluid: the evils liable to result from wounds
of the dura mater have been already mentioned, and illustrated by an
example.

The operation of trephine must also be resorted to in cases of
punctured fracture. One perforation will generally be sufficient to
enable the surgeon to remove the detached fragments of the inner table.

In fractures with depression, when the brain is oppressed and its
functions suspended, means must be taken to elevate the displaced
portion or portions to their natural level, and so remove the pressure.
For the accomplishment of this purpose, it may or may not be necessary
to divide the integuments. If they are entire, which is rarely the
case, a crucial incision must be made, or one in the form of the
letter T, and the flaps raised so as to show the extent of depression.
No portion of the integuments ought to be cut away; the preparatory
process of scalping, formerly in use, has been abandoned as cruel
and unnecessary. If a wound already exists, but is not sufficiently
large, it may be dilated in such a direction as appears most likely to
facilitate the after part of the proceedings. The elevation can often
be then effected by the judicious application of the lever, its point
being carefully placed under the depressed portion, and the sound
part of the bone being made the fixed point on which the instrument
acts. Those depressed portions which are completely detached, must be
removed; but those which adhere, either to the dura mater or to the
scalp, ought to be left after having been raised to their former sites,
as they will furnish a large contribution towards the filling up of the
deficient parietes. Reparation of the skull, when a small portion is
removed, or when a single narrow fracture exists, is effected by bone;
but when the opening is large, the deficiency is always repaired by
a dense ligament, to which the dura mater and integuments adhere. By
employing a small saw—represented in both ancient and modern surgical
works—so as to widen the fracture, or remove a projecting corner of
bone, sufficient room may be obtained for the introduction of the lever
and the removal of splinters. In old subjects, the bones are brittle,
and a small corner may be readily removed by pliers, or cutting
forceps, so as to allow the depression to be raised.

But it may be necessary, in order to elevate portions that are wedged
under the sound part of the cranium, to take away a considerable
portion of the latter. One or more circular pieces must be removed by
the trephine, and it may, perhaps, be necessary to cut out the parts
between these apertures by means of the straight-edged saw. The size
of the crown of the trephine must be varied according to the object
which is in view. The trepan is now disused, and the trephines best
suited to the purpose are those fluted on the side of the crown, with
the perforator made to slide and fix by means of a proper screw. The
centre pin, or perforator, is fixed on a sound and firm part of the
bone, and the edge of the crown made to project slightly over the
fractured margin. A few turns will suffice to fix the instrument. The
saw is then made to turn steadily and lightly, pressure being made when
the instrument is moving from left to right, until a pretty deep sulcus
is made. The centre pin is then withdrawn, the saw being sufficiently
retained by its own groove. The centre pin can scarcely be used at all
in children, the cranium being at that age soft and thin. I once had
occasion to operate with an old-fashioned trepan, at a distance from
town, on a child with abscess under the bone, occasioned by a punctured
wound from the point of a spinning top. The centre pin was long, very
sharp, and screwed in; and, if it had been used, would have perforated
skull, dura mater, and nearly half an inch of the brain, before the
saw could come in contact with the bone. I was obliged to use the crown
of the trepan, without a centre pin.

In patients at the middle period of life, a different feeling and
sound is communicated to the operator after having cut through the
outer table of the skull. Whether this change is experienced or not
after getting to some depth, he ought to proceed cautiously, moving
the saw lightly, quickly, and sharply, in the direction of the teeth,
and using no pressure. The operator should not be hurried, for he is
apt to do harm if he is; there is no inducement to make great haste,
for the patient does not suffer much, if any pain. After every two or
three turns of the saw, it is prudent to examine the track with the
flat end of a probe, or with a toothpick. If the perforation is found
to be completed at any point, then the instrument is to be inclined to
those which are undivided; and the fluted crown allows of this being
done with great facility. After the circle of bone is separated on all
sides, it is to be removed by forceps, or by means of the lever; and
the sharp points ought to be taken from the edge of the perforation by
means of the latter instrument, otherwise the dura mater may be fretted
and torn when following the natural motions of the brain. The lever
must be strong, and simple in its construction. And after a sufficient
space of bone has been removed, its point is to be introduced
cautiously under the part that requires elevation; the edge of the
sound bone at various points affords a fulcrum, and by persevering
and steady efforts, the object of the operation will be accomplished.
The dressing of the wound should be simple; the integuments are made
to cover the aperture, or as much of it as possible, and due support
is given by compress and bandage. The after-treatment must be varied,
and conducted according to circumstances. It may become necessary
to repress the granulations, or else to soothe the wound and abate
inflammatory action in the surrounding parts. Perhaps incisions may
be required, to prevent the formation of matter, and destruction of
the cellular tissue, and of the tendinous expansion, or to evacuate
fluid already secreted. The patient’s strength may require support. He
may stand in need of stimulants; or, on the contrary, the most active
means may be required to subdue vascular action, and to prevent the
evil consequences which would result to the important parts within the
cranium from such over-action.


_Inflammation of the Scalp_ occurs either spontaneously, or in
consequence of external injury, though slight; and is generally met
with in those who have lived freely and irregularly, and are of a bad
habit of body. It is more dangerous than inflammation of any other
part of the surface, on account of the sympathy and connection which
exists between the parts affected and those situated internally:
frequently, at an early stage of the affection, delirium occurs, with
violent fever. In slight cases, in which the external surface merely
is affected, there is little swelling, and but little pain or fever.
But when all the pericranial coverings are involved, the symptoms are
uniformly severe. The swelling is elevated and puffy, and extends to
the eyelids, to the face, and, in some cases, even to the neck: the
constitutional symptoms run high, and there is considerable risk of the
patient dying comatose. If he recover, and if the disease is little
interfered with, but allowed to take its own course, much sero-purulent
fluid is infiltrated into the cellular tissue, which generally
perishes, along with a greater or less portion of the tendinous
expansion lost by sloughing. Often, in neglected cases, a large abscess
forms, separating perhaps one-half of the scalp, and bulging over the
ear.

The constitutional treatment must vary according to the nature of
the symptoms which present themselves; in some cases they show great
vascular excitement, and in others they bear unequivocal evidence
of general debility from the first. In slight cases of the local
affection, it is sufficient to relieve the tension, and abstract blood
and effused serum by means of a few punctures, and afterwards to use
warm fomentation. More violent cases require free incision in the
direction of the fibres of the occipito-frontalis muscle, and thus only
can destruction of the parts be averted; the incision must necessarily
be deep, for the scalp is often swollen to the thickness of one or more
inches. When a depôt of matter has formed, it must be evacuated early,
otherwise there is a risk of the bone becoming extensively denuded and
exfoliation ensuing.

_Chronic thickening of the Scalp_ is a consequence, by no means
unfrequent, of slight injuries in those of strumous habit, but may also
occur without any assignable cause. In delicate subjects it is often
attended with chronic periostitis of other bones besides those of the
cranium. The patient perhaps complains of pains about the shoulders,
in the tibiæ, femora, the tuberosities of the ischia, the sternum,
the cervical vertebræ, or in the clavicles and ribs. He cannot bear
pressure on some points without suffering the most excruciating agony.
The pain is also much increased by motion of the parts, as by coughing
when the ribs are affected. Such painful affections of parts external
to cavities are often mistaken for diseases of the internal organs, and
are treated as such by violent bleedings, purgings, and starvation,
to the still farther impairment of the patient’s constitution. The
symptoms are frequently and correctly attributed to exposure to cold
and moisture, sleeping in a damp bed, sitting with wet clothes or on
the cold ground; but such affections are very apt to occur in those
whose constitution has degenerated into that peculiar cachectic state
formerly mentioned, after mercurial courses, whether short or severe;
or in those who for some real or fancied derangement of the digestive
organs have persevered in swallowing, for months or even years, the
universal panacea of some practitioners, Plummer’s or blue pill. The
bones and their coverings, of even the best constituted, can scarcely
resist a perseverance in such a course.

The swelling of the scalp is often general, and is slightly œdematous;
some points are more elevated than others, feel soft, and are the seat
of extreme pain when pressed upon. But such affections frequently
flit from one part to another; what was most unsound, at one time,
recovering itself, and painful swellings attacking that which was
comparatively free of disease. The same holds true in regard to the
other bones at the commencement of the affection; but when much change
of structure takes place, then the pain and swelling become fixed. The
pains are most severe during the night, being then so violent as to
deprive the patient of rest, and even prevent him from placing his head
on the pillow: they abate towards morning, and remain tolerable during
the day. They are always aggravated by change in the atmosphere from
dryness to moisture, and the prevalence of easterly winds is peculiarly
distressing to patients afflicted with such diseases. The swelling
is composed of thickened and vascular periosteum with œdematous
integuments. The bone too is often increased in size, and condensed,
from continuance of increased vascular action; and its surface is
roughened in consequence of its texture being opened out, and new bone
having been deposited. Death of portions of the bone often follows,
either spontaneously, or after slight bruises received during the
continuance of the disease. A few accidental blows on the head, and a
perseverance in the use of mercurial alteratives for a series of years,
gave rise to the state of matters represented in the accompanying
illustrations. The large dead portion represented was removed some
months before death. Here the deficiency in the cranial bones is partly
owing to ulceration, partly to death of portions of them. The patient’s
health becomes undermined by want of sleep and continual suffering; and
he may at the same time have relaxation of the mucous surfaces, with
increased discharge from them, produced by the same cause as occasioned
the affection of the coverings of the bones. He may be subject to a
relaxed or ulcerated state of the throat, increased or caused by the
slightest exposure; and may have hemorrhage from the nostrils, copious
expectoration, mucous stools, &c. The periosteal affection alone is a
troublesome and serious complaint.

[Illustration]

[Illustration]

When the pains are fixed and violent, we are sometimes obliged to
give small doses of the bichloridum hydrargyri at first, even though
there is reason to think that mercurial medicines, perhaps imprudently
or carelessly administered, have brought the constitution into its
present morbid condition. The good effects of this medicine are well
marked and speedy. The patient is freed from the nocturnal pain, gains
flesh, and the swellings subside. It ought not to be resorted to,
however, unless in severe cases, when the disease cannot otherwise be
successfully combated; and when used, it should not be continued longer
than is necessary for the removal of the more urgent symptoms: when the
pains begin to yield, it is time to discontinue the medicine. Great
care is necessary on the part of the patient; he must industriously
avoid exposure to moist atmosphere, and ought to be well and warmly
clothed, wearing flannel, chamois leather, or both, on the trunk and
extremities. A patient treated with the corrosive sublimate of mercury
is perhaps more subject to recurrence of the affection, after imprudent
exposure, for a considerable time afterwards, than if simple and less
powerful means had been employed. A cure can often be effected by the
exhibition of the compound decoction of the woods, with or without
antimony. Moderate diet and strict abstinence from wine and other
internal stimulants should be enjoined; the patient, soon experiencing
the good effects of temperance, is exceedingly willing to restrict
himself to a somewhat antiphlogistic regimen.

In cases of violent fixed pains, with swelling and threatening of
matter forming, incision may be sometimes practised with relief to the
patient, but is not to be had recourse to unless there is a risk of the
bone suffering. Local abstraction of blood is advantageous, and may,
if necessary, be followed by counter-irritation, as the application of
blisters or sinapisms. Friction with stimulating substances, or with
opiate liniments, is often useful when the disease begins to yield,
the pain and puffiness of the parts being thereby dispelled. The hair
should be kept short during the cure, and ought not to be allowed to
grow till the scalp is firm and sound.

The disease is often so far advanced that, in spite of the most active
treatment, abscess forms in one or more points; and, on the matter
being evacuated, the bone is found denuded. Exfoliation is then very
likely to take place.

Exfoliation generally follows denudation of the bone by accident, but
not uniformly. When the periosteum is stripped off by violent injury,
the bone in some cases does not lose its natural colour; granulations
arise from the exposed part, and it again becomes covered without any
part of its substance having been destroyed. Again, careful removal
of the periosteal covering, as in excising a tumour or ulcer by the
knife, may be followed by death of the outer table of the skull; small
portions only separating in some cases, whilst in others a large part
of the bone, and of considerable thickness, perishes. The cranial
bones may in part become dead throughout their entire thickness,
and separate, either after a severe bruise, or in consequence of
inflammatory action following injury or arising from disease. The
process of separation is either speedy or tedious, according to the
vigour of the constitution. The deficiency is repaired, in a great
measure, from the subjacent bone, when its whole thickness is not
thrown off. But when the breach is complete, the surrounding parts
assume the reparative action; the granulations from the dura mater and
integuments coalesce, and a dense membrane fills up the space.

The denuded bone should be kept covered and moist, and for this
purpose lint frequently wetted with tepid water is the best dressing:
spirituous or greasy applications can do no good. A free discharge
for the matter should be afforded, and the wound kept clean. If the
exfoliation goes on slowly, perforation in the dead bone may be made at
different points down to the living parts, with the view of expediting
the process. Exfoliations are sometimes retained by surrounding
granulations overlapping their edges and confining them in their
situation; or are fixed by atmospheric pressure, after separation has
taken place from the parts underneath by the action of the absorbents,
in the same way as a boy’s leathern sucker becomes firmly fastened
to the stone to which it is applied. In such circumstances a small
screw may be fixed into a perforation carefully made in the bone,
and thus the dead part may be lifted out without pain or difficulty,
when otherwise it might have lain for many weeks, keeping up the
discharge. In this way the large sequestrum, represented at p. 240, was
extracted from its bed. The powdered red precipitate of mercury may
be occasionally sprinkled on the parts surrounding the dead portion,
in order that the granulations embracing it may be destroyed, and the
part more completely detached. The general health must be all along
carefully attended to. Sarsaparilla with guaiac, sassafras, mezereon,
&c., is often useful, more especially if pains in other parts continue
to annoy the patient. Under such medicines he in general improves very
rapidly in appetite, flesh, and strength.

The scalp is sometimes, though rarely, the seat of malignant ulcer.
In the early stage the ulceration is not of great extent, and affects
only the soft parts; perhaps it is confined at first to the common
integument, but is extremely apt to extend to the deeper layers which
invest the cranium, and even to the bone itself. It is by no means
uncommon to find the cranium very extensively diseased, though the
affection originated in the superimposed soft parts. Such ulceration of
the bone is of a peculiarly destructive nature; it is a disease of the
osseous tissue, corresponding to the most malignant ulceration of the
soft parts. The bone around the ulcerated cavity is spongy and soft,
its margin is irregular, and bristles with numerous spiculæ; the centre
is composed of soft morbid deposit, entangling small portions of bone
which have become detached, and flabby, almost lifeless granulations
shoot from the distempered mass. Such disease, when the patient does
not soon succumb to its virulence, advances to a frightful extent,
affecting a large surface, destroying the whole thickness of the bone,
and even exposing the internal parts. In a case of this description,
which occurred in the Royal Infirmary under my care, the anterior half
of the cranium was totally destroyed, the left orbit contained a putrid
mass, consisting of the disorganised eye mixed with pus and bloody
fluid; the dura mater was exposed, and sloughed at several points,
and the unhealthy discharge from the parts lodged on the surface of
the brain. In malignant diseases of scalp, as of other parts, the
lymphatics become secondarily affected: the absorbents feel hard and
thickened, the glands in the neighbourhood enlarge and ulcerate,
and the sore thereby formed soon assumes the characters of decided
malignancy,—hard everted edges, an angry surface, and fetid thin
discharge.

Before the disease has become very extensive in the scalp, and when
it is still limited to the superficial parts, it may be removed by
the knife; the incisions being made at a considerable distance from
the margins of the ulcer, so that those parts which may be supposed
to have assumed a disposition to malignant action, may be taken away
along with the ulcer. In more advanced cases, it may be necessary
that the incisions should extend in depth to the bone; and it may
be prudent to insist on a portion of the bone exfoliating, the
periosteum being removed, and some potential cautery applied to the
exposed surface,—as the alumen ustum, oxydum hydrargyri rubrum, &c.
The actual cautery cannot be applied with safety to the cranium. Even
where the integuments only are removed, and that to a small extent,
and in a proper form, it is vain to think of approximating the parts
and procuring union by adhesion; the wound must granulate. There is
no difficulty in suppressing hemorrhage; either ligature or temporary
pressure may be employed according to circumstances. Mild dressings
are to be applied, and proper support afforded. The parts should be
kept clean, and for that purpose the surrounding scalp must be shaved
repeatedly.

_Tumours of the Scalp._—Tumours of a sarcomatous nature are seldom
met with in this situation, but the adipose are not so unfrequent.
The latter are easily removed, being seldom of large size, and their
attachments being loose, unless when they have been irritated by
accident or maltreatment. When sarcomatous growths do occur, they are
to be excised, with those precautions which were formerly mentioned
when treating of tumours generally.

Vascular growths not unfrequently form in the scalp, and attain
considerable size; in general they are either congenital, or the
degenerations of nævi materni. They may be so extensive as to forbid
surgical interference; or they may be so indolent, may partake so much
of the nature of simple varix, as not to warrant it. If small, they
can be readily removed by the knife, the incisions being made rapidly,
and wide of the diseased structure. If the tumour be prominent,
extensive, and at all active, the employment of ligature is a more
safe and equally effectual practice. One or two ligatures may suffice
to encircle the swelling, or, as in other parts of the body, it
maybe necessary to pass a great many double ones beneath the part,
to separate their extremities, and to tie them to each other around
the base of the tumour, the last being drawn so as to tighten all the
others. Little benefit can be expected from tying, either at once or
at different periods, the larger arterial trunks whose ramifications
supply the diseased structure, the inosculation amongst the vessels
around the tumour being so extremely free. But, in cases where the
disease cannot be otherwise combated with any hope of success, ligature
of the common carotid, on the affected side, may be tried as a last
resource. The practice has proved successful in some cases of this
disease, involving parts of the head and face to such an extent, or in
such a situation, as to forbid any attempt at removal of the growth.

Encysted tumours frequently form in the scalp, and, if undisturbed,
become large; they seldom occur singly. The disease appears in many
cases to be hereditary, and it frequently happens that several members
of one family are at the same time afflicted with it. The contents of
the tumours vary as to consistence, but are generally atheromatous.
The cyst is thick, and loosely connected with the surrounding cellular
tissue; but as the tumour increases, the adhesions often become firm
and intimate, more especially towards the skin. When the tumour is
of small size, it is unnecessary to adopt any preparatory measures
for its removal, not even to shave the scalp: the surface may be
cleared a little with scissors. The swelling is transfixed, in the
direction of the fibres of the occipito frontalis, by means of a curved
sharp-pointed bistoury, and its internal structure is exposed by the
knife being carried outwards. The soft contents are evacuated, and
the sac is easily extracted by means of common dissecting forceps.
The integuments are then laid down and retained in apposition, no
sutures being necessary, and in many cases the wound heals by adhesion;
sometimes a small coagulum forms between the edges of the wound, and
is detached some days afterwards; then slight suppuration ensues.
In larger tumours, however, a straight and narrow knife is perhaps
the most convenient instrument for accomplishing removal. The part
is transfixed, and in most cases it is necessary to take away an
elliptical portion of the integuments, a part of the cyst corresponding
to which is of course simultaneously removed; the remainder of the sac
is pulled out by the forceps. If the adhesions at certain points are
firm, they may be touched with the extremity of the knife, so as to
expedite the extraction; and if after the operation there is reason
to believe that the whole of the secreting surface has not been taken
away, a pointed piece of caustic potass may be applied to the suspected
parts. If the tumour is very large, the cyst can often be removed
without difficulty unopened, sufficient integument being left to cover
the exposed surface. In consequence of such operations on the scalp,
erysipelas often supervenes, and precautions ought therefore to be
adopted to prevent its occurrence, by a little preparation beforehand,
by keeping the patient’s bowels freely open, confining him to moderate
and mild diet, and avoiding exposure to moist atmosphere and easterly
winds.

Osseous tumours of the cranium seldom attain any great size, and are in
general neither troublesome nor dangerous. Small ivory exostoses are
the tumours most frequently met with in this situation, and require no
treatment whatever.

Tumours of malignant character occur, though rarely; commencing either
in the diploe of the skull or on the surface of the dura mater, soon
enlarging, and involving the parts around. Two or more sometimes form
in one patient; they are attended with excruciating pain, and rapid
destruction of the bone, and are followed by extinction of life either
at an early or remote period. They are entirely beyond the reach of
surgery; as are also those tumours, occasionally met with in children,
which project through the cranial sutures and contain fluid; such are
analogous to the disease named spina bifida, hereafter to be spoken of.

I may here remark, that puncture of the brain, with the view of
abstracting fluid in chronic hydrocephalus, is an operation not often
likely to be followed by success, and it may even accelerate the
fatal issue. Some cases are recorded in which benefit is said to have
arisen from the practice. Pressure was applied and kept up after the
evacuation of the fluid.


DISEASES OF THE EYE AND ITS APPENDAGES.

_Of Inflammation and Abscess of the Lachrymal Passages._—In former
times, all affections of the lachrymal passages, and of the parts in
the neighbourhood, were denominated fistula lachrymalis, and were all
treated nearly in the same manner, by opening the sac, and inserting
probes, knives, terebræ, scalpra, caustics, and red-hot irons; the
anatomy of the various parts being then ill understood, and the
opinions as to the origin and nature of the diseases being founded on
erroneous theories regarding the defluxion of acrid humours, formation
of imposthumes, fungous growths, &c. The term, however, which was
indiscriminately applied to all diseases in the inner corner of the
eye, accompanied with derangement of the lachrymal secretion, is now
confined to a distinct form of disease, as will afterwards be mentioned.

Inflammation sometimes occurs in the loose cellular tissue covering the
lachrymal sac,—whilst that cavity remains free of all disease,—and is
attended with some obstructions to the passage of the tears in their
natural course, on account of the eyelids becoming swollen, from an
extension of the inflammation. The morbid action resembles erysipelas
in its nature, and usually terminates in unhealthy suppurations; thin
purulent matter lodges in the opened out cellular membrane, a soft
boggy tumour is formed, and the superimposed integuments become of a
bluish colour, as in the case of other scrofulous collections.

Though the affection is at first unconnected with the lachrymal sac,
this organ may ultimately be involved. It may become the seat of a like
unhealthy inflammation, and matter may consequently form within its
cavity; or, on account of the pressure of interstitial deposit around,
the parietes of the sac may ulcerate before the abscess of the cellular
tissue in front has discharged externally. Thus, the cavities of the
lachrymal sac, and of the external abscess, will communicate with each
other. If, after an external aperture has been made either by nature or
by art, any doubt exist as to whether the sac is involved or not, such
doubt will soon be removed by dexterous use of the probe.

In the treatment of this affection, it will be necessary, at the
commencement, as in all other local inflammatory diseases, to attempt
the accomplishment of resolution, by attention to the general health,
local abstraction of blood, and warm fomentations. When matter has
formed, it ought to be evacuated as soon as possible by a small
incision, as there will then be less risk of the deeper parts becoming
secondarily affected; or if the integuments have sloughed, and the
matter has been discharged spontaneously, the natural opening may be
enlarged either with the knife, or with the caustic potass. If it be
discovered that the lachrymal sac is opened into, the same treatment is
necessary as if it remained entire; the matter is to be allowed free
exit, and granulation encouraged; in most cases, the aperture in the
sac is soon repaired, and the parts heal as quickly and soundly as if
the disease had been confined to the external cellular tissue. Light
dressing during the cure, preferable in all cases, is more especially
necessary in this situation.

_Of Inflammation of the Lachrymal Sac._—When the lachrymal sac becomes
inflamed, it enlarges considerably; the swelling is small, hard,
circumscribed, deeply seated, and extremely painful, more especially on
pressure. At first the integuments are of their natural appearance, the
increased action being confined to the sac, but they are soon involved,
and often to a considerable extent; they become red and swollen, and
as the surrounding parts are affected, the swelling increases. In some
cases, the eyelids, the caruncle, and the conjunctival covering of
the eye, participate in the inflammatory action. The inflammation is
in most instances caused, or at least preceded, by some obstruction
in the nasal duct, in consequence of which, the tears are interrupted
in their natural course downwards, and either accumulate in, and
distend the sac, or flow over on the cheek, the puncta lachrymalia
remaining open. After increased vascular action has been produced,
the lachrymal secretion is increased to a greater or less degree, and
much inconvenience is caused to the patient by the profuse discharge
following an unnatural course. When inflammation is intense, lymph is
effused into the passages, producing obstruction sometimes complete.
The mucous lining of the nasal duct becomes swollen, from the vascular
excitement, either throughout its whole extent, or at one point only;
and in either case the flow of the tears must be interrupted, either
partially or wholly, according to the degree of swelling. The vitiated
secretion of the part may also contribute towards narrowing the canal,
by lodging and concreting there. But a more complete and permanent
obstruction is formed by effusion of lymph, under or on the mucous
lining, as happens in other canals of similar construction: and in this
case also, the stricture may be partial or complete, according to the
quantity of effused matter, and the extent of surface affected.

As the inflammation abates, mucous fluid is copiously effused from
the surface of the sac, and the swelling increases, though the pain
is less. The collected fluid may be partially evacuated through
the puncta, either spontaneously, or in consequence of the patient
instinctively pressing with his finger on the swollen part; or the
puncta may be obstructed by the same causes as the nasal duct, and
then the discharge of the fluid is prevented in both directions; it
consequently accumulates still more, and causes greater bulging.
Fluctuation is perceptible, and the collection protrudes outwards and
forwards, being least resisted in these directions. It is seldom that
the puncta are obstructed, and consequently the swelling does not
attain any great size, the sac being relieved by some of its contents
always flowing upwards, after a certain degree of distension. As the
inflammation farther subsides, the mucous secretion diminishes, and
the accumulation and swelling are less: in fact, the patient may at
this period prevent a tumour from forming in the corner of his eye, by
from time to time pressing gently on the sac, and forcing the lachrymal
secretion upwards, as it begins to accumulate. This state of matters
may continue for a long period, without causing much inconvenience,
and getting neither better nor worse; the patient is merely obliged to
apply his finger and handkerchief more frequently to his eye than would
otherwise be required. In almost all cases, the obstruction of the
nasal duct is complete, or nearly so, and consequently the fluid cannot
pass downwards into the nose, though it may occasionally appear to do
so, on account of the discharge from the Schneiderian membrane being
increased at the same time with that of the lachrymal sac. The ductus
ad narem, though wide in the skeleton, is of very limited dimensions
in the living body, and is in consequence readily made impermeable to
mucous fluid, by even slight thickening of its lining membrane.

It has been already observed that the above-mentioned condition of
the parts may continue for a considerable period; but in other cases
purulent matter soon forms within the distended sac; or, at least, the
contents of that organ are so altered in colour and consistence as to
resemble intimately purulent fluid. The secretion may or may not be
pus, probably it is not in some cases; but as the decision of this
point is practically unimportant, the description of it as purulent
can scarcely be objected to. In most cases, when the puncta either are
or become clear, no suppuration, or deterioration of mucus into fluid
like pus, occurs; merely chronic distension of the sac continues, the
patient being able to avert incited action, by occasionally squeezing
out the contents, and thereby removing tension. There is merely an
Epiphora; or, as it is otherwise called, Blenorrhœa, or Stillicidium
lachrymarum. The last term is by some applied to increased lachrymal
secretion, without affection of the sac, the tears being secreted more
quickly than the puncta can carry them away, and consequently running
over on the cheeks, excoriating the surface, and producing an irritable
condition of the eye. The simple epiphora may be of long duration,
yet the parts are extremely liable to assume inordinate action, in
consequence of slight injury, or exposure to cold; thus suppuration
will ensue.

When purulent matter forms, fluctuation becomes more distinct, the pain
increases, and there is slight headache and fever. The integuments
inflame more and more, and, if the case is neglected, ultimately
give way by sloughing. A small ragged opening, often indirect, is
formed, and the contents of the sac are not thereby all discharged;
the thinner fluid only escaping, whilst the more viscid remains and
clogs the aperture. The swelling is not much diminished; the margins
of the aperture thicken, become indurated, and contract, the purulent
contents of the sac are gradually discharged, and the tears afterwards
flow through the opening. The parts are now in that condition to
which the term _Fistula lachrymalis_ is with propriety applied. The
swelling of the canal may gradually subside, the tears resume their
wonted course, and the opening may then contract, and the parts
cicatrise; but frequently the fistula remains open for a long period,
gradually diminishing in diameter, and only a small passage, almost
imperceptible, ultimately remaining, through which a few drops of
lachrymal fluid are occasionally discharged. Sometimes the fistula
closes entirely without the obstruction of the nasal duct having been
removed, and the lachrymal sac remains in consequence distended; then
the tears or mucus, either clear or turbid, can generally be squeezed
through the puncta.

[Illustration]

It frequently happens that the meibomian glands are the seat of morbid
action, along with the lachrymal passages; their secretion is changed,
becoming in some cases thick and caseous, in others puriform. By some,
affection of the meibomian glands has been considered as the cause of
inflammation and abscess of the lachrymal sac. This opinion, however,
cannot be agreed to, for the diseases are not always coexistent; and
besides, the affection of the surface of the lachrymal sac and ductus
ad narem is as likely to be the consequence of morbid action, extending
upwards from the nostrils, as of morbid secretion from the eyelids
blocking up and irritating the puncta and the lachrymal passages.
Disease of the meibomian glands in the under eyelid often exists along
with disease of the lachrymal passages, but the latter is generally the
primary affection; the conjunctival covering of the eyelid is at the
same time inflamed, swollen, and often granulated.

In some cases of abscess in the lachrymal sac, before the integuments
give way, the subjacent bone becomes diseased in consequence of the
pressure of the confined matter; portions are affected by necrosis,
and after their separation considerable deformity is produced. The
exfoliation is often very tedious, and is attended with discharge
of fetid thin fluid from the nostril, and from the ill-conditioned
lachrymal fistula.

Fistula lachrymalis is often merely one of the symptoms of disease
in the bones of the nose, with obstruction of the nasal duct,—as in
patients who have suffered from mercury.

_Treatment._—In the treatment of epiphora or blenorrhœa—that is,
chronic collection of a mucous fluid in the lachrymal sac, with weeping
of the eye—a primary object of attention is the state of the general
health. The habit of the patient will commonly be found weak, and, if
not decidedly strumous, at least inclining towards that diathesis. In
such cases the digestive organs must, if possible, be brought into a
vigorous state by tonics and nourishing regimen. The local treatment
chiefly consists in applying stimulants to the internal surfaces of the
palpebræ and lachrymal sac. For this purpose, solutions of stimulating
and astringent substances, termed collyria, and various ointments, are
employed. At first they ought to be used of rather a mild nature, and
their stimulating power must be afterwards increased gradually. The
applications are placed between the eyelids, and, becoming mixed with
the natural secretion, pervade the diseased surfaces; and, being taken
up by the puncta lachrymalia, are afterwards conveyed into the sac. It
was formerly the custom to inject the fluids into the sac; but this
is unnecessary so long as the puncta and canaliculi remain pervious,
and the permeability of these can be readily ascertained by means of a
small probe. Permanent pressure on the sac can be productive of no good
effect, and is extremely liable to do harm. The repeated application of
very small blisters over the sac has been found useful.

Introducing minute gold probes through the puncta has been much
recommended, but in the generality of cases can be of little service.
The probes are too limber for removing mechanical obstruction, or for
affecting in any way the contracted or strictured duct. But passing
of the probe may tend to remove the irritability of the passage,
as happens in the urethra, and thence some relief may follow. Much
dexterity is required in using either the probe or syringe. The puncta
are often very small, and it is in general necessary to dilate them by
means of the point of a common pin, before any instrument can be passed
through them into the sac. The point of the probe being introduced
into the punctum, either superior or inferior, must first be carried
towards the nose for about 2-10ths of an inch, the instrument being
lightly held betwixt the fore and middle fingers of the right hand. It
is then directed downwards and backwards. Care must be taken to prevent
entanglement in folds of the membrane. Should obstruction be felt, the
instrument is withdrawn a little, and then carefully and gently carried
in the right direction. The small syringe is managed with one hand,
whilst, with the forefinger of the other, the punctum not occupied by
the pipe is compressed.

Neither can much or any benefit be expected to follow attempts to force
obstruction in the lachrymal passages, by the weight of a column of
mercury. A plan of dilating and rectifying the nasal duct by styles
introduced through the puncta has been proposed, but scarcely deserves
to be mentioned as a means of cure.

When suppuration is threatened, with increase of the swelling,
inability of the patient to empty the sac by pressure, redness of the
integuments, &c., an early opening should be made into the tumour, in
order to prevent further and more serious mischief. A small opening
into the sac cannot be productive of so much injury as forcible
dilatation of the canaliculi, followed by and causing ulceration. The
point of a straight narrow bistoury is to be entered into the sac,
and carried on into the nasal duct, the knife being pushed downwards,
backwards, and a little inwards, in the direction of that passage. The
point to be punctured can always be readily ascertained by feeling for
the firm ligament which attaches the orbicularis palpebrarum to the
nasal process of the superior maxillary bone, as the upper orifice
of the ductus ad narem is situated immediately below this tendon; by
introducing the knife below the ligament, and within the sharp edge
of the orbit, and then carrying it forward in the direction already
mentioned, the surgeon cannot fail to enter the nasal duct. The knife
should be followed by a probe, and ought not to be entirely withdrawn
till the probe is fairly lodged in the duct, otherwise the surgeon will
experience much difficulty in the after proceedings. If the knife be
not pushed into the duct, a blunt instrument can scarcely be introduced
afterwards. Some force is required, but is not hurtful, provided it be
made in the proper direction, so as to remove the obstruction in the
duct without injuring the bones and other parts in the neighbourhood.
After the operation, some drops of blood should escape from the
corresponding nostril, showing that it has fairly entered this passage;
or the patient being made to expire forcibly, the nostrils being at the
same time compressed with the fingers, air, blood, and mucus are forced
upwards through the opening made.

Many and various modes have been pursued with a view of securing a
pervious state of the nasal duct. Instruments of different kinds have
been introduced through the puncta, through the opening in the sac,
and through the termination of the duct under the spongy bone, and
have been retained for a longer or shorter period, according to the
fancy, or theory, or plan of the surgeon. The first of the methods
of introduction is abandoned, as already stated. By the ancients the
passages in fault were got rid of altogether, being either cauterised
or destroyed by escharotics.

The passing of probes into the duct from its lower aperture is useful
in removing trifling obstructions caused by concretion of deteriorated
mucus, or slight thickening of the lining membrane, and in chronic
dilatation of the sac with probable contraction of the duct. But, at
the same time, it is an operation requiring much dexterity, and which
ought not to be attempted till after much practice on the dead body.
The first introduction of the instrument is always the most difficult,
from obstruction by a valvular projection of the membrane at the lower
orifice, the use of which in the healthy state of the parts must be
apparent. Destruction of it renders after-introduction of instruments
much more easy.

But the preferable practice is making an opening into the sac, and
then introducing instruments from the upper orifice of the duct; more
especially in cases where the swelling and pain are considerable.
The instruments employed for dilatation of the passage are tubes and
styles. The tubes are made either of silver or gold, of equal calibre
throughout, and of the same length as the passage. For some time
after their introduction they cause much irritation; this gradually
diminishes, and the wound heals over them. But, according to my
experience, the effects are not satisfactory. The irritation which
they at first occasion generally subsides, but abscess again occurs,
with much swelling, and it becomes necessary to remove the foreign
body. Again, the tube sometimes becomes obstructed by thickening and
concretion of the discharge, and then, when it is necessary to remove
it, the process is found to be by no means an easy one; a free incision
is required; a screw must be fastened into the tube, or, when that
cannot be accomplished, the foreign body must be laid firmly hold of
with strong forceps; altogether the extraction is very painful, and
often extremely tedious. In short, the practice of introducing tubes
does not appear to be founded on sound surgical principles.

After extensive and impartial trial of both the tubes and style, I
decidedly prefer the use of the latter. On the point of the bistoury
being fairly lodged in the lachrymal duct, a probe is passed along it;
the knife is then withdrawn, and the passage is gently dilated by the
probe. The probe again is followed by the style, which should be made
of silver, of the same thickness throughout, of the same length as the
duct, and with a flattened head placed obliquely to the body of the
style. The size of the style should be at first small, and gradually
increased. The irritation caused by the first introduction is in many
cases very severe, but the parts soon accommodate themselves to the
presence of the foreign body; the pain and swelling diminish, as also
the discharge. If a large style be pushed forcibly in at first, violent
inflammatory action will ensue, and much mischief may be produced.
After irritation has gone off, the tears pass readily down in the
nose by the sides of the style, according to the laws of capillary
attraction, little or no fluid escapes from the external opening, the
wound contracts around the instrument, and, its head being covered with
black wax, no deformity is produced. The instrument should be removed
from time to time, cleaned, and replaced. When, by the continued use of
styles gradually increased in size, the duct has been dilated to its
full extent, and appears restored to a sound condition, the instrument
may be withdrawn, and afterwards introduced only occasionally. The
external aperture, which has become fistulous from the long presence
of the foreign body, then begins to contract, and, on its completely
closing, the tears continue to follow their usual course, and the
disease is overcome. But sometimes a small fistulous aperture remains,
and there appears to be a disposition towards the renewal of the
affection; in such a case, a small style, not exceeding a thin gold
probe in diameter, should be introduced every evening, and retained for
some hours: this causes little or no inconvenience to the patient, and
insures the permeability of the canal.

Such is the method by which a permanent cure may often be obtained, and
which, in my opinion, is preferable to the use of tubes. If these are
to be employed, they should, as already mentioned, be nearly of equal
calibre throughout; the external opening must not be allowed to close
for a considerable time after the introduction of the instrument; and
the tube must be kept pervious for some time by a style introduced
through it. But by these means, which are essential for the success of
the practice, the main advantage arising from the use of a tube, viz.,
little irritation being produced at first, and the parts being allowed
to close soon over it, are completely done away with.

The practice of perforating the os unguis never can be required; it is
cruel, unnecessary, and unsurgical.

Sometimes the lachrymal passages are entirely destroyed. In such cases,
it has been found that no great inconvenience arises from their
obliteration, as the lachrymal gland ceases, in a great measure, to
secrete fluid, and the conjunctival secretion, after having performed
its office, evaporates from the surface. In truth, the lachrymal gland
always enjoys long periods of repose, and is only called into active
exercise of its functions occasionally, as the eye in its ordinary
condition is sufficiently lubricated by secretion from its conjunctival
covering.

The treatment of fistula lachrymalis, as has been well remarked
by an eminent author, must be varied and regulated according to
circumstances;—by the degree of obstruction in the duct, by the state
of the coverings of the sac, of the sac itself, and of the subjacent
bone, and by the general state and habit of the patient.

[Illustration]

_Encanthis_ is a tumour situated in the corner of the eye. The
caruncula lachrymalis appears to be the original seat of the disease,
at least it is involved at an early period. The growth is at first
small, and appears to be simple enlargement of the caruncle: it is of a
reddish colour, and its surface is studded with numerous granulations.
It often attains a very considerable size; and, on account of its
propinquity to the lachrymal passages, is accompanied with watering of
the eye, the puncta being either involved in the growth, or compressed
or displaced by it. Sometimes the whole inner corner of the eye,
from the margin of the cornea to the inner junction of the eyelids,
is occupied by the granulated swelling; and in such cases it is not
uncommon for the tumour to extend itself outwards, in the form of
a lunated appendage, on the under surface of each lid; thereby the
motions and functions of the ball are much impeded, and a prominent
deformity is occasioned. In most instances the growth seems to be
a simple enlargement of structure, and is of a benign nature; but
sometimes it is firm, hard, of rather a livid hue, with a smooth slimy
surface, and is decidedly malignant,—enlarging, and gradually involving
the surrounding parts.

Cancerous ulceration, attacking and destroying the eyelids, and the
parts around the ball of the eye, often commences in the situation
of the caruncle, or in a wart on the edge of the lid. Cancer, though
a rare and uncommon disease of the eyeball, frequently seizes on the
appendages of the eye, extending rapidly in all directions, and often
completely detaching the ball by ulceration. Warty tumours also occur
on the conjunctiva of the lids, or of the ball, and are inconvenient as
a source of much irritation to the neighbouring parts, even though of a
benign nature in themselves.

Extirpation, by means of a small pointed knife, or curved scissors, is
the only means to be relied on for the cure of such warty tumours, and
of encanthis. The growth must be fixed and pulled outwards with a small
hook, and carefully dissected away; the eyelids, and, if necessary,
the ball of the eye, being kept fixed with the fingers, or by means of
a speculum: the fingers are generally sufficient, and more convenient
than any instrument. If from the appearance of the parts, and from
induration surrounding the tumour, malignant action has evidently
taken place or is dreaded, then the incisions must be made wide of the
base of the swelling. For malignant, open, and extensive ulcerations,
nothing can be done farther than to allay the pain, and soothe the
constitutional disturbance. On the whole, encanthis is a rare disease;
however, I have seen, and operated on, several instances of it.

[Illustration]

_Encysted Tumours of the Eyelids._—These occur beneath the conjunctival
lining of either the upper or under lid, but most frequently in the
former. They form rapidly, but seldom attain any very considerable
size; and may be found to contain, along with glairy fluid, a mixture
of pus, or curdy matter. The contents, however, are generally glairy,
rarely atheromatous. The cysts are very thin and adherent, and the
tumour projects externally, forming a dusky red elevation of the
integuments. They cause considerable deformity, watering of the
eye, and stiffness and difficulty in moving the lids. On everting
the eyelid, the contents of the tumour are seen shining through the
distended conjunctiva, and present a bluish appearance. They are seldom
single, and are not remediable but by operation. It is improper to
attempt their extirpation from without, as there is a certainty of
cutting completely through the eyelid, the inner covering of the cyst
being merely attenuated conjunctiva. The lid is to be everted, and
an incision made into the prominent and thin cyst with the point of
a cataract knife; the contents can then be readily scooped out with
the end of a probe. It is impossible to dissect out the tender cyst
entire, and, when this is attempted, the cure can seldom be permanent.
If, after incision and discharge of the contents, nothing farther is
done, the disease will almost certainly return, in consequence of the
remaining cyst reassuming a secreting action. The only effectual and
radical cure is the application of a finely-pointed piece of caustic
potass to the interior of the cyst, after discharge of the contents and
cessation of bleeding. The cyst is thereby completely destroyed. A slip
of soft lint, dipped in oil, is interposed betwixt the lid and eyeball,
for an hour or two, in order to protect that delicate organ from the
caustic. The wound suppurates and heals kindly, and no mark is visible,
the incision having been made from within. I have had no instance of
return of the disease since adopting this practice; and I have operated
on many which had been previously treated by other and ineffectual
means. The laceration of the cyst with a pointed probe is sometimes
followed by a permanent cure, but it cannot be depended upon.

_Closure of the Eyelids_ may be either congenital, or a consequence
of injuries, as burns of the parts. The closure may be complete or
partial. In general it is partial, though perhaps extensive; and the
adhesions can be readily separated by the point of a knife, or small
probe having been previously introduced beneath; or a small and narrow
probe-pointed bistoury may be conveniently used for the purpose. In the
after-treatment means must, of course, be taken to prevent the lids
from again adhering.

[Illustration]

[Illustration]


_Ectropion_, or eversion of the eyelids, may be produced, merely by
swelling of the conjunctival lining protruding the lid: or the lid may
be relaxed, and the conjunctiva may swell in consequence of repeated
inflammation of the parts, caused by frequent and careless exposure;
or the disease may be the result of contraction, by cicatrisation of
the integuments of the face, as after burns, extensive superficial
wounds in the neighbourhood of the eye, or the effect of periosteal
disease of the orbit. The affection may exist to a greater or less
degree, being in some instances scarcely visible, and not troublesome,
whilst in others, the eyelashes lie on the upper part of the cheek,
and the swollen granulated conjunctiva is exposed. The lower lid is
generally the one which is affected. The disease may exist in both
eyes, or only in one. In strumous habits both are frequently affected
in a slight degree; and the upper lid, too, is sometimes turned a
little outwards. When eversion is of long continuance, and complete or
almost so, the conjunctival covering of the ball of the eye, and of the
cornea, becomes dry and wrinkled; in short, the membrane completely
changes its character, and becomes cuticular. In a lad who laboured
eleven years under eversion of the upper and lower lids—arising from
abscess and exfoliation of the external angular process of the os
frontis, following a blow received when a boy—the conjunctiva was hard,
wrinkled, scaly, and exactly similar to cuticle: this change of the
membrane also extended over the whole cornea. The surface of the eye
had lost its lustre, and vision was much impaired, the patient being
able to distinguish only very bright objects. By such cases, continuity
of the conjunctiva with the outer layer of the cornea is beautifully
demonstrated.

Some of the most intractable of all cases of eversion are the result
of burns. The constantly increasing contraction of the cicatrix draws
either the upper or the lower lid far from its natural situation,
and produces frightful deformity. The tarsal cartilages are greatly
extended, and in any operation for the relief of the patient it is
necessary to remove a portion before the lid can be properly adapted.

Great inconvenience is caused by the state of eversion: the surface
of the eyeball is subject to inflammation, in consequence of being
insufficiently protected; the change of its investing membrane is
a serious evil; and in some cases the cornea becomes extensively
ulcerated, unusually vascular, and opaque.

When the conjunctiva only is in fault, the deformity is slight, and
the state of matters is readily ameliorated by excision of the relaxed
portion. This is done by sharp curved scissors. As the wound gradually
contracts, the eyelid is drawn inwards, and, on cicatrisation taking
place, the parts have become restored to their healthy condition. Care,
however, should be taken that too much of the swollen conjunctiva is
not removed, otherwise the subsequent contraction may cause inversion
of the lid. Combined with the above practice, relaxation of the lid
itself will in many cases be remedied by removal of a portion of it
in the form of the letter V, by means of a sharp-pointed bistoury:
the edges of the incisions are afterwards put together by a point
of interrupted suture. When eversion arises from a cicatrix of the
integuments, the part in fault may be divided; but a temporary benefit
only can be procured. For, during the healing of the wound, the parts
again contract; and, though a portion of the conjunctiva is at the
same time removed, the contraction internally will hardly counteract
that which is going on externally. In order fully to obviate the evil
of this contraction of the cicatrix in inveterate cases of ectropion,
a form of plastic operation may be successfully resorted to. The
cicatrix being dissected out, and the tarsal cartilage brought neatly
into position, a piece of integument from the temple or cheek may be
adapted, and a portion of a new eyelid formed. The parts may sometimes
be brought into a good position without the necessity of borrowing
any portion of integument. A V-shaped incision can be made, the apex
pointing downwards, so as to loosen the under lid; and after it has
been drawn upwards and put straight, the edges of the lower part of the
exposed space are united by suture.

[Illustration]

_Entropion_, or inversion, consists in the turning in of the tarsal
margins of the lids, and generally takes place during inflammation
and swelling of the conjunctival lining of the lid. During violent
inflammation of the lid the conjunctiva and integuments are much
swollen, and bulge out externally; by the projection the margin is
forced mechanically towards the ball, and entropion takes place. But
in this state of matters, should the lid be by any chance everted,
and not replaced, then the bulging is from the conjunctival surface,
and prevents the margin from regaining its former site, and permanent
eversion or ectropion occurs. In fact, inversion and eversion, like
phymosis and paraphymosis, exist from the same parts being put in
different relation to each other. More permanent entropion is caused by
the contraction which follows removal of tumours from the under surface
of the lids, or destruction of large portions of the conjunctiva. The
disease is most frequently met with in the upper lid.

_Trichiasis_ consists in a vicious bend of the eyelashes, or in a
supernumerary growth in the rows or numbers of individual cilia,
whereby they are inverted, and sweep the surface of the conjunctiva
covering the cornea; thus great distress is caused by the friction of
the hairs and edge of the lid on the sensible surface of the eyeball,
and inflammation is frequently kindled and kept up by the continued
irritation; it is accompanied by its usual distressing symptoms when
seated in that organ, and too often followed by a greater or less
number of untoward consequences. Sometimes only one or two hairs are at
fault; in other instances, the half of the eyelash grows inwards; and
sometimes there is a double row of cilia; one set being in the usual
position, while the other projects against the eyeball. If proper means
are not taken to remedy the evil, and moderate the irritation which it
produces, the cornea becomes thickened and changed in structure; and
vision, at first impaired and indistinct, may be entirely lost.

The symptoms may be for a time palliated by plucking out the faulty
hairs, abstracting blood from the loaded vessels, and subsequently
using ointments or collyria,—the best of which, perhaps, is the
solution of nitrate of silver. In some cases it may be necessary to
employ counter-irritation, as blistering the nape of the neck; and in
all the general health must be strictly attended to. Other means may be
required, and will be mentioned when treating of chronic ophthalmia.

The permanent cure of the disease is effected either by removal or by
destruction of the roots of the cilia. The whole edge of the eyelid,
or the offending part of it, is removed with a sharp narrow bistoury,
the operator steadying the parts by laying hold of the cilia with the
fingers of his left hand. It is necessary to remove the mere edge only,
the cilia and their roots, and not the whole of the tarsal cartilage,
as has been proposed.

Inversion of the lid, from contraction of a cicatrix in the
conjunctiva, may be counteracted, by destroying with caustic, or
removing with cutting instruments, a portion of the outer integuments,
corresponding to the internal cicatrix. Forceps with broad points
are used for taking up a fold of the skin, and an oval portion is
then excised with a knife or scissors, cutting instruments being
less painful and more precise than caustics. Of the latter, the
sulphuric acid has been particularly recommended for this purpose.
The contraction of the wound releases the cilia from the power of the
internal cicatrix, and the parts are restored to their healthy state.

[Illustration]

The term _Pterygium_ is employed to denote a thickened and vascular
state of part of the conjunctiva. The diseased portion is generally of
a triangular form, commencing at the inner corner of the eye, extending
towards the cornea, gradually diminishing in breadth, and terminating
in a sharp apex, either at the margin of the cornea, or somewhere
between its margin and centre. The thickening is seldom great, but the
vessels which traverse the thickened part are numerous, enlarged, and
tortuous—are, in fact, varicose. The base of the pterygium is always
on the circumference of the eye, generally at the inner corner, and
its apex is seldom, if ever, situated beyond the centre of the cornea:
frequently the sclerotic conjunctiva alone is affected. The motions of
the eye are little disturbed by the disease, but vision is materially
impaired when a considerable part of the cornea is covered. Pterygium
is in general single, but sometimes, though very rarely, there are two
or more pterygia in one eye; and, in such cases, the patient’s vision
is seriously affected, in consequence of the apices of the different
pterygia uniting and coalescing on the cornea, and investing the
greater part of that organ with a thick and dark shade. When several
occur, they sometimes unite throughout their whole extent, and cover
the half or more of the eye. This disease is very common amongst
negroes and persons residing in equatorial climates.

When the pterygium is of considerable size, extending over the cornea,
the only remedy is excision. The apex of the web is laid hold of and
pulled outwards by forceps or a hook, and the whole diseased part is
then carefully dissected off with scissors, the incisions commencing
at the apex, and being carried on to the base. The wound gradually
contracts; and though an opaque cicatrix must form on the corneal
surface, the speck is of much less dimensions than the space formerly
occupied by the pterygium. If the web be thin and not exceedingly
vascular, it may be sufficient to make a semicircular section of it
transversely, by means of a hook and scissors, between its base and
the margin of the cornea; its growth is thereby arrested, and there
is a probable chance of its beginning to diminish, and ultimately
disappearing. When it is small, and so situated as to cause no
impairment of vision, it is prudent and good practice not to interfere
with it at all.

DISEASES OF THE EYEBALL are numerous, and various in their nature. Some
are acute, others chronic; and their attack is either sudden, or slow
and insidious. Most of them are attended with pain and other annoying
symptoms, and some cause loss of vision. Some are cured by internal
means; others require surgical operations; and the cure is either
complete and permanent, or palliative and temporary. Some destroy the
organ, and others, still more malignant, cause extinction of life. All
require much attention and care.

_Of Ophthalmia, or Inflammation of the Eye._—The symptoms and
appearances of ophthalmia vary much according to the particular
texture or textures affected. They require to be minutely attended
to, that the treatment may be varied in such a way as to obviate any
bad consequences which may be threatened. The great importance of the
organ, and the danger to its structure and functions which is likely to
occur from any other termination of the affection than resolution, must
never be lost sight of.

We shall first treat of inflammation of the more external parts of
the ball, an affection generally less dangerous than inflammation of
the interior, but at the same time of more frequent occurrence, and
produced by slighter causes.

Inflammation of the conjunctiva occurs in many individuals during very
warm and sunny weather. At such a period, the eye is often excited
by reflection of intense light from the surface of the earth; and is
irritated by sudden exposure to a degree of light to which it has not
been previously accustomed. Different directions of the sun’s rays,
and different kinds of light, seem to exert different influences
on the organ. The rays are most hurtful when they do not fall in a
perpendicular direction on the eye, but slopingly or horizontally.
Strong light from the moon, and light reflected from scarlet, are also
particularly injurious. Undue exertion of the eye weakens it, and
renders it prone to become inflamed. The eyes of infants are often
violently inflamed, in consequence of imprudent exposure to light
before they have been gradually accustomed to its stimulus. Again,
inflammation is caused by imprudent exposure of the eye directly to
cold, or by exposure of other parts causing suppression of their
discharges, whether natural or not. Inflammation of the conjunctiva
often follows suppression, however occasioned, of the menstrual or
hemorrhoidal discharges, as also suppression of discharges from
the urethra, from the Schneiderian membrane, or from behind the
ears. Irritations in the neighbouring parts, as in the mouth during
dentition, may also excite the disease. Immediate irritations, however,
are the most frequent cause, as the lodgement of extraneous bodies on
the surface of the organ—particles of sand, dust, snuff, pepper, or
gunpowder, minute insects, loose or inverted eyelashes. By the presence
of such substances, the eye is often kept in a very irritated state for
a long period. The most violent conjunctival inflammation is sometimes
produced by contact of gonorrhœal matter through carelessness.
Occasionally metastasis of inflammation takes place from one eye to
another; so that a person may be seen one day with severe inflammation
of the right, and on the following day with a similar affection of
the left, and the right entirely free from disease. Another cause,
sometimes met with, of inflammatory action in the conjunctiva, is
the lodgement of large foreign bodies in the orbit, with or without
destruction of the eye; as splinters of wood, straws, rusty iron nails,
sharp portions of stone, &c., penetrating the globe of the eye, or
parts in the immediate neighbourhood. Upon removal of the cause, the
redness, discharge of tears, pain, &c., sometimes subside without
inflammation having been established, the vessels of the part regaining
their contractility; but if the cause is continued for any considerable
time the effects do not rapidly abate. Wounds and other injuries of the
organ are generally followed by inflammation. But a simple clean wound
or puncture made with a fine instrument, as in many operations, and in
a favourable constitution, frequently produces little or no excitement
of the part. The degree of excitement must of course depend upon the
nature of the wound, the structure of the parts involved, the lodgement
or not of the body by which the wound is inflicted, and many accidental
circumstances. The eye may be injured by acids or by lime, and the
textures acted upon chemically; again, the membrane may be wounded by
pieces of hot metal, and then the destructive action is both chemical
and mechanical: in both cases active inflammation of the injured
conjunctiva is kindled. The state of the patient’s constitution
modifies very much inflammatory action of the eye, however induced;
and it has been observed, that dark eyes bear injury or incited action
better than those of a light hue. Not unfrequently conjunctivitis is
a secondary affection, accompanying eruptile diseases, as measles or
small-pox.

In considering the disease, it is necessary to keep in mind the loose
connection of the membrane with the subjacent parts, as well as its own
texture and functions.

In conjunctival inflammation, the patient first feels a degree of pain
and stiffness in moving the organ; and has always a feeling as if a
foreign body were present, whether such is the case or not. There is
also a degree of itching with a sensation of fulness in the part, and
this is followed by redness of the membrane, becoming more and more
intense. If the disease gain ground, the colour changes to a darkish
red or purple hue. To the redness succeeds heat, with profuse and
hot lachrymation. Then swelling supervenes, often to a great extent:
the vessels, both veins and arteries, are much gorged, and effusion
of serum or blood takes place into the loose cellular tissue which
connects the conjunctiva to the sclerotic.

In some cases, the effusion in this situation is very considerable;
lymph as well as blood is deposited, and a bulging forwards of the
conjunctiva is produced; the stretched membrane becomes thickened, of
a raw granulated appearance, and a bright scarlet hue, and the cornea
appears sunk in the midst of the swelling, and almost hid by it: this
state of matters is termed _Inflammatory Chemosis_, and only occurs
when the excitement is very intense.

Blood is frequently effused beneath the conjunctiva in small quantity,
in consequence of a bruise or other injury of the eye,—from violent
exertion, as during coughing,—or from a less degree of inflammatory
action than in the preceding case; but the swelling thereby occasioned
is comparatively trifling, and the effusion is, in general, speedily
absorbed. To this affection the term _Ecchymosis_ is attached.

In inflammation of the external parts of the eye, the redness begins
from the margins of the organ, and gradually diffuses itself towards
the cornea. Such is not the case in inflammation more deeply seated.
There is intolerance of light in a slight degree, and the patient is
inclined to keep the eyelids shut. At first the discharge from the
conjunctiva and meibomian glands is increased and changed, and flows
occasionally over the cheek, producing a scalding sensation. When the
eyelids are at rest, as during the night, they become glued together by
the viscid fluid from the meibomian follicles; but, if the inflammation
increases in intensity, the discharge is arrested.

In external inflammation there is more or less constitutional
disturbance, proportioned to the violence of the action and the
irritability of the system. In most instances the patient complains of
headache.

The above symptoms subside along with the inflammation; but, if this
has been at all severe or protracted, distension of the vessels to a
considerable degree continues, and the ophthalmia becomes chronic. This
change from acute to chronic takes place at various periods of the
affection, according to the intensity of the action, the nature of the
cause, and the irritability of the constitution. And again, the second
stage of ophthalmia may revert to the first, acute inflammation being
rekindled by fresh irritation of the organ.

_Purulent Ophthalmia_ most frequently occurs in warm climates, and
is attended from the first with profuse puriform discharge from the
conjunctiva. In the natural state of the organ, the conjunctival
discharge is pellucid, and so small in quantity as to be indiscernible;
but in this disease it possesses all the external characters of pus,
and is secreted in large quantity. The affection commences generally
in the under eyelid, with a feeling as if sand or foreign bodies were
lodged in the eye. The parts swell very much, and the eyelids become
more or less inverted, in consequence of serous effusion into their
cellular texture. Frequently the patient experiences an exacerbation
of the complaint about three or four hours after each meal. Though the
disease usually commences in the conjunctival lining of the eyelids,
the external coverings of the ball are often secondarily affected. In
some cases the bulb becomes the seat of lancinating pains; its coats
give way; the humours are discharged; and the eye sinks, with immediate
relief to the patient from the more urgent symptoms, but at the same
time with irreparable loss of vision. In other instances the effects
are less injurious to the structure of the organ, but equally so to
the sense of vision: the cornea becomes dull, and ultimately opaque,
or ulcerates, or partially sloughs; the swollen conjunctival surface
of the lids is covered with granulations, and secretes a copious
puriform discharge, with or without eversion, according to the degree
of swelling. At first the lids are more or less inverted, on account of
œdematous swelling of the cellular tissue: in the latter stages they
are everted by thickening and turgescence of the conjunctiva. This
membrane is at first villous and of a dull red colour, relaxed, and
its vessels enlarged and loaded; afterwards it becomes hard, almost
warty, and continues to discharge puriform fluid. The latter state
of the lining of the lid produces disease of the cornea, opacity of
a greenish colour, or an ulcer with intolerance of light, and other
symptoms of disorganisation proceeding in that tissue. The disease is
supposed to be contagious, and was the scourge of the British army for
many years after the campaign in Egypt. In that country it seems to be
caused by exposure to cold and damp during the night, and the intense
rays of light during the day, more especially when these causes act
on eyes which have not been accustomed to such vicissitudes. After
its invasion, it is communicable to others by contact of the morbid
secretion; and in individuals who have been once affected the disease
is very apt to recur when they are crowded together in unhealthy
situations.

A disease of equal malignity, and resembling in all respects the
Egyptian ophthalmia, occurs from the application of gonorrhœal matter
to the conjunctiva, or on sudden suppression of the gonorrhœal
discharge,—metastasis of the action sometimes takes place from the
urethral membrane to the conjunctiva. The eye is seldom saved from
the destructive effects of the violent inflammation which follows the
contact of the morbid fluid. Of all forms of purulent ophthalmia, the
gonorrhœal is the most rapid in its course and destructive in its
effects.

[Illustration]

Children are not unfrequently the victims of purulent ophthalmia—the
_ophthalmia neonatorum_. Immediately after birth the conjunctival
lining of the eyelids seems unusually red and turgid, and a great
degree of swelling soon takes place, so as to render separation of
the eyelids very difficult. Occasionally eversion of the lids occurs,
when the child cries, from sudden and forcible contraction of the
strong external fibres of the orbicular muscle. In general, the lids
soon relapse into their former situation; but sometimes the eversion
remains, if the internally projecting tumour of the conjunctiva is
allowed to become still more swelled from strangulation, caused by
the outer margin of the reflected lid. The inflammation spreads over
the ball; and, in general, the swelling of the conjunctiva, being
greatest at the circumference of the eye, bulges out the eyelids, and
turns in their margins. Puriform matter is secreted copiously, and is
confined, more especially when, from inattention, the margins of the
lids are allowed to become glued together. They often adhere so firmly
as to require a very considerable force for their separation, and when
opened the matter gushes out as if from the cavity of an abscess. From
confinement of the matter the inflammation is still more increased,
and the cornea involved. Whitish specks form on it, or it ulcerates,
and the ulcers make their way into the anterior chamber of the eye; or
portions of it slough, causing partial loss of the organ and openings
into the chamber, in consequence of which the aqueous humour is
discharged, and the cornea sinks and becomes flaccid. In many instances
the cornea becomes opaque, changed in texture, and increased in
thickness, so as to form a convex projection from betwixt the eyelids,
termed _Staphyloma_; the sclerotic coat also is occasionally affected
in a similar manner. A frequent cause of purulent ophthalmia in
children is imprudent exposure of the eyes to strong light, the parent
or nurse not remembering that the organ must be gradually accustomed to
the stimulus. Exposure to cold may also induce the inflammatory action.
The application of leucorrhœal or gonorrhœal matter to the eyes of the
child, whilst passing through the vagina of the mother, is perhaps
the most common cause of the disease. A very unhealthy state of the
constitution accompanies the affection: the scalp and other parts of
the surface are frequently covered with eruptions. A singular result
sometimes follows the purulent ophthalmia of infants. A small opaque
spot is observed on the capsule of the lens, which remains through life
a central spurious capsular cataract.


_Inflammation of the Cornea_ supervenes on simple conjunctival
inflammation, and frequently on the purulent. The vessels of the part,
both veins and arteries, previously carrying single and therefore
invisible blood corpuscules, become much dilated, are filled with
numerous globules, and hence are rendered red and conspicuous to the
unassisted eye. Writers on ophthalmic surgery, in their rage for
refinement, speak of three kinds of this inflammation—inflammation
of the external or conjunctival covering, of the middle tunics or
cornea propria, and, lastly, of the third coat, the capsule of the
aqueous humour: such distinctions, however, are found to effect no good
practical end, and it is unnecessary to follow them. One particular
layer of the cornea may be first attacked, but the whole structure
soon becomes involved. The inflammation generally commences in the
conjunctival covering. Vision is necessarily much obscured from even
slight inflammatory affection of the cornea. Part only of the organ may
be affected, but frequently the whole is involved. Sometimes only one
or two vessels remain dilated; but still they, passing over the centre
of the cornea, render vision indistinct. Opacity of the cornea, to a
greater or less degree, always attends dilatation of its vessels.

In inflammation of the internal and middle tunics of the cornea,
most of the enlarged vessels which traverse it are seen to be
continuations of those that ramify in the conjunctival covering; while
the anastomotic vessels derived from the sclerotic coat are smaller
and less apparent than those of the conjunctiva. The cornea, and the
sclerotic immediately surrounding it, frequently appear to be almost
entirely covered with meshes of their dilated capillaries. At first
the whole cornea has a clouded appearance, but as the disease advances
portions become distinctly opaque, and at these points either lymph
or pus is effused. Sometimes matter collects between the laminæ,
distends them, and, causing ulceration, discharges itself either into
the anterior chamber or externally. Inflammation of the cornea arises
frequently from lodgement of a foreign body in it: and ulcers of it
are often produced by a similar cause. If the extraneous matter is not
removed soon after its insertion, nature commences her endeavours to
detach it, and the process employed is ulceration. Sometimes, however,
a sac is formed around the foreign body as in other parts, and no ulcer
is produced.

Ulceration of the cornea also takes place in order to afford an exit
to matter formed between its layers deeply or superficially. Deep
abscess of the cornea is by no means a rare consequence of violent
inflammatory action in the part. A minute opaque spot is at first
seen; this extends, assumes a yellow colour, and does not change its
situation on the head being moved. The internal lamellæ may ulcerate
in consequence of the pressure; but this seldom happens; the matter
is discharged externally. Suppuration in this situation is often
attended with much pain. Abscess of the surface of the cornea is of
more frequent occurrence than one more deeply seated: from its external
covering yielding readily to the pressure of the accumulating matter,
it generally assumes a pustular form. The fluid in such cases is
sometimes absorbed, and no vestige of disease remains in the part; but
more frequently the apex of the pustule gives way, and an ulcer is the
consequence. A similar result takes place if an artificial opening is
made for evacuation of the matter; and it may be considered as a good
rule in practice not to interfere with collections in the cornea, as
there is a probable chance of the matter being absorbed, and the cornea
regaining its transparency; while it is certain that breach of its
surface, in such cases, though made by the most delicate instrument,
will give rise to ulceration.

_Pustular Opthalmia_ is at some seasons frequently met with: small
pustules, sometimes numerous, form on the conjunctiva, whilst that
membrane is turgid and its vessels dilated; the sclerotic conjunctiva
around the cornea is their most common situation, but sometimes almost
the whole conjunctival surface appears studded with them. When the
cornea is affected, the pustules frequently give way, and produce
ulceration; and when the pustules are numerous, and surrounded by much
vascularity, the part becomes opaque as well as ulcerated.

In weak constitutions _Ulcers of the Cornea_ occur from slight
causes,—exposure to strong light, intemperance, inverted or irregular
ciliæ, a granulated state of the lining of the lids, or from momentary
irritation of the part by extraneous matter. The ulcer appears at first
circular, but during its progress it often becomes of an irregular
form; its surface is depressed and ragged, and can readily be seen by
directing the patient to fix the eye, and then looking at the part
from one side. The edges are elevated; and the surface, which is of
an ash colour, discharges an acrid colourless fluid, as in similar
affections of all surfaces that are covered with a delicate, tense,
and exquisitely sensible expansion. Sometimes the ulcer is very minute
and superficial, and enlarges very slowly, if at all; but in other
instances it extends rapidly in depth and size, with great pain and
irritability of the organ, and intolerance of light. Occasionally their
increase is expedited by partial sloughing. At first, when the ulcer
is minute, the part often retains its natural transparency. But as the
disease advances, when the sore spreads superficially either by the
sloughing or the ulcerative process, or by both, the cornea becomes
opaque, often to a considerable extent, around the ulcerated part;
and if the ulcer extends deeply, so as to perforate the tunics, the
aqueous humour escapes, the iris falls forward, and the pupil becomes
distorted: in either case vision is impaired or destroyed. In some
cases great relief follows discharge of the humour, and the consequent
flaccidity of the cornea, the ulcers seeming to have been prolonged
and irritated by the fulness of the chamber. Sometimes an ulcer will
penetrate the laminæ of the cornea, even to the aqueous membrane. This
latter tissue may resist the ulcerative process, and will then be
pushed forward into the opening by the pressure of the aqueous fluid.
This is _the hernia of the aqueous membrane_, so called, instances of
which have been known to acquire a considerable size before the bag has
given way.

_Abrasion_ of the conjunctival covering of the cornea is produced by
accident, or follows incited action of the vessels. The abraded surface
either ulcerates, or contracts and heals kindly, with or without
opacity of the part. Breach of surface in the cornea,—whether an ulcer,
an abrasion, or a raw surface, caused by the giving way of a pustule,
or of a small abscess,—is constantly liable to irritation, on account
of not being protected by mucous membrane and mucous discharge: even
the contact of the tears irritates, and keeps up inflammatory action in
the membranes. When the ulcerative process ceases, lymph is effused,
and a grayish halo forms around the sore; the ash colour of the surface
of the sore disappears, and is succeeded by florid granulations,
extremely minute, which fill up the cavity; cicatrisation follows
in due time, with subsidence of all the symptoms and appearances of
inflammation. There remains, however, an opaque speck of a pearly
hue corresponding to the sore, but occupying rather less space. When
the cornea is perforated by ulceration, the sore sometimes shows no
disposition to heal, becoming a fistulous aperture through which the
aqueous humour is from time to time discharged. By this condition of
parts vision is much impaired, the cornea being always more or less
flaccid. Touching the fistulous opening with the nitrate of silver,
reduced by scraping to a very fine point, will often promote a healthy
action in the tissue, and effect adhesion of its sides.

The pearly speck which remains after cicatrisation of a corneal sore
is termed _Leucoma_, and is permanent. It is generally of an uniform
colour, but occasionally a black speck is perceptible in some part of
it. For, when an ulcer lays open the anterior chamber, part or the
whole of the aqueous humour is evacuated, and the iris falls forward;
a portion of the iris falling into the opening, provided this is
not in the centre of the cornea, closes it up, and becomes adherent
to that part. If the opening is large, the prolapsus of the iris is
considerable; and in some cases this membrane, being pressed on by the
humours, is forced through the opening in the form of a small bag.
This change of position is termed _Hernia of the Iris_; and the dark
sacculated portion of the iris which projects from the surface of
the cornea is called _Myocephalon_, from its resemblance to the head
of a fly. The myocephalon may remain for a considerable time, or may
sphacelate and drop away. The pupil is thus rendered irregular, is
perhaps nearly obliterated, or is drawn down behind the opaque part,
and thereby rendered totally useless to the patient. The impairment
of vision caused by Leucoma depends on the size and situation of the
speck. The disease is irremediable, though the thin cloudy opacity,
which frequently surrounds the leucoma, may be dissipated. The
operation of artificial pupil is sometimes required, in order to afford
a degree of vision in this affection of the cornea,—as well as in the
speck of a similar appearance occasioned by effusion and organisation
of lymph betwixt the deep lamellæ of the cornea, and which is termed
_Albugo_.

[Illustration]

Albugo occurs during the intensity of inflammatory attacks. It also
is surrounded occasionally by thinner opacity, but not depressed and
unequal on the surface, as leucoma sometimes is. Large and tortuous
vessels are generally seen passing into albugines, but meshes of dilated
vessels are seldom present. When the affection is recent, it sometimes
disappears under proper treatment, especially in young subjects; but
the albugo is by no means so readily removed as the _Nebula_, or thin
cloudy opacity which is the frequent consequence of obstinate chronic
dilatation of the conjunctival vessels. Nebula is superficial, and
consists of mere thickening of the conjunctival covering, from lymph
having been effused. It impairs vision, but does not destroy it, for
the affected part remains semitransparent.

In strumous constitutions specks of the cornea are often accompanied
with ulceration of the edges of the palpebræ, and destruction of the
ciliæ—_the ophthalmia tarsi_. The margins of the eyelids are red and
slightly tumid, and discharge an acrid fluid; the ciliæ are matted
together; pustules form at their roots; the bags which secrete them
are laid open and destroyed, and they consequently fall out. The
affection is often of long duration, and may be in part prolonged by
vitiated secretion from the meibomian glands. During its progress it
excites very considerable irritation in the whole eye, and, as has been
already stated, opacities of the cornea not unfrequently accompany it.
Veins become enlarged, and varicose on the conjunctiva, as also their
minute ramifications on the clear part of the ball; small reddish lines
appear on the cornea, and around them is “diffused a thin, milky, or
albuminous humour,” which destroys its transparency at that part.
Such spots may be solitary or numerous, and darken the cornea either
partially or entirely. They are always surrounded with a fasciculus of
enlarged veins.

In elderly people a dim opaque ring, of a greyish colour, sometimes
encircles the margins of the cornea, and is called _Arcus Senilis_; but
this can scarcely be looked upon as a disease.

Sometimes the cornea presents a _spotted_ appearance; and this state of
the organ is generally attended by obstinate inflammatory action in the
part. The affection, however, is rare. I have seen several instances of
it: in one, both corneæ were spotted, and sight was almost destroyed,
without much irritability of the organ. The disease yielded to external
stimulants, and the internal use of the bichloride of mercury. It is
met with in a chronic and very intractable form.

The cornea may sometimes be rendered dim by _over-distension_, the
aqueous humour being unusually copious.

Occasionally _sloughing_ takes place in the cornea from over-action. It
is dangerous to the structure and functions of the organ, according to
the extent to which it occurs.

_Ossification_ of the cornea is said to take place; but few cases are
on record, and these were in very old people.

The cornea sometimes becomes _conical_ to a great degree in persons
considerably advanced in life. The cone has its apex in the centre of
the organ, seems thick and crystalline when viewed laterally, and when
looked on from the front has a sparkling appearance. In some cases it
is opaque in the centre, and occasionally its surface is irregular.
Vision of objects at any distance is very indistinct; those placed
within an inch or two of the eye are most distinctly seen, especially
if looked on through a small aperture. The disease usually affects both
eyes, though not always in an equal degree. The patients cannot judge
accurately of distance, and see objects multiplied and disfigured.

[Illustration]

_Staphyloma_ has been already alluded to as an occasional consequence
of purulent ophthalmia in children. The cornea is thickened, prominent,
and opaque; and in most cases vision is either much impaired or
entirely lost. The prominence varies in different cases, being
sometimes very little elevated beyond the natural state of the part,
while in other instances it protrudes from between the eyelids. After
having attained a certain size it often becomes stationary; but very
frequently it continues to enlarge gradually. When the prominence is
large, much inconvenience arises from the eyelids not being allowed to
close; and the eye, being thereby deprived of its natural covering, is
extremely liable to become inflamed from external irritation. When one
eye is affected with staphyloma, the other not unfrequently becomes
similarly diseased.

Dropsy of the anterior chamber, or _Hydrophthalmia_, occasionally takes
place in persons of weak constitutions. The aqueous humour is either
secreted in greater abundance than it usually is, or absorption is
diminished. The cornea gradually accommodates itself to the increase
of the fluid behind, and becomes wider and more prominent, but retains
its transparency; in looking at the eye, the anterior chamber is seen
evidently enlarged, and occasionally the aqueous humour is of a turbid
appearance. There is little or no pain in the eyeball, but the patient
complains of an annoying sense of fulness and tension in the part. In
consequence of the vitreous humour also accumulating, the whole organ
is ultimately enlarged considerably, and its motions are thereby much
impeded. At first, vision of near objects is impaired, whilst the
patient sees very distinctly those placed at a distance; ultimately
sight is entirely lost.

_Exophthalmia_, or protrusion of the eye, attends the preceding
disease, and is also a consequence of various other morbid actions
in the globe and its neighbourhood, especially from the pressure of
tumours in the orbit. The chronic enlargement of the bulb is noticed
more fully in the succeeding chapters.

_Treatment of External Ophthalmia, and its Consequences._—The exciting
cause, if such exist and can be discovered, ought in the first place
to be removed. The surface of the organ and of the palpebræ should be
carefully examined, either with the naked eye or with a magnifying
glass, in order to detect any small extraneous body which may be
lodged in the part. In examining the inner surfaces of the palpebræ,
it is necessary, to produce complete eversion, to bring the parts
completely into view; and the most convenient method of accomplishing
this is to lay hold of the ciliæ between the finger and thumb, and
reflect the lid over a silver probe placed along its base. This can,
by a little practice, be accomplished readily without using a probe,
and even by the fingers of one hand only. This is the more necessary,
as small particles of foreign matter lodge more frequently on the
palpebral conjunctiva than on any other part. If a particle of glass,
metal, stone, &c., be discovered, it should be gently removed by the
flattened extremity of a silver probe, or by a scoop, a fine needle,
or a delicate brush. In some cases washing the surface by means of
a small syringe, filled with a bland fluid, is extremely useful; as
when an impalpable powder has been thrown into the eye, and can with
difficulty be removed, in consequence of spasmodic contraction of
the eyelids preventing exposure of the parts. The application of an
emollient poultice, with the addition of hyoscyamus, is beneficial when
it has been found impossible to remove the whole of a fine powder. When
particles of lunar caustic have, by accident, come in contact with
the eye, they are to be removed, as soon after insertion as possible,
by a fine hair pencil dipped in oil or fresh butter,—not in water.
Small loose bodies are generally carried, by the increased lachrymal
secretion, along the sulcus formed by the apposition of the eyelids,
to the inner canthus, and there discharged. And, in order to favour
this natural process for removing extraneous matter, the patient should
be directed to keep the eyelids shut, and as quiet as possible, to
cover them with his hands, and to blow his nose forcibly: thus the
greater number of the extraneous particles will be got rid of. Those
which remain lodged in the membranes must be speedily removed by those
artificial means which have been already enumerated. If entropion is
the cause of the inflammation, the eyelashes are either plucked out,
or completely destroyed by removal of their roots. The inflamed organ
should be carefully protected from the stimulus of strong light; the
patient is to be placed in a darkened room, and the eye protected by a
thin green shade. The shade, however, may be worn too long, so as to
induce an extremely weak and tender state of the organ.

If there be good grounds for believing that the incited action has
been caused by suppression of any discharge, that should be encouraged
to return, and the cause of the suppression must be avoided. If a
gonorrhœa have been suddenly arrested by the employment of stimulating
injections, these must be instantly discontinued; and some have even
gone so far, in such cases, as to introduce bougies impregnated with
gonorrhœal matter, in order to procure a renewal of the discharge.
In cases of suppression of purulent discharge from the ears, or the
surrounding parts, followed by external ophthalmia, a blister or
sinapism should be applied in the neighbourhood of the part from which
the discharge formerly issued. When the menstrual evacuation has been
arrested, leeches and fomentations should be applied to the pudenda, or
around the anus, and emenagogues administered internally; the patient
should be placed in a quiet and well ventilated apartment, and kept
free from any emotions of the mind; all noise and other sources of
irritation should be studiously avoided.

If the incited action in the eye do not subside, as it often will
not, on removal of the exciting cause, recourse must immediately be
had to very active means for its subjugation; for in no other organ
does inflammatory action proceed more rapidly to an unfavourable
termination. By timely use of antiphlogistic means, those consequences
of external ophthalmia, which we have already treated of, may be
avoided; and, with respect to most of them, it is much better to
prevent their occurrence, than combat them after they have been allowed
to take place. The eye is more valuable to a great proportion of people
than a limb; and the surgeon is very culpable if he be not master of
this part of his profession, and able to undertake the management
of every disease and accident to which the eye is liable. “In cases
of inflammation the general treatment is the same; but each variety
requires peculiar attention during the cure, depending on the structure
and function of the tissue affected.”

In the _first stage_ of external ophthalmia, active antiphlogistic
measures must be put in force. In full habits, and cases of intense
action, general bleeding must be employed, even to fainting, from the
veins of the arm or of the neck, or from the temporal artery,—and
repeated, if necessary, according to circumstances. Blood is sometimes
abstracted by cupping from the temples or the nape of the neck; but
it is a painful and uncertain mode of emptying the vessels. Local
bloodletting, in many cases, suffices to moderate the action; in all
it is most beneficial and important, after the employment of general
depletion. The application of leeches to the inner canthus is the most
effectual method of abstracting blood locally, as at that point the
venous return is made from the eye. If placed on the temples, they can
produce very little benefit; if on the outer surface of the eyelids,
ecchymosis follows, on account of the extreme looseness of the cellular
tissue in that situation. Or the angular vein, at the inner canthus,
may be opened with a lancet, and a considerable quantity of blood
thereby abstracted from the seat of the disease. Leeches applied to the
conjunctiva of the lower lid are sometimes advantageous; but leeching
and scarification are more useful in the chronic stage: and the latter
is injurious in acute ophthalmia. Saline purgatives, and antimonial
medicines, a very material part of the antiphlogistic regimen, must not
be omitted. Enemata, with occasional pediluvia, are much recommended
by some Continental writers. In bilious habits emetics, followed by
mercurial purges, will be found very useful. With respect to topical
treatment, warm applications are found to afford decided relief in
the first stage, and are, in consequence, generally used. By some,
however, cold water, or water with vinegar, is applied from the first.
Poultices, whether warm or cold, prove annoying from their weight. Warm
fomentations, simple or anodyne, are preferable, and may be repeated
according to the feelings of the patient; or the eye may be exposed to
the steam of water.

When by these means the violence of the symptoms has abated, as
usually happens in the course of a very few days, the organ must be
gradually accustomed to its natural stimulus, light. The shade must be
discontinued, and the room no longer darkened; and now leeching becomes
of great service, while the evacuation is to be followed by gently
stimulating or astringent applications, so as to produce contraction of
the still dilated, though partially emptied, vessels. Various collyria
may be employed for this purpose. Solutions of the sulphate of zinc,
of muriate of mercury, of sulphate of alum, of acetate of lead, or of
the lapis divinus—wine of opium—the citrine ointment, or the unguentum
oxydi hydrargyri rubri, &c.—or stimulating vapours of various kinds.
Camphor is a good addition to many of the applications. The collyria
may be cold, or slightly warmed; and maybe dropped into the outer
canthus, flowing over the eye, and escaping by the inner canthus,
according to the natural course of the fluids of the eye; or they may
be inserted at the inner canthus, the head being immediately afterwards
inclined so as to allow the fluid to pass towards the external canthus;
or they may be applied by means of an eyeglass. Warm fomentations,
and other relaxing remedies, however useful during the first stage,
are worse than useless, are hurtful in the highest degree, when the
affection has passed into a chronic state; as also are antiphlogistic
means, and exclusion of light,—remedies so essentially necessary in the
first stage.

In ophthalmia, attended with profuse _purulent_ discharge, the
structure of the eye is in great danger of being destroyed, from the
intensity of the action, and its liability to extend to the deep parts
of the organ; the most active practice is required from the first.
Copious general depletion, ad deliquium, must be quickly had recourse
to; and the patient must be freely purged, and kept in a state of
partial nausea for some time, by exhibition of antimonials. After
general bloodletting, the repeated application of leeches to the inner
canthus is necessary, in order to empty sufficiently the vessels of the
part. Where the chemosis is so extensive as to bury the cornea, as it
were, beneath the folds of the swollen conjunctiva, sloughing of the
transparent tunic is frequently threatened. In order to arrest this
fatal result, much good is often obtained by division of the chemosis.
A sharp-pointed bistoury is passed through the swollen membrane, and
radiating incisions practised, commencing at the corneal margins, and
directing them towards the circumference of the globe. Sometimes four
or even five of such divisions are called for, while care is taken not
to wound the sclerotic coat beneath. A considerable quantity of blood
is sometimes lost by this procedure, and, the chemosis subsiding,
the cornea is saved. Infusion of tobacco, solutions of acetate of
lead, and nitrate of silver, æther and laudanum, have been used as
applications to the eye from the very commencement of the affection;
but the propriety of the practice appears very questionable. Blistering
the nape of the neck proves highly beneficial, after the employment
of the antiphlogistic measures; and in many cases it is necessary
to keep up discharge from the blistered surface for some time. On
subsidence of the violent symptoms, the swelled conjunctiva is to
be attacked with escharotics and stimulants, as the nitras argenti,
sulphas cupri, or various collyria: then only can such applications be
advantageous; at an earlier period they must do harm. They repress the
exuberant granulations which may have formed, or may be forming, on the
conjunctiva of the eyelids, promote contraction of the dilated vessels,
diminish the relaxation of all the tissues, and stimulate the now
dormant action of the part into a healthy state of excitement. Gently
stimulating collyria may be injected betwixt the lids, by means of a
small syringe. In granulated conjunctiva, it is sometimes necessary to
remove a greater or less part of the diseased membrane by escharotics,
the knife, or scissors; and after this has been accomplished it is
well to encourage bleeding to a slight extent. In removing part of
the palpebral conjunctiva, care must be taken to avoid injuring the
cartilage of the tarsus; and, in the lower lid, not to take away too
large a portion, lest entropion should occur during cicatrisation. In
hospital practice, the infected should be separated from the healthy;
and promiscuous use of towels and sponges must not be allowed.

In _Purulent Ophthalmia of Children_, antiphlogistic means must
be pursued, if the patient is seen during the first stage of the
disease; but children do not bear depletion well. After the discharge
is established, the surface of the eye must be kept free of matter,
by frequent injection of a bland, tepid fluid; and stimulating or
astringent collyria should be applied three or four times a-day.

When _Inflammation of the Cornea_ is established, it is exceedingly
difficult to procure contraction of the vessels. Active antiphlogistic
measures must be employed in the acute stage; and in the chronic,
stimulant applications are to be had recourse to. As, however,
corneitis is frequently kept up in its chronic form, from deficient
constitutional power in strumous habits, strict attention must be paid
to the diet and secretions of the patient. Mild mercurial alteratives,
diaphoretics, and tonics combined, will often effect a cure, where all
local treatment has been tried in vain. When a large plexus of vessels
remain dilated on the part, the most effectual method of removal is to
divide them, as they ramify on the sclerotic, by means of scissors, or
a fine knife, and afterwards to employ stimulating applications.

The irritability of _ulcers_ on the cornea is diminished by the
application of nitrate of silver, in solution or substance. If in
solution, the application is used in the proportion of three to ten
grains of the salt to the ounce of distilled water; if in substance, a
portion, finely pointed, is gently applied to the sore, which may be
afterwards besmeared with a little oil or simple ointment, in order
to confine the action of the nitrate to the ulcerated part. It is not
necessary, but, on the contrary, hurtful, to rub the caustic freely
on the sore; a very slight application is sufficient to coagulate the
secretions on the part, and form a covering for protection of the
surface. In two or three days afterwards, when the temporary covering
has become detached, and when the irritability of the sore has in
consequence returned, it will be necessary to repeat the application,
but not till then. On each application, and few are in general
required, the sore is found reduced in size considerably. The collyrium
nitratis argenti is very useful in many obstinate cases of affections
of the eye and eyelids, the strength of the solution being varied,
according to circumstances.

In _Albugo_ and _Leucoma_, proposals have been made for excising,
scraping, or perforating the opaque part; but the cure by such means
is worse than the disease, as a raw surface is left larger than the
previous opacity, and the cicatrix which must inevitably form also
occupies a larger space, and is equally opaque. Leucoma and Albugo
are incurable diseases, though the opacities may become somewhat
thinner, by natural processes, after the lapse of a long period.
_Nebulæ_, however, are often removable. During the treatment of them,
or, rather, before beginning to treat them, it is of the utmost
importance to attend to the state of the surface of the eye, and of
the lids and eyelashes. Stimulating substances may be applied in cases
where the opacities are thin: powders of calomel, aloes, sugar, &c.,
have been blown into the eye; stimulating lotions or ointments are
preferable; one containing the nitrate of silver, with the addition
of a proportion of the liq. sub-acet. plumbi, is sometimes used
with advantage. These, however, are often of no avail, unless the
dilated vessels, when such exist, are divided, or a portion dissected
out; afterwards stimulants will be efficacious, and must be used
assiduously. The vessels may require to be divided again and again.

In _Ophthalmia tarsi_, gently stimulating ointments or lotions are to
be used, and in obstinate cases much advantage will result from the
application of blisters behind the ears and to the nape of the neck,
or from the insertion of a seton in the latter situation. In children
it is necessary to correct the state of the bowels, scarify teeth, and
remove other irritating causes to which that tender age is liable.

_Sloughing of the Cornea_ should, of course, be prevented, if possible,
by subduing the incited action before it has attained such intensity
as to overcome the power of the part. The slough is slow in separating
when the constitution has been much weakened; and sometimes tonics and
stimulants, both external and internal, are required to hasten the
process of separation. When the surface has at length become clean, the
same treatment is required as to an ulcer of the part.

_Conical Cornea._—This deformity can scarcely be cured, nor can any
optical contrivance effectually remedy the disturbance of vision.
When the apex of the cone is opaque, the removal of the pupil to the
circumference by operation affords the best chance of assisting the
sight of the patient.

When _staphyloma_ is small, neither impeding the motions of the
eye, nor preventing its being protected by the lids, no surgical
interference is called for, as the loss or impairment of vision cannot
be remedied, and as no other inconvenience than blindness is produced
by the change of form in the part. But when the diseased cornea
projects from between the eyelids the prominence must be diminished,
on account of the deformity which it occasions, and in consequence
of the eye being deprived of its natural protection of the lids, and
being thereby exposed to constant irritation. In such cases it is
necessary to take away a portion of the cornea, that the eye may be
so diminished in bulk as to retract within the eyelids; the size of
the part removed must be proportioned to the degree of protrusion. A
cornea-knife is passed into the prominence, and carried forwards so as
to transfix the part, in a direction from the external to the inner
canthus; and by the knife being carried on, with its cutting edge
looking downwards, a flap of the cornea is made. This flap is then laid
hold of by means of forceps, and removed either with the knife or with
scissors. The aqueous humour immediately escapes, and in most cases
the crystalline lens and vitreous humour are also discharged. The eye
consequently shrinks, and retracts within the palpebræ. The cut margins
of the cornea soon assume a reddish appearance—they form granulations,
the wound contracts gradually, and ultimately closes; but the eye is
necessarily much shrunk, and totally useless as an organ of vision.
Generally suppuration takes place, causing complete disorganisation of
the parts; and the preceding inflammatory action may be so intense,
and attended with so much constitutional disturbance, as to require
active measures for its moderation. Deformity may be in a great measure
removed by adapting an artificial eye to the shrivelled remains of
the natural one. When it is necessary to remove only a small part of
the cornea, the aqueous humour alone escapes, and during the cure of
the wound the patient not unfrequently enjoys a tolerable degree of
vision; but after the wound has completely closed, vision is again lost
completely.

_Hydrophthalmia_, also, is a disease in which little hope can be
entertained of materially benefiting the patient. In the slighter
cases, in which no very annoying symptoms accompany the affection,
vision may be improved by the use of optical instruments; mercurial
preparations may be employed in moderation, with the view of promoting
absorption of the superabundant fluid. When the disease has made
considerable progress, temporary relief may be obtained from puncturing
the cornea at its lower part, so as to discharge the accumulated
aqueous humour; but a cure can scarcely be expected from such a
practice, however often the paracentesis may be repeated. In the worst
cases the pain is so excruciating, and the system so much disturbed by
the local affection, as almost to warrant the destruction of the organ,
in order to relieve the patient; but, after all, even such severe
measures will most probably prove unavailing.

In _Exophthalmos_ the treatment must vary according to the
circumstances which cause the protrusion of the eyeball.


_Of Internal Ophthalmia._—Inflammation of the internal parts of the
eyeball sometimes supervenes on conjunctival inflammation, and then
the distinctive characters of the two affections are not perceptible.
When inflammatory action attacks the deep parts primarily, the external
ciliary vessels ramifying on the sclerotic coat are seen, enlarged,
shining through the conjunctiva; and, as they advance towards the
clearer part of the eye, they form a zone of a pink colour, whose
vessels run in a straight direction towards the margin of the cornea;
but between the zone and the cornea a distinct white line is often
interposed. Then large arborescent and reticulated vessels soon appear
on the white part of the eye; and from their being more superficial
than the first, and of a brighter hue, it is obvious that they belong
to the conjunctiva. They also approach the clear part of the eye,
and, if numerous, obscure the former vessels—as also the red zone and
white line—for they pass over them, and reach the corneal margins, and
often go beyond it, in continuous ramifications. The sclerotic, in
consequence, assumes a pink-red colour, and the cornea becomes dim.

The iris may be primarily and principally affected, and, if so, the
disease is termed _Iritis_; but in most cases all the other internal
parts suffer more or less. The iris changes its appearance, becomes
of a dusky hue, either in part or throughout, and red vessels are
sometimes distinctly seen in it; from grey or blue it changes to
a greenish colour, and when formerly black or brown it becomes
reddish. The size of the pupil diminishes, and the contraction is
often irregular, when the inflammatory action is intense. The iris
swells perceptibly, and the pupil loses its dark colour, or is almost
entirely closed, either from effusion of lymph, or from inflammation
and consequent opacity of the crystalline lens and its capsule. The
iris projects forwards, and diminishes the capacity of the anterior
chamber; the pupil is irregular, and often assumes an angular
appearance; and the irregularity becomes permanent from adhesion of
the pupillary margin of the iris to the capsule of the lens, lymph
being effused and organised, and forming a firm uniting medium between
the parts. Occasionally adhesions form at the middle of the iris, and
cause so great contraction as to give the pupil an appearance of being
double. Of course irregularities of the pupil are most distinct when
the part is dilated, either spontaneously or by the application of
belladonna. Tubercles sometimes form on the iris, and not unfrequently
it presents a granulated appearance. From the commencement of the
inflammatory attack the patient feels great pain in the organ and in
the forehead, and there is great intolerance of light. There is a
feeling of tension of the eyeball, followed by deep throbbing pain
increasing every instant. As the disease advances, the cornea is
rendered opaque by the fulness of the chambers, and the aqueous humour
becomes turbid and of a milky appearance; or lymph is effused into the
anterior chamber, and floats about in flaky portions. Occasionally the
vessels of the iris are so distended as to give way, causing effusion
of blood into the chamber, often in considerable quantity.

More frequently, however, puriform fluid is deposited, occasioning the
appearance termed _Hypopium_. The pus is either fluid or of a thick
curdy consistence: when fluid and thin, it mixes with the aqueous
humour, rendering it white and opaque; if of firmer consistence, it
lodges in the lower part of the chamber, but changes its position, and
mixes partially with the humour, on the head being moved; when dense
and curdy, it remains separate from the humour, and its position is not
altered by motions of the head.

During the progress of the inflammatory action, all the symptoms
increase; the pain shoots to the top of the head, and is much
aggravated by pressure on the eyeball. Of course vision is materially
impaired. Constitutional disturbance always accompanies the affection,
and exists in a greater or less degree according to the extent of the
disease. The iris may be primarily affected, but the other textures,
both external and more deeply seated, too often become involved; and
in aggravated cases the whole eyeball suffers. When the most internal
parts, as the choroid coat, the retina, and the vitreous humour, are
affected, sudden and bright flashes of light disturb the patient,
whilst vision is rapidly lost, and for ever. Occasionally the intense
over-action terminates in suppuration of all the affected textures, and
the eyeball soon becomes completely disorganised.

In _Rheumatic Ophthalmia_ the appearances of the diseased eye are
similar to those in ophthalmia produced by any other cause. But the
affection is accompanied with, and seems to arise from rheumatic
diathesis. There is pain in many of the joints, and frequently in the
scalp and portions of the face, increased on hanging the head, and by
pressing the parts. The pains are remittent, supervene at night, and
subside in the morning. In general the ophthalmia is external; but
in severe cases the internal parts become affected, and the eye is
sometimes lost by giving way of the cornea.

Internal ophthalmia is often occasioned by wounds inflicted either
accidentally or by operation. Laceration of the iris in the extraction
of cataract, or an improper performance of the operation for cataract
with a needle, is by no means an unfrequent cause of the affection.
Iritis often occurs during the exhibition of mercury in undue
quantities, and is said also to be a symptom of syphilitic taint. It
is, in many cases, preceded by cutaneous eruption, and seems to be the
consequence of the eruption being repelled, or interfered with in its
progress.


_Choroiditis._—The choroid membrane is sometimes primarily affected:
but more frequently the inflammation of this tunic is the consequence
of sclerotitis, or the disease last described. When the result of the
former cause, it generally takes on the rheumatic type. The early
symptoms are zonular redness of the sclerotic, accompanied by a general
impairment of vision, so that the patient expresses himself as if
looking through gauze or some dark network. Presently the sight becomes
more and more impaired, until a complete amaurosis results. The pupil
is generally in a semi-dilated state, and, instead of presenting the
intense black hue of the healthy eye, it reflects a greenish-grey
colour, dependent upon the effusion of a turbid fluid between the
choroid and retina. The nervous structures, becoming thus pressed
upon, lose their sensibility to light, and are paralysed. This form of
inflammation is generally chronic, and imperceptibly advances to the
iris anteriorly, and to the retina within; the ultimate termination
being complete glaucoma. Various dull and heavy pains accompany
this affection; and, in the latter stages, acute circum-orbitar
neuralgia is the most distressing concomitant. By long-continued
chronic inflammation the sclerotic coat appears to lose its powers
of resistance—the accumulating fluid pushes before it the weakened
tunic, and _Staphyloma Scleroticæ_ is produced. This protrusion of
the external tunic sometimes takes place in various parts, and to a
considerable extent, so that the figure of the globe is entirely lost.
The thinning of the sclerotic at these points allows the dark hue of
the choroid to shine through, and this, together with the bunched-like
appearance of the protruded portions, has entailed upon it the name of
_Staphyloma Racemosum_.

[Illustration]

_Treatment._—In the first stage of internal ophthalmia, active
treatment, properly conducted, should be successful in averting
the progress of the disease; in the latter stages, there is every
chance of vision being entirely lost. The treatment must be actively
antiphlogistic, consisting of general and local bleeding, the internal
use of purgatives and antimonial medicines, and strict abstinence. A
free use of mercury internally is said to check the disease, and, in
its advanced stages, to procure absorption of effused lymph. But the
inflammation can be subdued without the aid of that mineral, though its
effects are often powerful; and a recollection of the bad effects which
are so apt to follow its employment renders a prudent surgeon cautious
in having recourse to it. Mercurial ointment, with opium, rubbed on
the forehead, immediately above the affected eye, gives great relief.
The same relief follows friction with oil, in which the muriate or
other salts of morphia is dissolved. When the incited action declines,
the extracts of belladonna, hyoscyamus, or stramonium, rubbed on the
eyelids and brow, procure dilatation of the pupil, and thereby tend to
prevent its further contraction; but whilst acute inflammation exists,
the pupil is not dilatable; and it is consequently an encouraging
symptom when the pupil begins to yield to the influence of these
medicines. In hypopium it is sometimes necessary to evacuate the pus
when effused in large quantity, in order to prevent the injurious
effects that its pressure might occasion; but, if the quantity be
small, there is a good chance of its being removed by absorption.
In suppuration of the eyeball, whilst the other eye remains sound,
it may be prudent to open the cornea, and allow a free exit for the
matter, in order to prevent the healthy eye from becoming affected.
In the staphyloma of the sclerotic coat, when the eye, as it were, is
affected by a sort of chronic dropsy, (and this disease is met with
at various periods of life,) the tension and bulk of the organ may be
diminished by occasional puncture. The opening may be kept pervious by
the introduction of a conical probe from time to time. I have more than
once introduced a silk thread through the most dependent and prominent
part of the globe with good effect. The organ ultimately shrinks.


_Amaurosis_ implies an impairment of vision more or less complete,
arising from disease in the brain, in the optic nerve, or in the
retina, whether consisting of change or destruction of structure, or
derangement of function. Vision may be diminished or lost by organic
disease in the coats or humours of the eye, or by morbid formations
in the orbit; but to such the term Amaurosis does not strictly apply.
But, after establishment of the disease, other textures of the eye may,
and often do, become affected. Usually one eye at first is amaurotic;
but the other soon participates, and ultimately vision is impaired or
entirely lost in both. The disease may occur idiopathically, or be
symptomatic of other affections.

The general symptoms of amaurosis are the following. Headache is felt
for some time, either constant, or, as is most commonly the case,
occasional, and most severe in the forehead: in many cases the pain
is at times most excruciating. The eyesight gradually becomes weak;
distant objects are unusually obscure, or not at all observed; and
those which are near cannot be accurately discerned. For a short
time vision may seem to be restored, but soon it diminishes more and
more, all objects seem to be enshrouded in a mist, at first thin and
shadowy, but gradually becoming opaque and impenetrable; or a feeling
is communicated of a dark network obstructing the view. Unnatural
impressions are made on the retina; flashes of strong light, or
luminous sparks, appear to dart across the eyes; darkened spots are
seen where none exist; gnats, flies, or other minute bodies, various
in colour and brilliancy, seem to flutter before the face; or a single
dark speck intercepts the vision. Usually the pupil is dilated and
the iris insensible to the stimulus of light; and the former has not
its natural translucent aspect, but is dull and cloudy. But the state
of the pupil cannot be accurately determined in amaurosis, for not
unfrequently it is much contracted, and in many cases the iris retains
both its natural appearance and the full exercise of its functions.
The disease either advances to complete blindness, or stops in its
destructive progress, leaving the patient with vision impaired to a
greater or less degree. When the disease is established, pain in the
head and eyes usually either ceases quickly and entirely, or gradually
abates.

Amaurosis is sometimes temporary, occurring at regular intervals; and,
during its accession, it often varies in intensity. With some patients
strong light is intolerable, and vision is best in the twilight;
others court sunshine, finding their eyesight thereby much improved;
accordingly the former are said to labour under nyctalopia, the latter
under hemeralopia. Some can discern the shape of objects, but either
have no perception of the colours, or mistake the individual colours;
others not only see all objects indistinctively, but conceive them
distorted, double, or extensively multiplied: in some one-half of the
object looked upon is obscured—and frequently there is strabismus, in
consequence of the paralysis being only partial.

Organic amaurosis (that depending on organic disease) may arise from
the change of structure consequent on inflammatory action in the
retina, whether chronic or acute—from atrophy of that membrane and of
the optic nerve—from extravasation into the substance of the nerve, or
compression of it by morbid formations—from softening or suppuration
of the nerve and its connexions—or from various diseases of the
encephalon. Functional amaurosis may proceed from temporary plethora
about the optic nerve and retina—from intense and long continued
use of the organ—from derangement of the digestive apparatus—from
general debility, however induced—from excessive influence on the
system of poisons or powerful medicines—from concussion of the nervous
and cerebral substance, or from long continued irritation in the
neighbourhood of the eye. Amaurosis may also follow injuries of various
kinds.

In the treatment of organic amaurosis but little can be done, and that
little is unsatisfactory. In the functional form, however, vision
may be improved, if not wholly restored, by removal of the exciting
cause, and the carefully avoiding of such circumstances as seem to
predispose to the affection. After due constitutional treatment,
considerable benefit is often derived from counter-irritation;
and I have in many cases witnessed the good effects of blistering
the temples and besprinkling the raw surface with the powder of
strychnine,—a practice very far from nugatory. On removing the blister,
the cuticle and lymphatic effusion beneath are carefully scraped
away, and from one-eighth to one-half of a grain of the powder dusted
over the exposed cutis. The sprinkling is repeated daily, and the
dose gradually increased. When the surface dries, a fresh blister
is applied, and the use of the powder resumed. It may be employed,
when gradually increased, to the extent of two grains on each temple;
but, if spasmodic twitchings and constitutional disturbance begin to
show themselves, it must be immediately abandoned, and not resumed
till after some days, and even then in diminished doses. In not a few
cases, both of complete amaurosis, and of vision impaired to such an
extent that the patient could merely distinguish light from darkness, I
have by this practice succeeded in restoring the sight completely; in
others, vision has been very much improved. Still, by far the greater
number of amaurotic patients are incurable; and even those who have
derived benefit from strychnine are, I am strongly inclined to suspect,
exceedingly liable to relapse.

In the treatment of functional amaurosis, it will be necessary to
investigate minutely the causes on which the defective vision may
depend. Thus we may find a congestive state of the retina or brain,
arising from suppressed natural discharges, as the menstrual flux,
or the sudden suppression of habitual but morbid discharges, as the
healing of an old ulcer, &c.

Again, amaurosis maybe the result of irritation in some portion of the
alimentary canal, as from the presence of worms. Patients who have long
laboured under imperfect amaurosis have occasionally been suddenly
relieved by the discharge of a tape-worm. Difficult and painful
dentition in children not unfrequently gives rise to this disease.
Hence the treatment of functional amaurosis will necessarily vary with
the cause; and no general rule can, with any propriety, be laid down as
to our selection of remedial measures.


_Glaucoma_, or green cataract, is a disease of the hyaloid membrane
and vitreous humour, probably depending on a varicose state of the
bloodvessels. The pupil is usually dilated, irregularly oblong, the
iris being narrowed towards the upper and inner side. There is a
dull shining appearance at the bottom of the eye, not fixed as in
cataract, but varying according to the position of the light. The lens
becomes opaque and greenish as the disease advances, vision gradually
diminishes, and the iris is immovable. After sight is lost, the patient
has a perception of a luminous appearance in the organ when pressed
upon. Both eyes are generally affected, one after the other; headache,
often violent, attends the disease; many remedies, both external and
internal, may be tried on recommendation, though without effect: the
disease seldom, if ever, admits of cure.


_Of Cataract_, or opacity of the crystalline lens and its capsule,
attended with partial loss of vision.—The disease is, in general,
gradual in its progress: but sometimes it advances rapidly, as when
occasioned by a blow or wound. When slow, the opacity commences in the
centre of the lens, and extends gradually towards the circumference.
Before any change can be perceived in the organ, the patient sees
objects as if covered with a mist or veil; and, as the opacity becomes
distinct, vision is gradually impaired. During the day, vision is very
indistinct, as the pupil is contracted, and the rays of light reach
the retina only through the opaque centre of the cataract. But during
twilight vision improves, as then the pupil becomes dilated, and
admits of transmission of light through a portion of the transparent
vitreous humour, as well as through the semi-opaque margins of the
crystalline lens: for a similar reason, it is also more distinct after
the application of belladonna or hyoscyamus either to the eye or to
its neighbourhood. In the ordinary state of the parts, a clear black
ring is often visible around the opacity, either from the margins
of the lens being unaffected, or from the posterior surface of the
pupillary portion of the iris being pushed forwards by enlargement of
the lens. Patients, having become aware of the great improvement of
vision caused by dilatation of the pupil, are often contented to use
narcotic remedies externally, so long as they retain their dilating
influence—and, strange to say, they do not soon lose it—instead of
submitting to any operation. As cataract advances, even luminous bodies
cannot be accurately distinguished, though the situation from which the
light proceeds is perceived; thus the patient in a clear light may have
an indistinct perception of a candle or window, and in some cases even
of the bars of the window. The motions of the iris are not affected,
unless, in rare cases, when the cataract is large and compresses the
iris; or when the functions of the third pair of nerves have been
in any way impaired; or when the iris has been the seat of acute
inflammation.

Cataract may be confounded with other diseases of the eye, as with
amaurosis. But, in amaurosis, opacity, when it exists, is deep,
concave, greenish, or of a metallic appearance; whereas, in cataract,
it is of a more or less white colour, convex, and situated immediately
behind the pupil.

Cataract may be _lenticular_ only, the lens being opaque whilst its
capsule remains transparent. In such a case the disease is slow in
its progress, and the opacity uniformly commences in the centre of
the lens, and gradually extends to the circumference. The degree of
opacity varies in different cases, from cloudy dimness to complete
whiteness. In general the predominant hue is white or greyish, but not
unfrequently the opacity is of several colours, and occasionally of a
mottled appearance. The consistence also of lenticular cataract varies,
being sometimes fluid, occasionally extremely dense and almost osseous,
but most frequently of caseous consistence. When fluid, the cataract is
of larger size than the healthy lens; when caseous, the part usually
retains its former dimensions; and when dense, the lens is often
considerably diminished in size. The motions of the pupil are seldom,
if ever, affected.

Cataract may be entirely _capsular_, the capsule being opaque, whilst
the lens either remains free of disease, or has been removed by
natural or artificial processes. The opacity in this case does not
always commence in the centre, but frequently begins at the margin, and
is of a spotted or mottled appearance, and in general not uniformly
opaque. No black ring around the opacity is observed, though the
pupil be dilated; and the motions of the iris are sometimes slow. The
opaque spots are said sometimes to move when the position of the head
is changed. The anterior portion of the capsule, the posterior, or
the whole, may be affected; but the anterior is the part which most
commonly becomes opaque in the first instance.

In many cases both lens and capsule are affected; and then the cataract
is termed _capsulo-lenticular_. Occasionally the diseased lens, in such
circumstances, is of fluid consistence; and in many cases is spotted.

Portions of lymph, organised or not, lodged in the posterior chamber,
have by some been termed _spurious_ or _adventitious_ cataract; since,
when the pupil is shut by such effusion, the appearances presented are
somewhat similar to those caused by opacity of the lens, or of its
capsule. Such deposits, however, can readily be distinguished from true
cataract, being in general of a yellowish colour, in close contact with
the posterior surface of the iris, and, when organised, often streaked
with red vessels. Generally, too, the pupil is irregular from adhesions
between the lymph and the pupillary margin of the iris.

Cataract would, in some cases, appear to be hereditary,[27] and
frequently it is a congenital affection. In very young children it
may be caused by imprudent exposure to strong light. In adults it
often seems to be produced by the action of strong reflected light,
as by exposure to intense fires in forges, glasshouses, &c., or by a
dependent position of the head, accompanied with exposure to light.
People advanced in life are most subject to the disease.[29] It is not
an unfrequent consequence of internal ophthalmia, and almost invariably
follows the slightest wound or most delicate puncture of the lens: it
often occurs after slight injury of the lens or its capsule, inflicted
during attempts to form an artificial pupil. Cataract may occur rapidly
from extensive dilatation of the lenticular vessels; or from such
an injury of the eye as causes laceration of the vessels supplying
the capsule and lens, detaches them from their other connexions, and
consequently leaves them without a nutritive source.

Cataract sometimes, though rarely, disappears spontaneously, being
absorbed; but most frequently an operation is required to remove the
opaque body from the axis of vision, though no hurry is necessary
in having recourse to it. The chance of success from operation must
depend very much on the state of the different parts of the eye, on
the kind of cataract, and on the state of the constitution. Many
remedies, external and internal, and mercury amongst the rest, have
been employed with the view of dissipating cataracts; but all are
of no use. An operation, of one kind or another, only can be relied
on. And still, even in favourable cases, and in the best hands, the
contingencies attending operation are so great, that success cannot be
absolutely promised or expected. The mode of operating, and the kind
of operation, must be varied according to circumstances; and great
experience is required to determine the proper course of procedure
in each case. Steadiness is absolutely necessary both in the patient
and the operator, in order that the proceedings may be carried to a
happy conclusion. The operator must have a good eye; a steady, light,
and skilful hand; a fine touch; courage and caution—qualifications
necessary in all surgical operations, and in none more so than in those
on the eye.

When cataract is spontaneous, and vision not altogether lost, the
patient being able to distinguish bright objects, though unable to
direct his steps or follow his avocation—when the pupil is quite
sensible to the application or abstraction of light, or to the use
of belladonna, &c.,—when all the external parts are sound, the
cornea clear, the chambers of the proper size, and no reason to
suspect that the retina is affected—the prognosis in regard to the
effects of operation is good. When, on the contrary, the organ or the
constitution is not sound—when the patient is irritable in habit or
temper, or subject to gouty, rheumatic, or catarrhal complaints—when
headache has preceded the opacity, and vision is gone, or nearly so,
with flashes of light seeming to pass before the eyes—the prognosis
is very unfavourable. But even total blindness must not always be
considered as an indication of operation proving useless, for sometimes
the retina recovers its sensibility after removal of the cataract,
and thus sight has been restored in very hopeless cases. There is
no objection against operating, though one eye only is affected. By
some, operation is recommended as prudent, with a view of preventing
the opposite eye from suffering by sympathy; whilst others consider
it more safe to refrain from operating, lest violent inflammatory
action should follow, and, by extending to the other eye, cause
disease there. However, when the cataractous eye does not present
such appearances as forbid operation, I conceive it both prudent and
safe to remove the obstruction to vision, provided after-treatment is
carefully attended to, and all untoward symptoms actively combated
as soon as they appear. There is still a considerable difference of
opinion on the subject; but the patient, being anxious to get rid of
an inconvenience and deformity, often decides for the surgeon. When
both eyes are cataractous, a question arises as to operating on both
eyes at once. From my own experience I should say, that both eyes ought
not to be operated on at one time: if they are, there is great risk of
violent inflammation being established, and of the operation failing
to restore vision. Immediately after one eye has been operated on,
the other becomes very unsteady, and is altogether in an unfavourable
state for operation; and, if interfered with, the chance of a happy
result is but slight. But by operating on each eye at different times,
much less risk is incurred, and the chance of success is doubled.[30]
Cataract may be operated upon at all ages, excepting infancy and
the period of dentition. In congenital cataract, the eyes acquire
an uncontrollable rolling motion, and, if operation be delayed till
the patient has attained a considerable age, such motion cannot be
afterwards prevented. In such cases, therefore, the disease should be
attacked as soon as dentition is completed, for then an operation can
be undertaken with as little risk of injury to the organ as at a more
advanced age; and a child of twenty months or two years is unconscious
of what is intended, and can be more readily secured than at any after
period; besides the best period for education is lost if an operation
be not done early.[31]

Cataract is not remediable but by surgical operation. It may be removed
altogether by incision of the tunics of the eye, and extraction of the
opaque body; or by the introduction of a needle, it may be displaced
from the axis of vision, or so disturbed as to be acted on and removed
by the absorbents.

Operation with the needle is more generally applicable than that with
the knife, and is more easily performed. But much mischief may be done
with a needle, if the operator be not both cautious and dexterous; by
unskilful use of it many eyes have been lost.

In operations for cataract on the adult, the patient, having the eye
which is not the subject of operation covered, may be seated on a low
chair, opposite and near to a north window, in order that clear light
may be obtained. His head is supported on the breast of an intelligent
assistant standing behind. The upper eyelid is raised by the
assistant’s fore and middle fingers of the left or right hand, applied
so as to stretch the lid over the bulb; and the other hand is placed
under the patient’s chin, to steady the head. The eye may be very well
fixed by the fingers of the right or left hand of the operator himself.
He is, in that case, more conveniently placed behind or above the
patient’s head. The use of a speculum, for elevating the lid or fixing
the ball, is seldom admissible; and, if the eye be so unsteady or sunk
as to require it, the surgeon ought not to attempt extraction. No one
method can be exclusively followed; by a man of judgment, experience,
and skill, the operation will be varied according to circumstances.

The operation may be performed with the needle. The cataract is either
_depressed_ or _reclined_, and is then said to be couched. Depression
is preferred by many good authorities in surgery. The needle is
introduced at a line—or a line and a half, so as to avoid the ciliary
processes—from the junction of the cornea with the sclerotic, towards
the external canthus, and below the transverse diameter of the eye;
and the opaque lens, if solid, is entangled with the point of the
instrument, and pushed into the lower part of the ball. Thus the opaque
body is removed from the axis of vision, so as not to obstruct the
passage of rays of light to the retina; and, in successful cases, it is
highly probable that the lens, after being detached and displaced, is
altogether removed by the absorbents. Violent inflammation occasionally
takes place after the operation, followed with destruction of the
eye from suppuration; or the iris becomes paralytic; or the pupil
closes, and sight is gradually lost; or the cornea becomes flaccid,
with congestion of the vessels and turbidity of the humours. The
needle should be of a conical form, thickest towards the handle, so
as to prevent the humours from escaping during its introduction. It
should also be straight, excepting a short curvature of its point,
rather slim than otherwise, and not longer than from an inch to an
inch and a quarter. The extracts of belladonna or stramonium should
be used in all cases, previously to determining upon operations, in
order to ascertain the state of the humours, the size of the cataract,
and whether adhesion of the iris to the capsule of the lens exist or
not. Dilatation so produced is allowed to disappear almost entirely
before the operation is proceeded in. It is sometimes necessary to
steady the eye by means of a speculum, and the wire one of Pellier
is the best. By pushing the needle, held like a writing pen, gently
forwards, and towards the inner canthus, in a direction almost parallel
with the iris, its point is seen in the posterior chamber, opposite
the pupil. The instrument is then fixed in the opaque lens, and the
cataract is depressed obliquely downwards; the needle is disentangled
by a gentle twisting motion, and then withdrawn in the same direction
as it was entered. Before depressing, it is necessary to lacerate the
capsule of the lens, and this is accomplished by giving the needle a
rotatory motion, and moving its point in different directions; the
anterior portion of the vitreous humour is at the same time disturbed.
Laceration of the capsule may be too great, and allow the lens to
escape entire into the anterior chamber; inflammatory action is in
consequence excited, and subsides only when an opening has been made
in the cornea, and the offending body extracted. If the cataract
rise to its original situation on withdrawing the needle, it should
be again depressed, and kept down by the instrument for a short
time; and when the needle is then removed, its point should be very
carefully disentangled. The lens is said frequently to regain its usual
situation, a considerable time after the operation; but in many such
cases, the opacity in the pupil is not occasioned by the lens, but
by the capsule having become opaque. It is said to have arisen, when
very solid, twenty or thirty years after depression; and that in many
cases no absorption of it occurs. When the vitreous humour has become
disorganised, the lens often floats about, rising and falling with the
motions of the head.

In _reclination_, the point of the needle is placed on the upper and
anterior surface of the lens; and by raising the handle, and pushing
the point slightly forward towards the inner part of the eye, the
lens is removed from the axis of vision, placed inferior to it, and
has the relative situation of its surfaces changed—its anterior
surface becoming the upper, and the posterior the under; the superior,
posterior; and the inferior, anterior.

Solid cataracts only can be depressed or reclined. When a cataract is
fluid, it is sufficient to puncture, or lacerate slightly, the anterior
part of the capsule; as then the opaque contents will be diffused
through the aqueous humour, and soon removed by the absorbents. Should
the capsule become opaque, after the removal of its contents, the
needle must be at a future period introduced; the capsule is to be
lacerated and reduced to minute shreds, so that it may escape into the
anterior chamber. In the soft or caseous cataract, displacement is not
easily effected; and the surgeon must rest satisfied with exposing a
part or the whole of it to the action of the aqueous humour.

The above operations may be had recourse to when—from diminution of
the anterior chamber, adhesions of the iris, a morbid state of the
pupil, and the temper of the patient—extraction cannot be attempted.
When the cataract is small, it is immaterial how it is displaced;
when large and solid, reclination is to be preferred. The operator is
obliged to decide as to the mode of finishing the operation, after he
has introduced the needle, and thereby ascertained the consistence of
the cataract. If it is so soft as to permit the needle to move in all
directions, it is impossible to displace it; it must be broken up, and
left in situ.

In the mode of operation termed _keratonyxis_, the needle is introduced
through the cornea, about two or three lines from its margin,[32]
and the cataract is either depressed or broken up for solution.
Depression through the cornea is, however, an operation not to be
recommended, as the surgeon has much less command over the motion of
his instrument, necessary in this form of procedure, than where it
is introduced through the sclerotic coat. The pupil is previously
dilated by belladonna, and the dilatation should be continued for some
time afterwards. The puncture may be made at any part of the corneal
circumference; it soon heals, and leaves no scar. The operation can be
performed without much disturbance of the organ, and it is applicable
when the cataract is soft or fluid, as in children, or its consistence
doubtful. Young subjects should be placed recumbent during the
operation, and rolled up in a sheet, so that they can have no command
over their limbs.

_Extraction_, in favourable circumstances, and in dexterous hands,
is a beautiful operation, and most satisfactory; but ought not to be
undertaken unless the surgeon has perfect confidence in himself. It
can be resorted to only in adults, great steadiness on the part of the
patient being absolutely necessary. The case, too, must be judiciously
chosen. The conjunctiva must be sound, and indeed almost no operation
on the eye should be undertaken unless this membrane is in a healthy
condition; the cornea should be transparent in every part—the anterior
chamber of a proper size—the pupil regular—the iris steady, and not
protruded—and the cataract solid; there should be no rolling motion of
the eyeball, and no adhesions of the iris. I repeat, the iris should
be steady, for a tremulous motion of it indicates disorganisation
and fluidity of the vitreous humour; in such a case, the humour can
with difficulty be prevented from escaping; or the lens may fall
into the bottom of the eye, and all efforts to remove it will then
prove abortive. And though such descent of the lens should not occur,
still the organ is in a very unfavourable state for operation, being
apt to become affected with deep inflammation, followed by complete
amaurosis, or by closure of the pupil. The patient is prepared for
the operation by moderate living, and attention to the secretions and
digestive organs, for some time previously; and after the operation
leeching may be necessary either as a precautionary measure, or when
inflammation has occurred. Immediately before having recourse to any
of the operations for cataract, a small blister may be applied with
advantage behind one or both ears, and kept open for some few days,
as a precautionary measure against inflammatory action in the organ
operated upon.

The operator is usually seated immediately before the patient, and
so that his breast may be on the same level with the patient’s head;
if not ambidextrous, he may often be obliged to assume very awkward
attitudes. The recumbent position, however, is preferred by many
operators, and has the great advantage in the superior steadiness of
the head of the patient. The hand of the surgeon may also be rested on
the back of the couch, as, if ambidextrous, he will invariably take
his position behind the patient, in order that he may have the command
of the upper eyelid in his own hands. The incision is made either in
the lower or upper half of the cornea. The knife should have a very
keen edge, and become gradually broader and thicker, from its point
backwards: in using a narrow instrument there is danger of the aqueous
humour escaping. The best knife is Beer’s, well made. The light must
be good, the patient’s head completely steadied, the eye well fixed by
the fingers of the assistant, and the other one covered by a bandage.
No speculum should be employed, and the pupil should not be dilated by
belladonna. The surgeon, supporting his elbow on his knee, or resting
his fingers on the cheek of the patient, holds the knife like a writing
pen—in the right hand, if the left eye is to be operated on, in the
left, if the opposite (that is to say, if he sits before his patient:
if, however, he places himself behind, this must be reversed)—and
ascertains the steadiness of the organ by touching the cornea gently
with the side of the knife. The cornea is punctured about a line from
its margin, and near the outer extremity of its transverse diameter,
the point of the knife being directed towards the centre of the eye,
lest it should enter between the laminæ. The knife is then passed
through the anterior chamber, with its side parallel to the iris, and
its point is brought out at that part of the cornea exactly opposite
to where it entered: transfixion is thus completed, and by pushing
the knife steadily forward, without any sawing motion, a semicircular
section is effected. As soon as transfixion is accomplished, the
operator has complete command of the eye, and all pressure should be
taken off—the assistant should now merely keep the eyelid raised.
Should the edge of the knife not come easily through the cornea, its
passage maybe assisted by pressure with the finger-nail.

After the pupil has been allowed to dilate, by covering the eye for
a few seconds with the hand, the capsule must be opened sufficiently
for the escape of the lens. The eyelids are gently raised, a fine
curved needle, or curette, is introduced through the incision, and by
it a crucial wound is made in the capsule. The lens is then either
entangled in the point of the needle and withdrawn, or very gentle
pressure is made on the globe, so as to force out the lens; and, should
it not readily pass through the wound of the cornea, it can be removed
from the anterior chamber by a small scoop. After removal, the eye is
allowed to rest; then careful examination is made; and, if any opaque
substance remain, it is extracted by the needle or scoop. If the
capsule is opaque, it must be taken away along with the lens. Before
closing the eyelids the corneal flap should be carefully adjusted, and
any matter lodged between the divided surfaces removed: loose eyelashes
are to be taken away, inverted ones should be previously extracted, and
the margin of the lower lid should be so placed as not to disturb the
flap.

In transfixion, the point of the knife should not be brought out too
low, nor too much towards the centre of the cornea; and care should be
taken to avoid entanglement of the iris. When the iris falls forward so
as to come under the edge of the knife, and be in danger of division
should transfixion be proceeded in, pressure may be made on the cornea,
so that the remaining aqueous humour may repress the iris from its
untoward situation; or the knife may be withdrawn, and the operation
delayed till the eye has become quiet, and the inflammation, if any,
has subsided; or the incision may be completed with a blunt-pointed
narrow knife, or with probe-pointed scissors. Division of the capsule
by the point of the knife during transfixion has been practised; but
it is an unsafe, though dexterous, measure. In opening the capsule
care should be taken not to separate its attachments, otherwise it
will become opaque, and thereby passage of light to the bottom of the
eye will be again obstructed. Neither should much pressure be used for
extrusion of the lens; for, in the case of a large and firm cataract,
the iris may be lacerated, and the humours escape. When any of the
vitreous humour has escaped, in consequence of its cells having been
broken down, and its tenacity diminished, the eye soon fills again, but
good vision is hardly to be expected.

After the operation, applications to the eye should be very light; a
rag dipped in cold water, and renewed occasionally, is sufficient.
All stimulants of the organ, as light, should be avoided, and
antiphlogistic treatment adopted. Should violent pain supervene,
bleeding, both local and general, and other means for subduing
inflammatory action, must be had recourse to. The eyelids should not
be raised or exposed for at least three days, unless in extraordinary
circumstances. Belladonna is of use when gradual contraction of the
pupil occurs. In very favourable cases, vision is completely restored
in the eye; in others, the functions of the two eyes do not correspond,
and vision is confused: the patient requires to wear a convex glass
before the one which has been operated on.

[Illustration]

The operation of making an _artificial pupil_ is far from being
uniformly successful, and ought not to be had recourse to unless vision
is entirely lost, or so much impaired as to be insufficient for the
guidance of the patient’s steps. It is necessary on account of central
opacity of the cornea—leucoma with entanglement of the iris—and entire
closure of the pupil, or diminution of it, with concealment of the
remainder by corneal opacity. It may be required after badly performed
extraction of a cataract, the iris being entangled in the scar of
the incision, at a distance from the junction of the cornea with the
sclerotic; or on account of closed pupil from inflammation, when,
perhaps, the cornea is all clear. The operation is varied according
to the size of the anterior chamber, the presence or absence of the
crystalline lens, the extent of sound cornea, and the condition of the
iris. Interference is useless when disease of the retina is suspected,
from the extent of the previous disease—from violent inflammation, with
or without discharge of part of the contents of the eyeball. Three
distinct methods of operation are pursued.

[Illustration]

I. Simple division of the iris, or _corotomia_, may be practised
when the iris is stretched, as after extraction. It is performed by
introducing a small knife, like a needle, through the anterior or
posterior chamber,—the surgeon being in this regulated by the size of
the anterior chamber and the presence or absence of the lens,—pushing
its point through the iris, or cutting that membrane vertically,
horizontally, or both, to an extent sufficient for the transmission of
light. If the anterior chamber be of its natural size, a small opening
may be made in the cornea with a cataract knife, or a double-edged
broad and thin one; and through this opening small scissors may be
introduced for division of the iris.

II. _Corectomia_, or cutting out a portion of the iris, so as to make
the opening oval, square, or angular. This is performed by introducing,
through an aperture in the cornea, scissors and forceps, or hooks,
double or single—the latter to lay hold of the iris, the former to
divide it. After the escape of the aqueous humour, a portion of the
iris may be made to protrude; and, on the projecting portion being cut
off, the membrane, with a proper opening in it, regains its natural
situation, in consequence of discharge of the humour from behind.
This operation is applicable only in few cases; the whole, or the
greater part, of the cornea must be clear, and the anterior chamber not
diminished in size, so that sufficient room may be afforded for the
introduction of instruments between the iris and the concave surface of
the cornea.

In those cases where the natural pupil remains along with a still
transparent lens, while vision has been destroyed by a central opacity
of the cornea, the use of sharp and pointed instruments is forbidden.
Sharp hooks or scissors would endanger wound of the crystalline, and
the case becoming complicated with traumatic cataract. The blunt hook,
as proposed and used by Mr. Tyrrell, is here to be preferred. A small
opening is made through the cornea, as the most convenient part, and
the hook carefully introduced and entangled in the existing pupil: the
iris is then drawn to the corneal wound, and either left entangled in
the section, or removed by a pair of curved scissors. A pupil is thus
formed opposite to the remaining transparent portion of the cornea.

III. _Corodialysis_, or separation of the iris from its ciliary
attachments, is the method most easily performed, and most generally
applicable. The eye is fixed either with the fingers or with a
speculum; and a curved needle, perhaps more curved than that usually
employed for cataract, is introduced either behind or before the
iris, and at the upper, outer, inner, or lower part of the ball, as
circumstances may require. An artificial pupil at the lower part is by
much the most useful; but, if the lower part of the cornea is opaque,
it must be made opposite to the inner or outer clear part. The point
of the needle is entangled in the attached margin of the iris, and by
raising the hand quickly, and partially withdrawing the instrument, the
connexions are separated to a sufficient extent. Effusion of blood into
the chamber, and to a considerable extent, follows these proceedings;
and it is only after its absorption that it can be ascertained whether
benefit is likely to result or not. After all these operations,
inflammatory action requires to be kept down by antiphlogistic
measures, abstraction of blood, purgatives, antimonials, and, perhaps,
mercurial preparations. It is questionable whether belladonna can be
useful in preventing closure of an artificial pupil.


_Wounds of the Eyeball and its Neighbourhood._—Wounds near the eye,
though unimportant in themselves, require considerable attention,
on account of the eye, or its appendages, being likely to suffer in
consequence. Thus, transverse wounds of the forehead or eyebrow,
if their edges be not approximated accurately and soon, may cause
prolapsus of the eyelids; or the eyelids may become swollen and turgid,
or erysipelatous, in consequence of inflammatory action attacking the
wound. When wounds of the forehead are in a perpendicular direction,
their margins are easily preserved in apposition, having little
tendency to retract, and there is no risk of the relative situation of
the eyelids being altered. If there be considerable loss of substance
in the lower part of the forehead, from the nature of the wound, when
inflicted, or from its having become the seat of unhealthy suppuration,
on cicatrisation of the part the eyelid will be drawn upwards, and
perhaps more or less everted. There is reason to believe that a
degree of blindness, and even complete amaurosis, has been caused by
wound of the eyebrow, the superciliary nerve having been contused,
wounded, or otherwise injured; or the functions of the eyeball may be
disturbed by concussion from injury. Paralysis, also, of the levator
palpebræ superioris, or of several of the muscles belonging to the
eyeball, may follow injury of the forehead and neighbouring parts,
from either laceration or concussion of the nerves. Wounds of the
eyelids, particularly when neglected, may cause much change of relative
situation in the parts, and thereby produce both inconvenience and
deformity. In some instances, the relative position of the puncta
lachrymalia is altered by the cicatrices of the eyelids or tarsal
cartilages, when the original wound has been imperfectly adapted: hence
results an incurable epiphora.

In wounds, such as those above mentioned, it is of great importance
to bring the raw edges into contact, and retain them so; and, in most
cases, one or more points of interrupted suture are necessary. Adhesive
plaster may be at the same time applied, but of itself is insufficient
to effect permanent coaptation.

Wounds of the eyeball, however slight, require much attention, being
inflicted on an important and highly sensible organ, and there being
always a risk of destructive inflammatory action. If the breach of
surface be clean, simple, and superficial, rest of the parts will in
general be sufficient to effect a cure. Lacerated wounds, and such
as penetrate into the interior of the eyeball, cannot be expected to
heal without morbid action having been excited: inflammation must be
anxiously looked for, and actively combated as soon as it appears.
When a foreign body lodges in the wound, it must be early removed.
But in certain cases it is imprudent to attempt extraction of foreign
matter; as when a small shot, or other minute substance, has lodged
in the interior of the eyeball. In such circumstances we can only
adopt such measures as prevent and subdue morbid excitement. The
organ may remain little disturbed for a short period, but violent
inflammatory action soon occurs, and, though subdued for a time,
again breaks forth, and, by its successive attacks, may ultimately
destroy the eyeball. Frequently all endeavours to avert untoward
results are unavailing, and the functions of the organ are more or
less impaired—the cornea may become opaque, the iris may protrude, the
pupil may become irregular, contracted, or obliterated—the crystalline
lens may lose its transparency, amaurosis may occur from injury of the
retina, the humours may be evacuated, and the eye sink in its socket.
The entrance of a large foreign body into the orbit may displace the
globe, and cause it to protrude between the eyelids: in such a case
the body should be removed and the ball gently replaced; vision may be
soon regained; but, if the protrusion has been such as to cause much
stretching of the optic nerve, blindness more or less complete remains.
Fatal effects may follow wound of the eye, on account of the foreign
body, as a sharp-pointed instrument, penetrating the thin parietes of
the orbit, splintering the bone, and injuring the brain.

_Orbital Inflammation._—Inflammation seldom attacks the parts situated
between the orbit and the eyeball; but, when it does, the affection
is very serious. The action is very acute, and proceeds rapidly to
suppuration. The pain is excruciating, extends to the whole head,
accompanied with a sensation of extreme tension in the orbit, and is
much increased by the slightest motion of the eye: and from the matter
accumulating around the ball, and being confined to the unyielding
orbit, by the dense fibrous expansion which extends from the margin of
the orbit to the interior surface of the eyeball, the globe is pushed
forwards, and distends the lids. The palpebræ become erysipelatous,
and swollen by serous effusion. Violent inflammatory fever occurs;
and, as the disease advances, all the symptoms are aggravated, and
become almost intolerable. The globe is farther protruded, and the
retina is insensible to light. At length the accumulated matter makes
its way to the surface, and is discharged, giving great relief to the
patient, and permitting the protruded globe to regain its situation.
The inflammation seldom extends to the eyeball.

In the early stage of this affection, the most decidedly antiphlogistic
measures are imperiously called for. When fluctuation can be felt,
or when the symptoms indicate that suppuration has taken place,
whether fluctuation is perceptible or not, an early opening into the
affected part should be made through the dense orbital ligament. Thus
a free exit is allowed for the matter, the patient is instantaneously
relieved, and the extent of the local mischief is limited. It is unsafe
to wait for the spontaneous evacuation of the matter: such a process
is necessarily tedious, and, before it has been accomplished, the
orbital bones may have become diseased; they may have given way at
certain points, and the matter may have escaped within the cranium. The
artificial opening should always be free, and deep if necessary.

_Tumours in the Orbit._—Sarcomatous tumours occasionally form in the
cellular tissue of the orbit. They occur at all periods of life, and
may, by slow and gradual increase, cause the eyeball to protrude and
disturb its functions; or their growth is rapid, and accompanied with
great suffering. In some cases, the eye is made to protrude to a great
degree, and by the extension of the optic nerve vision is impaired;
in others, the patient is totally blind at the commencement of the
disease. Yet the eye may be displaced to no small extent without
amaurosis following. The optic nerve appears to bear a good deal of
extension without disturbance of its functions. The majority of tumours
in this situation are of rapid growth, their structure is soft and
medullary, they sooner or later furnish a fungus, and, though removed
at an early period, are generally reproduced. The exophthalmos is often
the first indication of such a growth, and it is sometimes greater in
the early part of the disease than afterwards, when the fascia passing
down from the edge of the orbit has given way. The malignant tumours
are most frequently met with in childhood, though morbid growths of a
bad kind form in the eyeball at different periods of life. They often
follow the infliction of a blow or wound. The patient’s sight speedily
declines, without any known cause; there is pain in the forehead,
temple, and eyeball; the ball protrudes, perhaps slightly, and at
first is not otherwise changed; but on careful examination a dimness
can be perceived deep in the eye. The opaque body approaches the pupil
and fills it, and may in this state be mistaken for disease of the
crystalline lens; but the tumour soon pushes forward the iris, and
fills the anterior chamber. It has an irregular surface covered with
flocculi. Blood-vessels are observed ramifying on it, and by this it
is distinguished from cataract, should the accompanying symptoms not
have previously convinced the surgeon of the nature of the disease.
If not interfered with, the cornea ulcerates, a fungus appears, often
grows with great rapidity, and may either furnish not a drop of blood,
or bleed profusely. The eyelids are œdematous and permeated by large
venous branches. Abscesses form around; the lymphatics of the neck are
involved; and the patient succumbs. The original tumour may possess the
usual structure of medullary sarcoma, may be of a melanotic nature,
or may contain a mixture of both; or it is of harder consistence,
containing cells filled with bloody, glairy, or other fluid. The
whole coats of the eye are seldom involved: part remains sound, but
compressed and disfigured by the morbid mass, and the humours are
either absorbed or discharged.

Circumscribed tumours, exterior to the ball, and surrounded by a
cellular cyst, may be removed by careful and cautious dissection,
without injury to the important parts. A free incision is made along
the edge of the orbit, in the course of the fibres of the sphincter
oculi. The tumour is exposed, laid hold of with a hook or small
vulsellum, and separated from its attachments by a knife, the edge of
which is directed towards the new growth. A man, aged 26, had laboured
under blindness with exophthalmos for eighteen months. A tumour could
be felt above the eyeball, which I dissected out, along with the
lachrymal gland, to which it adhered. It was of medullo-sarcomatous
structure, and of the size of a plum: at one point it contained a mass
of coagulated blood. After its removal, the eye resumed its place and
functions. The patient remains well; but such favourable cases are rare.

If the affection be more extensive, it may be necessary to remove
all the contents of the orbit: but, in disease involving the entire
structures, there is little chance of the patient remaining free from
it: it almost uniformly returns, as is also the case whenever the
disease has commenced in parts of the eyeball. The optic nerve is
often affected at an early period: its cut surface is unsound; and
from this, again, springs a fungus which grows rapidly. But under many
circumstances the surgeon is not only justified in removing the orbital
contents, but called upon to do so. The operation, though cruel and
painful, need not be tedious. The commissure of the eyelids is divided
with the point of a bistoury, and the forepart of the ball laid hold
of firmly and deeply with a vulsellum—that is, forceps provided with
a double hook at each extremity of the blades. A straight bistoury
is then entered at the margin of the orbit, pushed down to the base,
as near as possible to the entrance of the optic nerve, and carried
round the tumour rapidly, the blade towards the handle being made
to move more quickly than the point. The nerve is cut across, and,
after the removal of the morbid mass, the cavity is sponged out and
examined. The lachrymal gland, and other soft parts, particularly if
altered in texture, are raised with a hook, and removed by means of
curved scissors. In young subjects, and in adults, when the disease
is far advanced, the parietes of the orbit are thin, softened, and
attenuated by pressure: the knife should therefore be used cautiously,
and it is, perhaps, safer to finish excision with a narrow, curved,
and probe-pointed bistoury, after having penetrated to the bottom of
the orbit with a sharp-pointed knife: all other curious and crooked
knives are useless. Bleeding is restrained by charpie, pressed firmly
and quickly into the cavity, and supported by compresses and bandage;
but, before introducing the dossils, all coagula and fluid blood should
be carefully sponged out. Afterwards, excited vascular action, with
pain in the head and wound, may in some subjects require abstraction
of blood, the exhibition of purgatives and antimonials, and immediate
removal of the dressings, followed by fomentation and poultice. When
matters proceed favourably, the charpie is removed gradually as
suppuration advances, and the granulations are supported with light
dressing, either dry, or moistened with some slightly astringent
lotion. The discharge will gradually cease, and the granulated surface
cicatrise under the level of the eyelids. In such circumstances the
deformity may be remedied, after the parts have become quiet, by the
adaptation of an artificial eye of enamel, made so as to resemble
exactly the other eye. It is worn without inconvenience, removed at
night like artificial teeth or a wig, and cleaned and replaced in
the morning. Such a substitute is also useful when the humours have
been evacuated, or the organ destroyed, by injury or the effects of
inflammation. Too frequently the morbid growth is reproduced, and that
rapidly. It may be restrained by escharotics, the red oxide of mercury,
potass, acetate of lead, acids, or the actual cautery; but the patient
is thereby put to much pain without a chance of ultimate benefit.

It is too true, that the hopes of a cure, after the extirpation of the
eyeball for malignant disease, are defeated by the prior existence
of a similar affection within the cranium. In the majority of cases,
death has occurred from tumours of greater or less extent, along the
course of the optic nerve, or their tract: behind the commissure, and
extending to the optic lobes and even cerebellum.


[STRABISMUS.

Strabismus, or squint, as it is vulgarly designated, may be defined
to be an aberration from the natural direction of the optic axes, by
which the consent between the eyes is destroyed, and vision more or
less impaired. The resulting deformity varies in different cases,
from the slightest possible cast to the most disagreeable obliquity.
The affected organ may be turned inwards or outwards, upwards or
downwards, according to the muscle upon the derangement of which
the squint depends. When the eye is directed inwards, it constitutes
what is called convergent strabismus; if, on the other hand, it
inclines outwards it is said to be divergent. The upward and downward
obliquities have not received any particular names. As might be
supposed, these different forms of strabismus do not occur with equal
frequency. On the contrary, two of them are so rare that I have not
yet met with an instance, though I have examined the eyes of a very
considerable number of persons labouring under this infirmity. These
two forms are the upward and downward, both of which, but especially
the latter, are so seldom witnessed that their occurrence may well be
doubted, except as the result of external violence.

The most common variety of strabismus by far is the convergent, in
which the eye is directed inwards, or inwards and upwards. Of 536
cases collected from various sources by a writer in the Philadelphia
Medical Examiner, 506 were of this description, a proportion which
fully accords with my own but more limited observation. The degree of
obliquity may be very moderate, or so great that when the person looks
directly forwards with the sound eye the cornea of the other shall be
almost entirely concealed at the inner canthus. It is worthy of remark,
that in this form of the lesion, at least so far as my own experience
goes, the organ rarely, if ever, inclines downwards, but nearly
constantly somewhat in the opposite direction.

Next in point of frequency is the divergent form, which, however, is
comparatively rare. Of 866 cases reported in the work above alluded
to, it was noticed only forty-four times; and thus far I have myself
seen only three or four examples of it. The eye in this variety of
strabismus is seldom drawn out very far, nor is it so apt to be
attended with the same amount of upward obliquity as the convergent.

It seems to be the general sentiment of writers on strabismus, that, in
the great majority of cases, only one organ is affected. Thus, in the
article in the Philadelphia Examiner, before adverted to, it is stated
that the distortion occurred 459 times in one eye, and only 47 times
in both. Dr. Dix, of Boston, in a small treatise on strabismus, makes
a similar remark. Of 50 cases which fell under his notice, the lesion
is said to have been limited to one eye in 36. Now I am convinced from
a good deal of experience that nothing can be more unfounded than this
opinion, which is to be deprecated the more because it is calculated to
lead to very serious errors in practice. I unhesitatingly assert, that
in nearly all instances, at least of convergent squint, both organs are
implicated, though not in an equal degree. Usually—perhaps always—one
is more affected than the other, which the patient, therefore, regards
as his good eye, as it is the one which he constantly employs in
viewing objects. Nor is it surprising that this should be the case,
when we recollect the remarkable sympathy existing between these
structures, and the fact that when one eye is diseased the other is
very liable to take on morbid action also. Amaurosis of one eye is very
often followed by a similar malady of the other, and the same is true
of cataract and some other affections. In the natural state there is a
perfect agreement between the optic axes, produced by the harmonious
action of the straight muscles, but when this consent is destroyed,
as it is in strabismus, the eyes lose their parallelism, and the
distortion in question is the consequence.

As was previously intimated, one eye is commonly more affected than the
other, and this, if I mistake not, will be found to be the left, though
it is impossible, in the existing state of the science, to indicate
the proportion. Mr. Lucas thinks that the proportion in favour of the
left eye is as three to two; Dr. Phillips of Liège, on the other hand,
maintains that the right organ is more frequently involved than the
other. It rarely happens that both eyes become deranged simultaneously;
on the contrary, one generally squints first, and after a while the
lesion begins in the other, the interval being probably very short.

Whether strabismus occurs with equal frequency in both sexes, is still
an unsettled question. Of thirty-two cases on which I have operated,
only five were females, whereas in the fifty cases published by Dr.
Dix, of Boston, only nineteen were males, thus exhibiting a most
remarkable disparity in reference to this point. The difference, if
any, is perhaps not great either way, and, as it is of no practical
importance, it need not be pursued any farther here.

The exciting causes of this affection are numerous and diversified. One
of the most frequent is imitation. Nearly one-seventh of all the cases
that occur are probably induced in this manner. Hence our schoolrooms
may be regarded as a fruitful source of mischief, one cross-eyed child
being often the cause of strabismus in many others, merely from that
habit of imitation to which the young are so much addicted. Ophthalmia,
by whatever cause induced, is another, and that a very common source
of this distortion. I have seen repeated instances of this kind, and
many others are mentioned by authors. Convulsions, eruptive diseases,
such as measles and scarlet fever, hooping-cough, derangement of the
digestive organs, injury on the eye, and difficult dentition, may all
be enumerated as so many causes of the lesion in question. Frequently
it arises without any assignable reason, and when the individual is in
the most perfect health. Occasionally it is congenital, or, what is
more probable, makes its appearance within a few days after birth.

It is supposed that strabismus is occasionally hereditary. This is
doubtful; for if we sometimes meet with cross-eyed children whose
parents, one or both, are similarly affected, it by no means proves
that the distortion was transmitted to them in the manner of certain
maladies. It only shows a coincidence, which may be explained, in
most instances, on the assumption that the children have acquired
the obliquity by imitation, or by some other cause, not that it was
entailed upon them previously to birth. In the same manner we may
satisfactorily account for the existence of strabismus in several
members of the same family, of which a remarkable instance has recently
come under my own observation. Of three brothers, one has three
children affected with it, another two, and a third one. The parents
have all sound eyes, and so have the uncles and aunts, except one,
on whom I operated successfully several months ago. Last autumn I
operated for cataract on three children belonging to a gentleman from
Mississippi, who informed me he had six others at home, of whom three
were affected with strabismus. Both parents, as well as their immediate
relatives, are free from the affection.

Strabismus essentially consists in a contracted state of one or more
of the muscles of the eye. This, as was before intimated, is commonly
the internal rectus. The shortening, varying according to the extent
of the squint, is always attended with a corresponding elongation of
the opposite muscle, so that it gradually loses, either in whole or
in part, its antagonising influence. How this affection is brought
about, in the first instance, is still unknown, though it is probable
that it depends upon some lesion of the nerves which supply the
muscles of the eye, rather than upon any actual lesion of these fleshy
bundles themselves. Be this as it may, when the resultant distortion
is permanent, the affected muscle, from being constantly engaged in
holding the eye in its unnatural position, acquires a corresponding
degree of development, in accordance with a law of the animal economy
that, in proportion as an organ is exercised, will be its size and
strength. The more frequent occurrence of convergent strabismus is
owing, doubtless, to the fact that the internal straight muscle is not
only larger and stronger than the others, but that it is inserted much
nearer the cornea, deriving thus two important mechanical advantages.

One of the most disagreeable effects of strabismus is the deformity
to which it leads, rendering the individual an object of constant
observation and ridicule. Were this confined to infancy and childhood,
it would be of comparatively little consequence, but when we reflect
that it continues through life, and that it is a source of incessant
mortification, the influence which it exerts upon the temper and
disposition of the sufferer must often be of the most unhappy kind. A
still more serious effect, however, is the impairment of the vision
of the affected eye, which, never entirely absent, sometimes amounts
nearly to a total loss, from the insensibility of the retina, which is
sometimes as complete as in confirmed amaurosis. In another series of
cases the person is myopic, or sees objects only at a short distance.
In some instances, again, there is double vision, or objects appear
indistinct, and run as it were into each other, the image painted on
the retina being confused and imperfect.

The distortion in question can be remedied only by a surgical
operation, it having no tendency to a spontaneous cure. On the
contrary, it generally manifests a disposition to increase,
particularly in children of a nervous, excitable temperament. In fact,
the very worst forms of squint I have ever witnessed were in persons
of this description. The question then arises, at what age ought we
to operate? My opinion decidedly is the sooner the better. Provided
the child be in good health, and not under one year of age, I would
not hesitate a moment to resort to the knife for its relief. And why
should we? The operation itself is not particularly painful, and if it
be done at an early period it will commonly be necessary to perform
it only on one eye, whereas if it be postponed until the age of ten
or twelve, as some have suggested, we shall not be able to effect a
cure without dividing the corresponding muscle of the opposite side.
Moreover, the sight in the meantime will become considerably impaired,
the retina will lose its insensibility, and the individual be an object
of ridicule and insult; all of which may thus be obviated. But it may
be urged that a resort to the knife at this tender age will be both
difficult and dangerous; difficult, because of the struggles of the
little patient, and dangerous, because of the great susceptibility of
the nervous system. In regard to the first of these points, it may
be stated that the resistance, however great, may be easily enough
surmounted by proper management; and, as it respects the latter,
that it has been vastly overrated. Operations much more severe are
frequently performed even at a much earlier period. I have seen the
primitive carotid artery successfully tied in an infant of less than
six months; and I have myself repeatedly operated, with similar
results, for harelip, and that too in the very worst forms of that
malformation. I do not, therefore, in these objections, see sufficient
reason for deferring the division of the affected muscle.

The instruments which I employ for the operation, are two lid-holders,
a double sharp-pointed hook for fixing the eye, a pair of dissecting
forceps for pinching up the conjunctiva, and a scalpel or pair of
scissors. The surgeon should also be provided with two or three small
sponges and a basin of cold water.

The lid-holders (Fig. 1.) are each about six inches long, made of steel
with an ivory handle, quite slender, and curved at the extremity, which
is fashioned after the manner of a fenestrated speculum, and not more
than a third of an inch in width. These instruments may be conveniently
replaced by a common speculum and the fingers of an assistant: still,
they are very useful, and I prefer them to any other contrivance. The
hook for fixing the ball is double (Fig. 2.), resembling that contained
in some of the older eye-cases. It ought not to exceed five inches in
length, and should be provided with a movable slide, to allow of the
proper separation of the branches, each of which, two lines in width,
terminates in a short hook as delicate as the finest needle. The
forceps need not be quite the ordinary size; and, as to the scissors,
the common pocket-case pair will answer the purpose much better than a
curved or more delicate instrument. The knife I rarely use. A curved
director (Fig. 3.) is serviceable, as it enables the operator to judge
of the extent of his incisions.

[Illustration: _Fig. 1._]

[Illustration: _Fig. 3._]

[Illustration: _Fig. 2._]

In performing the operation, the patient may be either in the
semi-erect or reclining posture, with his head supported by an
assistant, or properly elevated by pillows. I generally prefer the
latter, as the eye is more manageable, and the patient less apt to
faint than when sitting. The face should look towards the light, and
the sound eye be covered with a bandage, to enable the patient the
better to roll the other outwards. If the surgeon be ambidexter, it
does not matter where he stands: but if he uses one hand more adroitly
than the other, he should place himself on the right side when he
wishes to operate on the left eye; and, conversely, on the left if he
wants to operate on the right. Only two assistants are necessary; one
of whom, standing at the head of the patient, elevates the upper lid,
and fixes the eye by inserting the sharp hook into the sclerotic coat,
about two lines behind the cornea: the branches of the instrument
being separated one-fourth of an inch, and the interval between them
accurately corresponding with the horizontal axis of the eye. This
precaution is important, and should never be neglected, otherwise it
will by no means be so easy to find the affected muscle. The points
of the hook should be fairly implanted into the substance of the
sclerotic tunic, but no more. If it be passed simply through the
conjunctiva, it will be impossible to steady the eye, to say nothing
of the danger of lacerating that membrane, and thus inflicting
unnecessary pain upon the patient. On the other hand, if it be pushed
through the fibrous coat, violent inflammation might be set up. The
other assistant, placed on the side of the affected eye, depresses the
lower lid, and hands the sponges to the operator. It is sometimes more
convenient to let this assistant steady the eye.

[Illustration]

Everything being thus arranged, the operator pinches up a small fold of
the conjunctiva, just behind the hook, or, in other words, about three
lines behind the cornea, and makes a vertical incision into it with the
knife or scissors, as he may prefer. Relinquishing the forceps, the
edges of the wound will at once retract, exposing thereby a surface
from four to six lines in length by two or three in breadth. At this
moment there is usually some degree of hemorrhage, amounting often to
more than half a teaspoonful, especially if the incision has been made
too far back near the semilunar valve, where the parts are always more
vascular than further forward. To arrest this a small sponge, pressed
out of cold water, should be repeatedly applied; or, if it prove
troublesome, the operation may be suspended until it ceases. The ocular
fascia[33] is next divided, when the muscle, now fairly exposed, is to
be cut across with the scissors, one of the blades of which is passed
behind it. The moment this is accomplished, the eye, from the force
exerted upon it by the hook, springs towards the opposite side, and the
muscle retracts within its sheath, especially if it has been thoroughly
liberated from its connexions with the surrounding parts. To effect
this, which I regard as of paramount importance, the scissors should be
carried for some distance around the ball, nearly as far, indeed, as
the margins of the adjacent straight muscles.

As soon as the affected muscle is divided, the eye usually at once
resumes its natural position in the orbit, moving, if the other be
sound, in perfect harmony with it. Occasionally, however, it retains
some degree of its original obliquity; in which case it becomes
necessary to reapply the instruments, to ascertain the cause of it.
This will generally be found to depend upon an imperfect division of
the muscle, or of the surrounding cellular tissue, by which the muscle
is prevented from retracting sufficiently within its sheath. In some
instances it remains without any assignable cause, but rarely beyond a
few minutes, or, at farthest, a few hours.

The operation being over, the eye is bathed in cold water, to rid it of
any blood that may remain in the wound, and the patient is confined in
a dark apartment. Low diet should be enjoined for a few days, and, if
inflammation arise, recourse must be had to antiphlogistic measures. In
no case have I yet been obliged to abstract blood; a dose of aperient
medicine being all that was required. Locally cold or tepid water may
be used, as may be most agreeable to the patient’s feelings. When there
is a good deal of pain in the eye, with more or less constitutional
disturbance, such as slight shivering, headache, and nausea, warm
drinks and an opiate will be required. The ecchymosis which attends
this operation, and which is sometimes considerable, demands no
particular treatment: no inconvenience arises from it, and it commonly
disappears in a few weeks. I have never known suppuration or abscess
to follow the division of the muscles of the eye; such an occurrence
implies unusual violence, and cannot be too much condemned. The same
remark is applicable to the wounding of the sclerotic coat, and the
escape of the humours of the organ; an accident which has happened
several times in the hands of ignorant bunglers.

A few hours after the operation is completed, the margins of the
incision become coated with coagulating lymph, which is sometimes
effused in such quantities as to give rise to considerable pain, and
a sensation like that produced by the presence of a foreign body.
The vessels in the parts around are somewhat enlarged, there is more
or less lachrymation, and the lids feel stiff and uncomfortable. The
sclerotic coat at the bottom of the wound remains visible for five or
six days, when it becomes covered with granulations, which, uniting
with those at the sides, gradually fill up the gap; the whole process,
from the commencement to the completion of the cicatrization, occupying
from three to four weeks.

Now and then the process of cicatrization is retarded by the
development of fungous granulations. When this is found to be the case,
they should be snipped off with the scissors; a procedure decidedly
preferable to the application of the nitrate of silver, which is not
only painful but rarely effective.

It has been recommended by some surgeons that, as soon as the soreness
occasioned by the operation has subsided, the patient should begin to
turn his eye in a direction opposite to that in which it was held by
the contracted muscle, and that these efforts should be continued daily
until it regains its natural position in the orbit. In my early cases,
before I had devoted much attention to the subject, I adopted and acted
upon this suggestion, but the result in every instance disappointed me.
Nor do I now perceive any good reason for following it, since it does
not seem to me to be founded upon correct principles. Where the eye
still retains some degree of obliquity after the operation, it may be
positively assumed that the section of the affected muscle, or of the
fasciæ by which it is invested, has been imperfect; and when this is
the case it would be in vain to expect Complete success. Again, the eye
operated on may be entirely straight, and yet not move in concert with
the other. This I have witnessed repeatedly, and hence my invariable
rule is to divide at once the corresponding muscle of the opposite
side, for the reason already mentioned—that the distortion generally
involves both organs.

The operation for strabismus is liable to occasional failure, the
principal causes of which may be thus enumerated:—1. Imperfect section
of the affected muscle, or of the ocular and submuscular fasciæ. To
this subject I have already several times alluded, and it is not
necessary, therefore, to offer any further remarks concerning it in
this place, than to say that the operator should never neglect to
divide these structures most thoroughly. In bad cases the scissors must
be carried up and down as far as the contiguous straight muscles, so
as to denude completely the sclerotic coat for more than one-third of
its circumference. The fasciæ must be effectually raked up, otherwise
it will be impossible for the muscle to retract fully within its
sheath. 2. Excision of a portion of the conjunctiva, eventuating in
contraction of this membrane during the process of cicatrization, may
be stated as another cause of failure. As there can be no necessity for
such a procedure, since it does in no wise facilitate the operation,
I need hardly say that it should be studiously avoided. 3. Strabismus
is sometimes complicated with other diseases, such as convulsions,
epilepsy, hydrocephalus, and analogous lesions. When this is the case,
the operation cannot be performed with any prospect of success, and
had better be declined altogether. The existence of amaurosis does
not necessarily lead to failure; if cataract be present, it should be
broken or depressed either at the time of the operation or before. 4.
But the most powerful cause of all, in my opinion, and one which has
not been sufficiently insisted upon by writers, is the coexistence of
strabismus in both eyes, and the fact that our operative procedures
are usually limited to one of these organs; a circumstance at variance
alike with good practice and common sense. In several instances in
which only partial success attended my efforts, the whole difficulty
was fairly ascribable to this cause; and so thoroughly am I persuaded
of its importance, that I have laid it down as a rule never to
operate on one eye only when it is certain both are affected. The
only exception to this is where the patient is very young, when the
section of a single muscle will sometimes, though even then not always,
be sufficient. 5. A fifth cause of failure is the readherence of the
posterior extremity of the muscle to an unfavourable point of the
sclerotica, by which it is again enabled to exert an undue influence
over the movements of the eye. The manner of obviating this occurrence
has been already indicated.

The effect upon vision is at first rather disagreeable, at least in
some instances. It is only by degrees that the affected organ recovers
its functions, and in many cases a considerable period must necessarily
elapse before this is brought about. Occasionally, in fact, the retina,
from long disease or other causes, is so effectually paralysed that the
sight is never restored, and it is in instances of this description
that a slight return of the distortion may be looked for, however
well the operation may have been executed. Another effect sometimes
witnessed is double vision. This is obviously dependent upon a want
of agreement between the optic axes, and rarely lasts more than a few
days, unless the obliquity has been only partially remedied.

The only other effect which it is necessary to notice here, as
attendant upon this operation, is a peculiar prominence of the eye.
This is generally well-marked, though not equally so in all cases, and
imparts to the organ a full, bold expression; it is accompanied with a
considerable separation of the lids, and is caused by the liberation of
the organ from its confined situation.

The preceding remarks have special reference to convergent strabismus;
with slight modifications they are applicable to the other forms of the
lesion. From the more exposed situation of the eye the outer straight
muscle is much more easily approached and divided than the internal;
as to the relative facility of operating on the upper and lower, I
can say very little from personal experience, but should suppose the
difference, if any, to be trifling. As to the oblique muscles, I have
not had occasion to divide them in a single instance, nor should I,
from the knowledge I have on the subject, deem such a step necessary,
it being very doubtful whether they have any agency in the production
of strabismus. In several instances in which these fasciculi were
divided by Lucas, Calder, and others, no impression whatever was made
upon the distortion, and nearly all surgeons agree in the opinion that
they should not be interfered with.

Attempts have been recently made to disparage the operation for
strabismus, on the ground of the alleged tendency of the eye to return
to its original malposition, or the occurrence of a new deviation. No
proof, however, of such a result, founded upon an adequate number of
statistical facts, has been given to the profession. In my own cases,
so far as my information extends, not a single relapse has taken place
where the operation was performed on both eyes, although nearly a year
has expired since some of them submitted to it. Confirmatory of this,
it may be stated that Dr. F. B. Dixon[34] of Norwich, England, has
recently published a list of forty-one cases of convergent strabismus,
in thirty-one of which, twelve months after the division of the
internal rectus, both eyes were perfectly natural; in five, where one
organ alone was operated on, there was slight obliquity of the other;
in two, the squint was changed to a leer, and in three others, the eye
returned to its former malposition. These results, which are in the
highest degree gratifying, are sufficient to show that the operation
in question, first performed by Professor Dieffenbach of Berlin, in
October, 1839, deserves to be classed among the established resources
of surgery, which rarely exhibits such an amount of successful
terminations.]


_Of Nasal Polypi._—These tumours vary in texture and disposition, as
formerly stated: but the soft mucous or benign polypus is, fortunately,
by much the most frequent. Generally a great many coexist in one
or both nostrils, growing from different parts of the Schneiderian
membrane. Sometimes there is but one tumour, of a large size; and
in some cases a large cyst, containing colourless fluid, fills the
nostril. When numerous, they are in different stages of growth, and
generally adhere to the membrane by a narrow neck, though sometimes
several are attached by the same pedicle. It is not uncommon to remove
ten or twelve polypi, or even a greater number, before the nostril is
cleared. The parietes of the narrow passage betwixt the anterior and
posterior nares is their most common situation, though their bases may
proceed from the cells of the superior spongy bone.

The membranous covering of the inferior spongy bone, or of the anterior
cavity of the nostril, is often at the same time relaxed: indeed, this
of itself causes slight obstruction to the passage of air, and may be
mistaken for polypus by the patient and the unexperienced. Projection
of the cartilaginous septum to one side, with thickening of its
covering, may also give rise to the same mistake. This formation is not
uncommon, indeed it is rather frequent; and the projection is generally
to the left side, with corresponding depression of the right. The
circumstance may perhaps be accounted for by the pressure of the thumb
overbalancing that of the fingers in the habitual practice of clearing
the emunctory.

[Illustration]

In polypus, the passage of air is obstructed, the patient feels as if
labouring under a common cold—his head is stuffed: in cold and dry
weather air passes through the cavity, though with difficulty; in a
damp day the obstruction is complete. The tumour evidently increases,
comes lower down, and even projects upon the lip. There is watering
of the eyes, the lachrymal secretions being prevented from flowing
into the nostrils; and, in cases of old standing, the patient is deaf,
from the pressure of the tumours on the extremities of the Eustachian
tubes. This latter symptom is not constant, but depends on the position
of the tumours. I recollect an old gentleman, an elder of the kirk,
afflicted with nasal polypus, who for thirty years had not heard his
clergyman, though for twenty of these years he had attended service
regularly, and from a sense of duty. On removal of the tumours hearing
was perfectly restored.

The nose changes its form, is expanded and flattened. If the disease
is extensive, and particularly if the tumour is malignant, the bones
are separated, the eyes are protruded, and pushed outwards; indeed,
the face is so distorted as to have been compared to that of a frog.
Even in the benign form, when of long duration, great deformity of the
features is produced, and the patient rendered very uncomfortable.
Besides the symptoms already detailed, he suffers from acute pain in
the forehead—he breathes loudly and with difficulty, particularly when
asleep—he has lost the sense of smell, and does not relish food or
drink—and there is often profuse discharge of a dirty mucous fluid,
both externally and into the pharynx.

Soft mucous polypus may exist for many years, without depressing the
palate, or projecting into the fauces. The anterior nasal cavity is
its most frequent seat, and it widens and fills up the fissure between
the anterior and posterior cavities: frequently it projects backwards,
but is not visible, though it may be felt with the finger behind the
soft palate. Its growth is slow. It may become malignant, as well as
other adventitious structures equally simple; but such an occurrence
is extremely rare. It may exist for many years; and, when at length
removed, will be found of simple structure; and, if the operation
be well conducted, no reproduction will take place. The tumours are
supposed to be easily regenerated; but the truth is, that they are
seldom eradicated completely. In general some are left, and these,
emerging from the narrow space or cells in which they were confined,
soon become fully developed—they expand, and speedily take the place of
those which were removed. They can never be got rid of at one sitting:
the operation requires repetition once and again; and of this the
patient should at the first be made aware.


_Malignant Polypi_ are met with in different degrees of advancement.
Many are firm and fibrous, with an irregular surface and wide
attachment—do not grow with great rapidity—furnish a sanious and bloody
discharge, and give rise to painful feelings. If interfered with, their
increase is accelerated. If removed completely, reproduction may not
take place.

Tumours with broad bases, and of soft medullary consistence, attended
with extensive change in the structure of the membrane, and softening
of the bones and cartilages, grow very rapidly, fill the cavities and
expand them, giving rise to great deformity, as seen opposite. They
show themselves on the face, through the nostrils—protrude through
the floor of the orbit—get into the mouth behind the palate, through
the tuberous processes of the superior maxillary bone—or project
through the alveolar processes. The discharge from them is profuse
and fetid, and in some cases blood flows in no small quantity. Such
growths usually commence in one or other of the sinuses connected with
the cavity of the nose—sometimes, though rarely, in the frontal sinus.
When seated in the antrum maxillare, pain is experienced in the cheek
for a short time before swelling occurs. Soon the part enlarges, its
coverings are thickened, the bony cavity expands, and the patient’s
sufferings are excruciating. The teeth loosen, and sanious matter is
discharged from their roots. The tumour extends into the nostril, and
soon runs the course already mentioned. Malignant disease sometimes,
though rarely, commences in the anterior cavity of the nostril.

No satisfactory cause can be assigned for the appearance of either the
benign or malignant form of polypus.

The nostrils can be readily cleared of benign polypi, but seldom
completely, as already stated, by one operation: in several cases,
wherein only one or two tumours obstructed the cavities, I have had no
occasion to repeat my interference. If the attachments are broad and
extensive, a small curved blunt-pointed bistoury, or probe-scissors,
may be employed for their separation. Sometimes the tumours can be
pushed off by the finger, or by a probe with a blunt and forked
extremity: then they either are blown out by the patient, or fall
into the posterior cavity, thence into the pharynx, and are coughed
up or swallowed. In cases such as are usually met with, forceps and a
small vulsellum are the best instruments. The forceps should be about
half the size of those generally used or sold by cutlers as polypus
forceps. The patient is seated facing a good light and the body of the
prominent tumour is laid hold of by the vulsellum; the forceps are then
introduced, with the blades expanded, and carried backwards so as to
reach its neck, which is then to be firmly grasped by the instrument,
and gently twisted, so as to separate its connexions with the membrane.
No force, no jerking or pulling, is allowable. It may happen, even with
the gentlest and most careful management, that a small fragment of bone
comes away along with the tumour; but this generally can or should be
avoided: the cure is not rendered more certain by such an occurrence,
as has been supposed. One tumour being thus detached, the same process
is repeated with the others, till the cavity is cleared so far as
hemorrhage or the patient’s fortitude will admit. Both nostrils, if,
as is usually the case, both are stuffed, may be emptied at the first
sitting, so as to enable the patient to blow through them. When the
tumours filling the passage to the throat have been removed, so as to
allow the ready egress and ingress of air, and when the forceps can be
passed along the floor of the cavity, and are expanded and shut without
meeting any obstruction, examination is to be made with the finger. In
those who have long laboured under the disease, the fissure between
the cavities is so much expanded as to admit the little finger easily,
and by it the situation of the remaining tumours is ascertained, and
instruments guided to them.

After the operation the nostrils are stuffed gently with lint, to
prevent the access of cold air; and, if the hemorrhage be profuse,
long pieces of lint pushed well back will generally be sufficient to
arrest it: if not, the posterior cavity must be plugged from behind.
It is prudent to prepare for the stuffing posteriorly in bad cases in
which violent hemorrhage may be expected. Instruments with springs,
&c., have been contrived for the purpose, but are useless, and cannot
always be had. A loop of thin flexible wire, or of thick catgut, is
passed along the floor of the nostril, and on reaching the throat
is caught by the finger, or by a hook or forceps, and brought into
the mouth. A piece of strong thread is then attached to the wire or
catgut, and the latter is withdrawn; one extremity of the thread
hanging from the nostril, the other from the mouth. To the middle
of the thread a piece of lint rolled up to the size of the point of
the thumb is affixed, and this is pulled back into the mouth, and
directed into the posterior nares with the fingers; by the pressure
of these, and by pulling at the thread, the dossil is firmly wedged
into the aperture. Lint is preferable to sponge, as being more easily
removed; sponge swells, and is apt to produce inconvenience. The plug
must be well proportioned to the opening: if too large, it cannot be
lodged in its situation; if too small, it does not fill it, and may be
pulled through altogether. It should be smaller, of course, for young
subjects and females than in adult males. It may be necessary to close
both nostrils in this manner, when both are bleeding profusely, or
when they communicate through an aperture in the septum. The anterior
cavity is then closed with lint, and the hemorrhage, however violent,
is completely commanded. The posterior plug is removed on the second
or third day by pulling the oral extremity of the thread, and, if need
be, by pressing through the nostril with a strong probe. Plugging may
be required in epistaxis from other causes, when other means, as cold
applied to the surface of the body, and astringent injections to the
part, have failed. The latter remedy is not much to be depended upon.

The operation for polypus may be repeated when the parts have
recovered, and the pain and discharge ceased. Ere then the patient
again finds himself unable to propel air easily through the nostril,
and, on examination, greyish, shining tumours are again visible. The
same process of extraction is repeated until all are eradicated.
Escharotics may be then applied with some advantage, but must be
used with caution, and not of too active a nature: nitrate of silver
and the red oxide of mercury are those commonly employed. But it is
questionable whether these applications have any effect in preventing
the future growth of the tumours.

The malignant form of the disease, even in a very early stage, is
unmanageable: the tumours, if removed, are speedily reproduced, and
the fatal termination may be accelerated by the interference. I have
removed tumours from the antrum maxillare, and from the frontal
sinus; but the parts became soon occupied by morbid growths of a more
formidable character than the preceding: the membrane and bone appear
to assume a disposition to generate such, and the fungous protrusions
cannot be kept down with escharotics, nor with the actual cautery: nor,
after free removal with cutting instruments, have escharotics, however
freely applied, any effect in counteracting the inherent disposition to
the disease, and preventing its recurrence.

The antrum, when filled with such tumours, is easily laid open. The
cheek is divided perpendicularly from over the inferior orbitary
foramen to the mouth, and the soft parts are dissected from off the
bone. The cavity may then be exposed by means of a small trephine:
but this instrument is scarcely ever required, the parietes being so
softened as to yield easily to the knife: pliers or cutting forceps may
be useful in enlarging the cavity. By the guidance of the finger, the
attachments of the morbid growth are separated with a blunt-pointed
bistoury; and a scoop is used to turn out the diseased mass. The
root of the tumour is then touched with a red-hot iron, and by this
implement, or by dossils of lint, the hemorrhage is easily arrested.
But such operations, considering the result of those which have been
practised, are scarcely justifiable.

It has been proposed for this disease to remove the tumour, along with
its investment—to separate and dissect out the superior maxillary
bone. It is a very severe operation, and one which puts the patient’s
life in imminent jeopardy, from profuse hemorrhage or constitutional
disturbance. In one case, the surgeon began the operation after having
tied the common carotid of the affected side; but, having made the
incisions of the cheek and palate, was obliged to desist, on account
of the violent bleeding: eight days after, the common trunk of the
temporal and internal maxillary was tied on the opposite side, and
the incisions repeated, but the result was the same; the growth
increased, and the patient perished. The disease is very insidious in
its progress, and has gained much ground before the patient becomes
alarmed and applies for surgical aid. The parietes of the antrum are
expanded and softened; the tumour has projected behind through the
tuberous process, upwards through the plate of the orbit, or inwards
to the nostril; and has contaminated by its presence and contact all
the neighbouring parts. Then removal of the maxillary bone, or of all
the bones in that side of the face, can be of no service. The disease
is seldom if ever seen by the surgeon early enough to admit of any
operation being practised with the least chance of ultimate success. At
a sufficiently early period, the removal of the bone—of the parietes
of the cavity containing, and from which the tumour has grown, must
without doubt afford a better chance, and is, in every point of view,
to be preferred to the old operation described above of what was called
trephining the antrum. In one case of soft and brain-like tumour
filling the antrum, and evidently commencing there, I succeeded in
removing the entire disease. The patient remained sound. I have more
than once seen the operation performed for this soft and malignant
growth of only some months standing; portions of the bone and tumour
crumbled under the fingers of the operator—the operation was harsh,
painful, and appalling—the cases hopeless. Execution of the manual
part is not attended with serious difficulty, and it can seldom be
necessary to tie arteries previously. To expose the bone, the cheek is
divided from the angle of the mouth, to the origin of the masseter,
and a second incision made from the inner canthus to the edge of the
upper lip near the mesial line, detaching the alæ of the nose from the
maxillary bone.

The flap of the cheek thus formed is dissected up, and the nasal
process of the maxillary bone and the body of the os malæ are divided
with a saw, or with strong cutting pliers. An incision having been
made through the covering of the hard palate, near the mesial line,
a small convex-edged saw is applied to the bone; and the alveolar
process is cut through by the pliers, after extraction of the middle
and lateral incisors. The bone is then pulled downwards and forwards,
and its remaining adhesions separated by means of the knife or
pliers. This last part must be accomplished rapidly, so as to reach
the vessels, and arrest the hemorrhage. During the progress of the
operation, cut branches of the facial and temporal are commanded by
ligature or pressure, and the violence of the hemorrhage is moderated
by compression of the carotids. After removal of the bone, the deep
vessels, branches of the internal maxillary, are secured either by
ligature, or by firm pressure with charpie or dossils of lint. The
facial flap is replaced, brought together over the charpie by which
the cavity is filled, and united by interrupted or convoluted suture.
Cures by such proceedings, in such cases, are reported; the patients do
not always die immediately after the operation; but there is reason to
complain of want of candour as regards the ultimate result.

The disease, it is said, has been arrested by ligature of the common
carotid; the allegation is not borne out by facts, nor is it easy to
discover on what principle the practice was adopted. Such a result
is not to be expected _à priori_, nor to be believed without farther
trial; and these trials are not likely to be made.

The superior maxilla is liable to become the seat of other tumours
beside the preceding. It may be occupied by fibrous tumour, commencing
in the bone, or in the alveoli. The tumour feels hard, and very often
not encroaching upon the antrum, is evidently circumscribed, and
presents a smooth and botryoidal surface. It has not that disposition
to involve neighbouring parts, hard as well as soft, but may remain
long without extending farther than the superior maxillary bone, and
occupying only a part of it. In such a case, excision of the maxillary
bone is warrantable, and ought certainly to be performed; for there
is no risk of the parts being extensively contaminated. I met with
one instance of it in the latter situation a good many years ago. The
patient was a female, about twenty-five years of age. The tumour was
of four years’ duration, and its origin was attributed to a severe
bruise of the cheek upon the corner of a table. The teeth had loosened
soon after the injury, and the disease commenced in the gums. When
she applied, there was a hard prominent swelling in the forepart
of the maxillary bone, and a firm tumour involved the gums on the
same side, and a part of the hard palate: the disease had made much
progress during the previous six months, but had evidently none of the
malignancy of the soft tumours which originate in, or early involve,
the cavity of the antrum: at first it had possibly been of the nature
of epulis. I removed the bone in the same way as already described,
and had the satisfaction to find the disease completely taken away.
The hemorrhage was restrained by compression behind the angle of the
jaw during the incisions, and not more than ℥iii. of blood were
lost. The tumour, when cut into, presented a homogeneous and fibrous
appearance; at one or two points, softening had begun, and a small
quantity of pus had been deposited. The external wound healed by the
first intention, and the internal cavity granulated kindly. The patient
remains perfectly free of disease, and bears little mark of so serious
a disease or of so severe an operation. Within the last four or five
years I have repeated the operation for this disease very often, and
with uniform success. The cases are recorded in the _Medico-Chirurgical
Transactions_, vol. xx., in the _Lancet_, and _Practical Surgery_, to
which the reader is referred for further information on the subject.
One of the tumours had attained an enormous size, and weighed nearly
four pounds.

[Illustration]


_Of Inflammation, Abscess and Ulceration of the Nose, and Cavities
connected with it._—Inflammation may be excited in the nose by external
injury, as a bruise, or fracture, or displacement of the bones. The
acute symptoms are swelling and discoloration of the integuments,
turgescence of the Schneiderian membrane, which covers the septum
narium and the turbinated bones, and consequent obstruction to the
passage of air. Unless active measures are pursued, abscess follows,
with great swelling and obstruction; and extensive loss of substance,
with deformity, may ensue. Unless the acute symptoms, the short
duration of them, and the rapid supervention of tumour be considered,
the swelling may be mistaken for polypus.

The septum suffers more than other parts of the nose, from the
concussion produced by a blow, and is in general more seriously
affected by the morbid action which is induced. Matter is effused
beneath the membrane, in one or both sides, usually in both, and
tumours are thereby formed, which project into the cavities of the
nostrils; when attentively examined, fluctuation is felt, and, if the
affection has existed for a considerable time, the abscesses are found
to communicate with each other, the septum having been absorbed or
necrosed at one or more points. An individual received a severe blow
over the extremity of the ossa nasi, and a slight wound was produced.
The breathing soon became obstructed, by swelling in the nostrils, and
great pain in the part was complained of. A large tumour formed on the
septum, and completely filled the cavities; it was opened, and a great
quantity of matter evacuated. The septum was destroyed by ulceration to
a considerable extent, and a slight falling down of the middle of the
nose followed. Such cases are of common occurrence.

Independently of any vice in the constitution, ulceration of the
nostrils may be induced by injury, and proceed until great ravages
are effected, if the treatment be not properly conducted. A young
gentleman, playing at ball, was struck accidentally on the nose with
the flat part of his companion’s hand. Inflammation took place,
externally and internally, and the passage of air was obstructed,
abscess formed, and the matter was evacuated spontaneously; extensive
ulceration ensued; the cartilage and bone became affected, portions of
them separated, and a bloody fetid sanies flowed from the nostrils.
All the cartilaginous and part of the bony septum were destroyed; the
morbid action ceased after having continued for a long time; but the
organ was curtailed, sunk on the face, and altogether much deformed. In
this case I first proposed, and some time afterwards performed for the
first time, the operation for the formation of a new columna nasi from
the lip.

The alæ, as well as the septum, may suffer from external injury, indeed
the whole cartilaginous part of the nose may be destroyed.

Incited action must be subdued by abstraction of blood from the
external parts, or from the Schneiderian membrane, leeches being
applied in sufficient numbers, and repeated. Should suppuration not
be prevented, the abscess, particularly when internal, must be early
opened; the surgeon is, perhaps, somewhat to blame, if the patient,
having been under his care from the first, sustains any deformity. If
abscess has formed on both sides of the septum, each must be opened
freely; afterwards hot fomentations are to be used, and the cavity
should be frequently cleansed by the injection of a bland and tepid
fluid.

Intractable ulceration of the nostrils is often induced by trifling
irritations or injuries in constitution, either originally unsound, or
rendered so by imprudent conduct; slight blows on the prominent part
of the organ produce swelling with discoloration, and that is followed
by abscess and ulceration. Internal ulceration is frequently caused
by the continued use of snuff, or the presence of other irritating
matters,—by irritation communicated from diseased gums or alveoli, or
from decayed or crowded teeth, particularly the incisors of the upper
jaw—by stumps in any part of the mouth, or the pivoting of artificial
teeth on them—or by introducing the dentist’s perforator, with a view
of destroying the nerve of a tooth. I have seen ulceration, and loss of
substance in the skin, membranes, and bones of the face, arising from
each and all of these causes.

The ulceration occasionally commences, even in young subjects, in a
wart or fissure on the integuments of the nose or upper lip; it thence
extends to the alæ and floor of the nostrils; the cartilages, and
even the bones, are destroyed; the discharge is thin, acrid, bloody,
and fetid, and the action is with much difficulty controlled. The
disease is met with of various degrees of severity and malignancy; it
may cease spontaneously, may appear to be arrested by constitutional
and local treatment, or, resisting all means employed against it,
may go on consuming portions of the face, both hard and soft;
destroying the nose, lips, and eyelids, and ultimately the bones
in their neighbourhood. Horrid cases are occasionally met with, in
which scarcely the vestige of a feature is discernible—the patient is
nourished, and life is often protracted for a long period, by food
conveyed over the root of the tongue, through funnels or tubes. _Noli
me tangere_, and _lupus_, are names applied to the advanced stages of
the disease.

_Ozœna_, which denotes the internal ulceration of the nose, or rather
the discharge indicating such, is generally of long continuance.
The discharge is at one time profuse, at another scanty; sometimes
it ceases almost entirely, but the accompanying fetor, of a most
disgusting nature, is still perceptible on approaching the patient,
or coming within the influence of the air expired over the diseased
surface; the stench is particularly offensive when portions of bone
are separating. The bones may die either from inflammatory action in
them running high, or from being uncovered and deprived of support by
ulceration of the investing membrane. In many cases, the disease is not
arrested till the cartilaginous and bony septum, the turbinated bones,
the hard and soft palate, and frequently the alveoli, are completely
destroyed. The patient, if he live, is in a miserable plight;—his
countenance is deformed and ghastly; the situation of the nose is
occupied by a large dark and foul sore; the discharge is profuse and
weakening; the expired air is as a pestilence to himself and those
around; speech is almost unintelligible; breathing is difficult;
the strength is gradually exhausted; and the spirits sink under the
harrowing impression of misery. All these ills result more frequently
from the injudicious employment of mercurial preparations than from
any other cause. In almost every instance, the predisposition to such
frightful ulcerations has been induced by the use of mercury, and can
readily be traced to it. Exposure to atmospheric changes, during or
after the exhibition of mercury, may render the mucous surface and the
coverings of the bones more susceptible of the disease; that medicine
may be given with the utmost precaution, but for long after the
constitution cannot shake off its influence; and too frequently more of
the poison is administered for disease produced by it. Ulceration of
the tonsils, and other parts in the fauces, often coexist with disease
of the nostrils.

Ulceration of the nostrils is arrested with difficulty. It cannot
be expected to cease till dead parts have separated, become loose,
and fall out, or are removed by art. Portions of the bones, forming
the floor of the nostril, can often be removed, when dead, through
ulcerated apertures in the palate; whilst others are brought away
through the nostrils, there being generally sufficient space
allowed for their discharge—the nasal cavities being laid into one
by destruction of the columna, and more or less of the septum.
Occasionally the ossa nasi, or parts of them, escape through an opening
in the superimposed integuments; sometimes they cannot be discharged
otherwise, as in the following case:—Matter had come to the surface
over the nasal process of the frontal bone, an incision was made for
its evacuation, sequestra were found loose, and some extracted; one was
pushed down with the view of pulling it through the nostril, but this
was found closed from the effects of small-pox.

Various applications to the ulcerated cavities are employed. Injections
of spirituous and aromatic lotions are used to wash away the discharge
and correct the fetor, as diluted tincture of myrrh, or of aloes,
a lotion containing a proportion of kréosote the sulphate of zinc,
solutions of the chlorides of lime or soda, &c. Applications, soothing
or stimulant, are made to the exposed sores according to their
appearance and disposition. When the ulcer is of an angry and irritable
aspect, it is to be touched lightly with the nitrate of silver,
in substance or solution, and then covered with a bread and water
poultice. Fowler’s solution of arsenic is useful in some cases, when
the object is to clean or destroy the surface; this is also effected
by a slight application of the potass. A very manageable and efficient
escharotic is the chloride of zinc. It is mixed with an equal quantity
of dried plaster of Paris or flour, and made into a paste, with a few
drops of water for application. Black wash sometimes agrees well, as
also a liniment of olive oil and lime-water, with citrine ointment
(three parts of the former ingredients to one of the latter), or the
sulphate of zinc lotion. When the sore is very indolent, showing no
signs of granulation, it may be touched occasionally with spirit of
turpentine, either pure or combined with alcohol, and afterwards
covered with an ointment composed of ung. ceræ and spir. terebinthinæ;
under this application ulcers often heal, after having resisted all
others. But nitrate of silver applied gently, and repeated at the
interval of two or three days, will, in the majority of cases, be found
the most efficient remedy, combined with the simple dressing of tepid
water. Constitutional treatment must not be neglected. When the disease
cannot be traced to mercurial action, small doses of the bichloride
of mercury are allowable when excitement is required. The arsenical
solution given internally sometimes produces good effects. In foul
internal disease of the nostrils with cachexia, no medicine exerts so
beneficial an influence on the general health and local disease, as
sarsaparilla, exhibited either in decoction, in extract, or in powder.

Loss of substance, from ulceration or injury, is repaired by surgical
operation. A portion of integument is borrowed from some other part,
and by the adhesive process is made to cover and supply the deficiency.
Such operations were contrived and practised by Sicilian and Italian
surgeons some centuries ago, and were revived in our day in Germany.
The integument was borrowed from the upper part of the arm; it has
sometimes not been applied immediately, but detached gradually, and
allowed to thicken, to change its consistence, and to become more
vascular, previously to its adaptation to the mutilated organ. When
considered sufficiently prepared, it has been shaped so as to fit
accurately, though still remaining attached at one point to the arm;
the cicatrized edges of the deficient parts should then be made raw,
and the new substance affixed by suture; the original attachment is
preserved entire, and the patient kept in a constrained position—the
arm and head being approximated and bound together by apparatus—for
many days, till union occurred. Then the flap is separated entirely,
and the new nose moulded into its proper form, by subsequent paring and
compression.

The Rhinoplastic operation, introduced from India—where from time
immemorial it has been practised by one of the castes—has superseded
the preceding, and is variously modified. It is less difficult in
execution, not so liable to failure, and more easily undergone by the
patient. The same preparation of the flap is not required, though
it is said that the Indian operators are in the habit of previously
pummelling, with the heel of their slipper, the integument to be
used for the new nose, so as to excite the circulation, and produce
thickening; from the similarity of texture in the integument of the
face, its application to the new situation is not much observed.

The apex and alæ can be readily repaired by a flap of proper shape
and dimensions from the forehead. The cicatrized edges where the nose
formerly rested, must in the first place be dissected off pretty
deeply, so as to be prepared for the attachment of the new appendage.
The size of the lost organ, and the dimensions necessary for its
replacement, are then to be taken into consideration. It is recommended
to make a mould in wax of the part, and after flattening it out, to use
it as a guide for the incisions. But a piece of card or soft leather is
more convenient; this having been cut of the proper size and form, is
laid down on the forehead, the part representing the root of the nose
resting between the eyebrows. It is held firmly by an assistant, whilst
the surgeon traces its dimensions first with ink, or at once with a
knife carried deeply through the integuments. The pattern is then
removed, and the flap dissected down, being laid hold with the finger
and thumb, or with a hook. It is then twisted round, the lower part
being left undisturbed. This attachment at the root of the nose may be
narrow and long, so as to admit of its being twisted, but it is not to
be cut thin; it must embrace the fibres of the corrugator supercilii,
so that its vascular supply may be abundant. The incision on the side
opposite to which it is proposed to make the turn may be brought a
little lower than the other, so as to facilitate the twisting. After
bleeding has ceased, the flap is applied to its new situation, and
retained in apposition with the raw edges of the truncated organ by a
few points of interrupted or convoluted suture; a little oiled lint
is placed in the nostrils to support the flap, but no other dressing
should be applied. To cover the part with pledgets of lint smeared
with ointment, and adhesive strap, can answer no good purpose, and the
subsequent removal of such must endanger the adhesion. The attention
must now be directed to the wound of the forehead; the lower part is
easily brought together, and retained by a stitch; thereby the whole
surface is diminished, and what remains will soon be repaired by
granulation. It is at first dressed merely with a pledget saturated
with tepid water, afterwards some stimulating lotion may be gradually
added. The operation should not be performed in very cold weather,
and even in summer the patient should be enjoined not to leave his
chamber. The lint may be removed in three or four days, and then, too,
some of the stitches may perhaps be dispensed with. The flap will be
found adherent, but loose, and raised by every expiration; very soon
granulations rise from the inner surface, the part derives support from
below, and becoming firm, preserves its form well. It will be necessary
during the cure to keep the nostrils of their proper size and shape, by
means of dossils of lint, or well-fitted tubes.

[Illustration]

Nothing has as yet been said of the columna. In the Indian operation it
is provided for by a slip purposely brought down from the forehead, and
attached to the point which the root of the original columna occupied.
Their flap is shaded as in the following figure. In the greater number
of foreheads, an encroachment must be made on the hairy scalp, in
order to obtain this part of the flap; and after bringing it down and
ingrafting it into the lip, there is a risk of its not adhering, as
happened in a case on which I operated now many years ago. Besides,
during the healing of the internal surface, it will be difficult to
prevent it from shortening, and turning inwards upon itself, and thus
pulling down the apex of the nose. In the case to which I alluded,
a columna was made, after consolidation of the rest of the organ,
from the upper lip, as will be immediately explained; and in again
performing the operation for restoration of the whole nose, I should
proceed on the plan of taking only a flap sufficient for the apex and
alæ from the forehead, and should borrow the columna from the lip. In
this way the risk of failure will be diminished, and the form of the
lip materially improved. The columna might be provided at the same time
with the other parts; but it would be more advisable to delay this part
of the operation till a few weeks after adhesion of the other flap has
been perfected.

Since writing the preceding observation, I have in a very great many
instances performed the operation according to the plan here proposed,
and with the most perfect success. The form of the nasal flap was
this. The little projection was made in order to be turned down, so
as to form the tip of the nose; as well as to constitute a convenient
attachment for the columna, which was subsequently to be made.

[Illustration]

In separating the connexion with the forehead, a thin wedge-like
portion is removed, and the raw surfaces, after the cessation of
bleeding, are laid in apposition, and retained by gentle compression.
But this should not be done till the new nose is consolidated and
perfect.

Restoration of the columna is an operation which, in this, and other
civilized countries, must be even more frequently required than
the restoration of the whole nose. This latter operation came to
be practised in consequence of the frequency of mutilations as a
punishment; the punishment for some of our sins is left to nature, and
she generally relents before the whole of the organ disappears. The
columna is very frequently destroyed by ulceration, a consequence,
as before stated, of injury or of constitutional derangement. The
deformity produced by its loss is not far short of that caused by
destruction of the whole nose. Happily, after the ulceration has
been checked, the part can be renewed neatly, safely, and without
much suffering to the patient. The operation which I have for some
years practised successfully, and in a great many instances, is
thus performed:—The inner surface of the apex is first pared. A
sharp-pointed bistoury is then passed through the upper lip, previously
stretched and raised by an assistant, close to the ruins of the former
columna, and about an eighth of an inch on one side of the mesial
line. The incision is continued down, in a straight direction, to the
free margin of the lip; and a similar one, parallel to the former, is
made on the opposite side of the mesial line, so as to insulate a flap
composed of skin, mucous membrane, and interposed substance, about a
quarter of an inch in breadth. The frænulum is then divided, and the
prolabium of the flap removed. In order to fix the new columna firmly
and with accuracy in its proper place, a sewing-needle—its head being
covered with sealing-wax to facilitate its introduction—is passed
from without through the apex of the nose, and obliquely through the
extremity of the elevated flap; the small spear-pointed harelip
needle answers even better: a few turns of the thread suffice to
approximate and retain the surfaces. It is to be observed, that the
flap is not twisted round as in the operation already detailed, but
simply elevated, so as to do away with the risk of failure. Twisting
is here unnecessary, for the mucous lining of the lip, forming the
outer surface of the columna, readily assumes the colour and appearance
of integument, after exposure for some time, as is well known. The
fixing of the columna being accomplished, the edges of the lip must
be neatly brought together by the twisted suture. Two needles will be
found sufficient, one being passed close to the edge of the lip; and
they should be introduced deeply through its substance; two-thirds, at
least, of its thickness must be superficial to them. Should troublesome
bleeding take place from the coronary arteries, a needle is to be
passed so as to transfix their extremities. The whole cut surface is
thus approximated; the vessels being compressed, bleeding is prevented;
and firm union of the whole wound is secured. The ligature of silk,
which is twisted round the needles, should be pretty thick and waxed;
and care must be taken that it is applied smoothly. After some turns
are made round the lower needle, the ends should be secured by a double
knot; a second thread is then to be used for the other needle, and
also secured. With a view of compressing and coaptating the edges of
the interposed part of the wound, the thread may be carried from one
needle to the other, and twisted round them several times; but in doing
this, care must be taken not to pull them towards each other, else the
object of their application will be frustrated, and the wound rendered
puckered and unequal. Last of all, the points of the needles are to be
cut off with pliers. No farther dressing is required; as previously
remarked, no good end can be answered by any application, and the
separation of dressing may afterwards be troublesome; discharges from
the neighbouring passages are retained by it, fetor is produced, and
union interrupted. The needles may be removed on the second or third
day; their ends are cleared of coagulated blood, and, after being
turned gently round on their axes, they are to be cautiously withdrawn,
without disturbing the thread or the crust which has been formed about
them by the serous and bloody discharge. This often remains attached
for some days after removal of the needles, and forms a good protection
and bond of union to the tender parts. Some care is afterwards required
from the surgeon and patient in raising up the alæ, by filling them
with lint, and thus compressing the pillar, so as to diminish the
œdematous swelling which takes place to a greater or less degree in
it, and to repress the granulations. It is besides necessary to push
upwards the lower part of the columna, so that it may come into its
proper situation; and this is done by the application of a small round
roll of linen, supported by a narrow bandage passed over it and secured
behind the vertex.

Independently of the great improvement produced on the patient’s
appearance by the restoration of the lost part of so important a
feature, it may be observed, that, when the columna has been destroyed,
the lip falls down, is elongated, and becomes tumid, particularly at
its middle, so that borrowing a portion from it materially ameliorates
the condition of the part; the cicatrix being in the situation of the
natural fossa, is scarcely observable.

The alæ of the nose, deficiencies in the upper, anterior, or lateral
parts of the organ, in the forehead, &c., may be supplied from the
neighbouring integument, on the same principle as the preceding
repairs. In many of these operations the flap can be so contrived
and cut out, as that it can be applied without its attachment being
twisted. The form of such flaps is here given.

[Illustration]

It is merely necessary to bring the portion which has been dissected
from the subjacent parts of the forehead, cheek, or lip, to the part
prepared for its reception, by effacing the angle betwixt it and the
connecting slip. A flap to supply the greater part or even the whole of
the organ may thus be transplanted.

The integuments covering the apex and alæ of the nose are sometimes
opened out in texture by interstitial deposit, forming a lipomatous
tumour, lobulated, discoloured, and intersected by fissures. The
sebaceous follicles are enormously enlarged, so as sometimes to
admit the point of a small quill. On making a section of the parts,
accumulations of sebaceous or atheromatous matter are found inclosed
in cysts of considerable capacity. Turgid veins ramify superficially;
and the surface is of a reddish blue or a purple colour, varying its
hue from time to time, according to the state of the health, and
the changes in the circulation. The enlargement often attains great
magnitude, producing much deformity. Vision is obstructed, and the
introduction of food, both solid and liquid, interfered with: the lobes
tumble into the wineglass, spoon, and cup, and sometimes they are so
elongated as to require being pulled aside in order to uncover the
mouth. Breathing is also impeded more or less, by encroachment on the
nasal orifices. The disease may be often attributable to hard living;
but many, not intemperate, labour under it.

It is desirable to have the tumour removed, even before it has become
large; and it can readily be conceived that local applications must
fail in bringing the skin and cellular tissue into a healthy condition.
Incision is required. If both sides of the nose are affected, a
small scalpel is carried down in the mesial line through the altered
structure, and, whilst an assistant places his finger in the nostril,
the surgeon lays hold of the integument with a sharp hook, and
carefully dissects away the diseased parts, first on one side, and
then on the other, so that they may correspond exactly, or present the
same uniform appearance. The vessels are then tied, and sometimes a
considerable number bleed smartly; oozing may continue, but is readily
suppressed by continued pressure, the nostrils being well stuffed.
Afterwards such dressings are to be employed as agree with the stages
of the sore. After cicatrization, the comfort and appearance of the
patient are much enhanced; and there is no risk of reproduction—the
disease is one of the skin, and all that is affected has been removed.
Sketches taken from one, of very many patients, on whom I have operated
for the removal of this shocking deformity, are given in the _Practical
Surgery_, p. 306-8.

[Illustration]


_Inflammation of the antrum maxillare_ is occasionally met with; but
the surgeon is more frequently called upon to treat the consequences
of this action in it. The symptoms of inflammation of the antrum
are violent throbbing pain, referred to the part affected, to the
temple, and to the teeth implanted in the alveolar processes that
form the lower part of the cavity; the side of the face is swelled
from infiltration of the soft parts, and the Schneiderian membrane
of the corresponding nostril is generally observed red and swollen.
The affection can frequently be traced to exposure to cold; it may
be the result of external violence; but is usually an extension of
disease in the sockets of decayed teeth. Unless active and early
measures are taken to subdue the inflammatory attack, the antrum
becomes distended by increased and vitiated discharge from its lining
membrane. The swelling of the cheek becomes more apparent, since, to
increased infiltration of the soft parts, enlargement of the cavity is
superadded. The enlargement of the side of the face, and the bulging
into the orbit are seen in the accompanying cut. The membrane covering
the small aperture through which the antrum and nostril communicate
partakes of the general thickening, and thus no outlet is left for the
accumulating fluid. The escape of matter from the nostril, on the head
being turned to the opposite side, has been laid down as an indication
of accumulation or abscess in the antrum; the statement is incorrect,
and is a result of surgery being professed by those who have not
practised it, but judge of morbid states and their signs and symptoms
by the healthy condition of parts only. In the skeleton, fluid no doubt
will run over from the osseous shell, in some positions of the skull;
but it cannot escape from the cavity when covered with membrane, and
that membrane subject to vital actions. In short, the symptom is not
observable in the disease in question.[35] Extensive ulceration of the
parietes of the antrum towards the nose may, perhaps, take place, as a
consequence of the accumulation, and the matter may then escape by the
nostril, if not allowed an exit otherwise; but such is not a common
occurrence.

In general, the cavity is considerably enlarged before the matter comes
to the surface. If not interfered with, it usually escapes through
the sockets of decayed teeth, or, the anterior thin parietes being
absorbed, it comes down by the side of the canine or small molar teeth,
and is discharged slowly, so as to annoy the patient by its flavour and
fetor, without the abscess being emptied, or a chance of cure afforded.

Accumulations of fluid sometimes takes place in this cavity, give
rise to great enlargement of the sinus, and continue for many months,
without pain or much inconvenience, and without any matter escaping.
The bony parietes are attenuated, yield to slight pressure, and
return to their original level with a crackling noise, such as is
produced by parchment. The contained fluid is thin, greyish, and
contains flocculent solid particles. In short, the antrum maxillare is
occasionally the seat of chronic, as well as of acute abscess.

Cancerous ulceration sometimes takes place in the cavity; the matter
is not long confined, the parietes soon soften, the teeth drop out,
the alveolar processes disappear, and a large opening is formed, which
furnishes a fetid, sanious discharge.

In inflammation of the antrum, carious teeth must be removed, blood
must be abstracted from the neighbourhood of the affected part—leeches
being applied to the gums, the Schneiderian membrane, and the
integuments—and fomentations to the cheek should be frequently and
assiduously employed. When the cavity has become distended with
fluid—mucous, muco-purulent, or purulent—such must be evacuated without
delay; and the opening must be of such size, and so situated, that the
fluid may escape as soon as secreted. In removing diseased or crowded
teeth opposite the part, an opening may be made from the extremities of
the fangs having projected into the cavity; it is in a good situation,
but cannot easily be made of sufficient size; an aperture of but small
extent may be sufficient for the draining of an abscess in soft
parts, but here the divided texture is unyielding, and the perforation
must be free. Bad teeth are taken away with the view of abstracting
a source of irritation which may give rise to, keep up, or induce a
return of collection in the antrum; but extraction of sound teeth, to
obtain an exit for the matter, is not warrantable. Even when they are
extracted for a different reason, and discharge of matter follows, the
surgeon must not be contented, but must make another and more efficient
opening. The membrane of the mouth is to be divided on the forepart
of the maxillary bone, immediately above the first small grinder, and
a large perforator then pushed into the antral cavity; little force
is required, for the parietes are soft and partially absorbed. The
perforation should be of a size sufficient to admit the little finger;
thereby a free and dependent exit is allowed for the concrete as well
as the fluid matter. Curdy and very offensive stuff is sometimes found
in great abundance in this cavity. If the discharge is very fetid, and
long of drying up, and if there is an appearance of disease in the
osseous parietes, injections into the cavity may be required, though
seldom. They are occasionally useful in dislodging the atheromatous
matter. In general the discharge gradually diminishes, the membrane
of the antrum resumes its healthy condition and functions, and the
aperture in its parietes is shut by a fine ligamentous substance.

[Illustration]


_Ulcers of Lips._—The prolabium is liable to ulceration from various
causes; from long-continued irritations, as sharp corners of teeth,
rugged tartar on the external surfaces of the teeth, the habitual use
of a short tobacco-pipe; from external violence; from the application
of acrid matter; or from an ulcerative disposition unconnected with
external circumstances. The constant and free motion of the parts is
prejudicial to healing, and consequently the sores often remain long
open. Though ulcers on the lips are generally of a bad character, it
does not follow that all are so. Many are simple; but these, after
remaining long, are apt to degenerate. Others from the first assume
malignant action, and unfortunately they are more frequently met with
than simple and well-disposed sores. The malignant sore often commences
in a warty excrescence which ulcerates at the base; the ulceration
extends, the warty appearance is succeeded by ragged and angry fleshy
points, the surrounding parts become indurated, and the stony hardness
spreads. The appearance which the sore presents is that of open
cancer, described at page 147, and represented on preceding page. The
ulceration may either be limited in depth and extent to a small part
of the lip, or may involve the greater part of the prolabium, and that
without much induration. It is generally situated on the right side
of the lower lip; sometimes in the angle of the mouth; the upper lip
is rarely affected. I have removed a few malignant ulcers from this
last situation. Sooner or later the lymphatic glands participate in
the disease; a chord of indurated lymphatic vessels is felt passing
over the jaw in the course of the facial artery, and the glands with
which these are more immediately connected, soon enlarge and become
hard. This disease, though by some pathologists said to be “improperly
called cancer,” differs apparently in no respect in its progress,
and is in all respects as malignant as the disease commencing in any
other structure and in any other way. Indurated swellings over the
jaw, lymphatic or not, usually depend on the labial disease; they in
some instances increase very slowly, in others acquire such volume
as to induce by their pressure on neighbouring parts alarming and
dangerous symptoms at an early period. Without much increase of size
they sometimes attach themselves firmly to the bone, and involve it
in the disease. The malignancy seems to acquire fresh virus, the skin
ulcerates with fetid discharge, all the neighbourhood is speedily
infected, and the patient sinks slowly under the evil.

Simple ulcers of the lips may be made to heal readily,—by abstracting
the exciting cause, preventing the motion of the lip by the restraint
of a bandage, disusing the part as much as possible, and by employing
such applications to the sore as are best suited to the character and
appearance which it may present; but it must be borne in mind that
all remedies can be of little service unless motion of the lip be
prevented. Sores of a bad kind must be attacked early, otherwise no
hope of success can be entertained. Escharotics are not to be trusted
to; the knife is the only effectual means of removing the disease.
When the sore does not involve much of the lip, the molar teeth
having been lost, and the alveolar processes absorbed, the cheeks
are thus rendered flabby and relaxed: in such circumstances, all the
diseased part is taken away with facility, and the features are not
thereby deformed, but rather improved. The part cut away resembles
the letter V, the angle being towards the chin: this form of incision
is preferable, on account of the diseased portion being chiefly in
the prolabium, and the parts afterwards coming together very neatly
and readily. The lip is stretched by the operator and his assistant
laying hold of the prolabium on each side of the portion destined to
be taken away; a narrow straight bistoury is passed through the lip,
at the angle of the form of incision; and the operator, standing in
front of the patient, makes the first incision towards himself, by
bringing the knife up to the prolabium. He then takes hold of the
part to be removed, and laying the edge of the knife on the prolabium
at the other side of the induration, cuts down to the point where
the instrument originally entered. The incisions must always be made
far from the indurated parts. The edges of the wound are retained
in apposition by means of convoluted suture, as formerly described.
When the wound is extensive, as when a considerable part of the cheek
is involved, approximation may be accomplished by a few points of
interrupted suture, and afterwards the parts may be more securely and
accurately fixed by convoluted sutures placed between the interrupted.
When a large portion of the cheek is removed, as for disease which had
commenced at the angle of the mouth and extended around, all the parts
cannot be brought into contact, and some of the deficiency remains
to be filled up by granulation. The neighbouring parts stretch, and
the deformity that may be the immediate result of the operation in a
great measure disappears after some time. In cases of superficial and
malignant ulceration of great extent, no attempt can be made to bring
the parts together after excision: great deformity, and almost total
closure of the mouth, would be the consequence. The diseased parts must
be freely removed (for this is the primary and essential part of the
operation, all other considerations yielding to it), and the deformity
will prove much slighter than might be supposed: granulations arise,
and considerable reparation of the lost parts thence ensues. Still
there is a risk of the sore, at first healthy and active, gradually
assuming the nature of that for which the incisions were made.

It may be necessary to remove the whole lip, or the greater part of
it. Hence arises much inconvenience to the patient; he is much reduced
by the profuse secretion and loss of saliva; the surrounding parts
are excoriated and irritable; his clothes are wetted; his speech is
very indistinct; his teeth become thickly coated with tartar; and he
is in short kept in a state of constant annoyance. The part may be
supplied from under the chin; but this reparative operation should
not be performed at the same time with the removal of the original
and carcinomatous lip. By making two operations, with a considerable
time intervening, the chance of success is greater, and indeed the
difficulty is much diminished. After removal of the disease, allow
the parts to fill up by granulation and contract as far as they will,
then form a new lip. I have done so in several instances; in one case,
the parts had perished by external violence; in another, they had
been destroyed by some powerful escharotic. A piece of soft leather,
of the size and shape of the under lip, is placed under the chin, and
a corresponding portion of the integuments is reflected upwards, an
attachment being left at the symphysis menti. The callous margins of
the space formerly occupied by the original lip are pared; and the
flap, having been twisted round, is adapted to the edges of the wound,
and retained by points of interrupted or convoluted suture. To insure
adhesion, the attachment at the chin should be left thick and fleshy;
the flap should not consist of mere integument, but contain no small
share of the subcutaneous cellular and adipose tissues, in order that
circulation may be vigorous in the part. The integuments below the chin
are naturally lose, and consequently the margins of the wound there are
readily approximated. The flap soon becomes œdematous, and remains so
for some weeks; it must be supported by a compress and bandage. After
adhesion of its upper part is completed, the mental attachment, which
prevented the lower portion from uniting, is to be removed; a bistoury
is introduced beneath the non-adhering point, and carried down so as
to divide the attachment, which is then removed by a second stroke
of the knife. The lower part of the flap is now laid flat and close
to the chin, and supported by a bandage. In the adult, union may be
retarded by the edges of the flap twisting inwards, and interposing the
hairs upon them between the opposed surfaces; when such is the case,
the offending margins must be pared away. The advantages of such an
operation, when successful, are too evident to require detail.

Removal of glands in the neck or beneath the jaw, that have become
diseased in consequence of malignant disease in the lip, is attended
with danger, and not followed by any benefit. But for this disease I
have known most bloody and cruel operations undertaken,—even portions
of the jaw to which the glandular tumours adhered have been cut out.
Such proceedings cannot be too strongly reprobated.


_Congenital Deficiencies of Lips, Palate, &c._—Congenital deficiency
of the lip uniformly occurs in the upper one; it is either simple or
complicated. Frequently there is only a fissure on one side of the
mesial line. This may, though seldom, be combined with division of the
soft or of the hard palate; or there may be a fissure on each side of
the mesial line, with an intervening flap. The flap may be either of
the same length as the rest of the lip, or more or less shortened; and
it may be either free, or attached to part of the alveolar process.
In such cases as the latter, the central alveolar processes and
teeth often project considerably beyond the arch of the hard palate,
greatly increasing the deformity. The deficiency of the lip produces
a disgusting and horrible deformity of the countenance; and when
there is division of the palate, the voice is indistinct, or almost
unintelligible.

The simple fissure of the lip, without deficiency of the palate, is
easily remediable by operation. As already mentioned, the fissure is to
one side of the mesial line; and its edges, covered by a continuation
of the prolabium, are rounded off at their lower part. The operation is
not attended with much loss of blood, nor is it very painful. It can
be performed at any period of life, but in young children it is not
advisable to have recourse to more severe operations on these or other
parts. Children bear the loss of blood badly, and their nervous system
is apt to be shaken; convulsions are induced, and often terminate
fatally. The most proper age for removing deformity by operation is
from two and a half to four years; there is then no danger incurred,
and during the growth of the individual the parts recover more and more
their natural and healthy appearance.

[Illustration]

The operation for single harelip consists in paring off freely the
edges of the fissure, and removing completely the rounded corners
at the free margin, thus. This is most neatly, quickly, and easily
accomplished by passing a straight bistoury through, from without
inwards, so as to penetrate the membrane of the mouth, above the angle
of fissure. The parts are stretched by the fingers of the surgeon
or assistant, whilst the instrument is carried downwards, so as to
detach a flap composed of the edge and rounded corner. Unless the
rounded portions are taken clean away, an unseemly notch is left in
the prolabium, where in the natural structure is prominent. A similar
proceeding is followed on the opposite side. Hemorrhage is prevented
by the assistant making gentle pressure whilst he stretches the lip.
Two sewing needles, the heads covered with a small nodule of sealing
wax, are introduced as directed after the operation for removal of
diseased parts in the lower lip, and the twisted suture completed. For
some years I have used pins made purposely; they are spear-pointed
and tempered near their points. From their length they can be easily
inserted without being fixed in a handle, or provided with a head. One
needle should always be passed close to the free margin of the lip.
No further dressing is required, for reasons already assigned. The
forceps of different kinds for holding the edge during its removal are
worse than useless; and paring with scissors is to be reprobated, as
an effectual means of preventing immediate union. By the plan above
recommended, bruising is avoided, and union takes place rapidly.

[Illustration]

Fissures, more or less extensive, of the hard palate, generally
attend double harelip. The position and size of the intermediate
portion of the lip, and of the superior maxillary bone, are various;
and the operator, in forming his plan of procedure, must be guided
by the state of the parts. If the fissures are not very wide—if the
intermediate portion of bone, that adhering to the septum narium, is
not prominent—and if the soft parts covering this are free and long,
the operative procedure is simple. Two such operations as are described
for single harelip, the latter performed at an interval of some weeks,
are required. Thereby the intervening flap is united first to one side,
and then to the other.

If the flap is short and free, without osseous projection, the
operation may be concluded at once, thus:— The edges are pared on both
sides, and the parts brought together as in single harelip, the small
intervening flap not preventing apposition below. One pin is passed at
the prolabium, the other traverses the flap. In all cases, in fact, the
operation may be concluded at once.

When the bone projects, and the flap is long, the parts may be rendered
favourable for the operation by gentle and continued pressure; the
osseous prominence being reduced, so as to restore the natural position
of the soft parts.

When, as not unfrequently occurs, there is projection of the bone,
and the soft and hard parts seem to be incorporated with the apex of
the nose—when, in short, little or no intermediate flap exists, the
protruding portion of bone may be removed by cutting forceps down to
the level of the palatine arch; and then the soft parts can be brought
together by one operation, as for single harelip.

In some cases, when the space between the palatine plates of the
superior maxillary bone is wide, it may be necessary, by mechanical
contrivance, fitting on metallic apparatus possessing a strong spring,
to approximate the bones before attempting to unite the lip. The cases
must be very rare, where the soft parts cannot be otherwise brought
together: when they can be united, their equable and continued pressure
will have the effect of gradually approximating the hard parts.

When the hard palate is deficient, the patient is subjected to great
inconvenience from food escaping into the cavities of the nose, and, in
later life, horrid wretchedness of articulation occurs. It can readily
be understood, that surgery is of very little avail here. Recourse
must be had to mechanical contrivance. A plate of metal (gold or
platina), or a piece of ivory, or of sea-horse bone, may be fitted to
the opening, and retained either by accurate adaptation, having sponge
or caoutchouc attached to the upper surface, or by wires, elastic or
not, resting on the neighbouring teeth. It may be made of a piece with
artificial teeth, if any are required. The sponge is objectionable,
as retaining the discharge, and thereby imparting an unpleasant odour
to the expired air. But it is no easy matter, and often altogether
impracticable, to retain such apparatus when the soft palate is also
deficient. The time at which such contrivance is to be adapted may
admit of some dispute. If done early in life, the natural tendency
of the parts to approximate may be interfered with and subverted; if
dispensed with till a later period, the patient gets into a habit
of snuffling and speaking so indistinctly, that the closing of the
aperture is productive of little or no improvement. Perhaps the period
of commencing the child’s education should be delayed till he be seven,
eight, nine, or even ten years of age, and then the artificial palate
may be applied advantageously in every respect.

Fissure of the soft palate is usually accompanied with separation
of the bones from which it is suspended. The size of the fissure is
various, and depends very much upon the state of the hard parts. In
some cases, the extent of separation is great; in others, the edges
are readily approximated by making the patient throw the muscles
into action. The latter class admit of operation with a view to
permanent union of the edges of the fissure. But it is a proceeding
which, to insure success, requires not only great steadiness,
coolness, and dexterity on the part of the operator, but the utmost
courage, submission and self-denial on the part of the patient. These
qualifications can scarcely be expected in patients under twelve or
fourteen; and, consequently, the operation should not be attempted till
after that time of life.

Before proceeding to operate, it should first be ascertained that the
fissure is not of such extent as to prevent apposition of its edges,
without great dragging of the parts; for, if the separation be wide,
temporary approximation may perhaps be effected by ligatures strongly
applied, but the apposition will not be complete or accurate throughout
the whole fissure, and adhesion will not take place; the palate will be
too much stretched, as to throw off the ligatures by ulceration at the
transfixed points of its margins. The patient must be made aware of the
nicety of the operation, of the responsibility that rests upon himself,
and be exhorted to steadiness and patience. A single exclamation of
pain may subvert the whole proceedings. He is seated opposite to a
strong light, and made to open the mouth wide; if necessary, the jaws
may be kept separate by a wooden wedge, placed so as not to interfere
with the operator. The head is thrown back, and held steadily by an
assistant. The operator depresses the tongue by the forefinger of the
left hand. A long, narrow, sharp-pointed bistoury is passed through
the velum, close to its attachment with the palatine plate, and about
a sixteenth part of an inch from the edge of the fissure: it is then
carried downwards to the point of the uvula, so as to detach a narrow
slip from the whole edge. The same is done on the opposite side of the
fissure during the proceeding, and to facilitate it the point of the
uvula on each side may be held by long and properly pointed forceps.
After allowing the patient a short rest, the coagula and mucus are
cleaned away from the parts, to prepare for union. Long bent needles,
in fixed handles, and armed, are passed through the pared edges on each
side. On one side the ligature is thin, the opposite thick and strong;
the former is attached to the loop of the latter, and withdrawn,
leaving the strong ligature passed through both apertures; and by this
the margins are gradually approximated, and retained by a firm knot. A
second point of suture, and a third, if necessary, is applied in the
same way, and as represented in the “Practical Surgery,” p. 558. Or a
single short curved needle may be used. It is introduced by means of a
portaiguille, with a long handle, and passed through, first from the
outside of one edge, and then from the inside of the other. A ligature,
either of thread or of pewter wire, can thus be conveyed at once; if
the latter is employed, it is secured by twisting, and the ends cut off
by pliers; the needle is attached to the wire by a female screw in its
end. It is advisable to make incisions in the direction of the fissure
on each side, through the mucous lining, in order to take off the
strain from the stitches.

Afterwards, success depends on the patient. All attempts at
articulation, and even deglutition, must be strictly forbidden for
three, four, or five days.

_Inflammation_ of the Soft Palate, Uvula, and Tonsils, requires in
general little surgical treatment. Reiterated attacks may sometimes be
traced to the progress of a wisdom-tooth, or to the presence of stumps
in the posterior part of the upper or lower jaw. Perhaps the most
common cause is sudden suppression of the discharges from the skin, and
from the adjoining mucous surfaces, in consequence of exposure to cold.
The affection is accompanied with pain and difficulty in swallowing,
and frequent and difficult excretion of mucus. The secretion of the
saliva is increased, the attempts to swallow it are frequent, and the
inflamed parts being thereby put in motion, the pain is aggravated.
From the inflammatory action extending along the Eustachian tube, the
patient describes the pain as shooting towards the ear. The parts are
red, and soon becomes swollen; in some cases to so great an extent,
as completely to prevent deglutition; occasionally the breathing is
impeded; but the inflammatory swelling must be very great indeed,
to obstruct the openings into both mouth and nostrils, and thereby
threaten suffocation. The voice is hoarse, croaking, and husky; and,
when the swelling is considerable, the patient speaks only in a
whisper. The internal swelling is often accompanied by an external
painful tumour of the lymphatic glands, and the pain is much increased
by external pressure. There is more or less concomitant fever, preceded
by slight shivering.

Removal of the local cause, and mild antiphlogistic measures, are
usually sufficient to effect resolution, and put a stop to the disease.
General bleeding will seldom be required; blood is abstracted locally,
either by scarifying the internal surface, or by applying leeches at
the angle of the jaw. Fomentations afford much relief, and may be
applied either externally, or internally by inhalation of the steam of
water, or of water and vinegar. The greatest benefit is experienced
from this remedy during the early stage, it being then employed either
to promote salutary effusion and effect resolution, or at a later
period to forward the secretion of purulent matter. At the same time,
antimonials, purgatives, warm drinks, diaphoretics, and the pediluvium,
are not to be neglected. In the relaxed state of the parts, after
subsidence of the violent symptoms, stimulating and astringent gargles
may be used with advantage.

But in neglected cases, or those originally violent, suppuration,
sometimes extensive and dangerous, occurs in the cellular tissue,
betwixt the pillars of the soft palate, or betwixt the layers of the
velum. The swelling thereby formed may be so large as to impede the
passage of air by both the mouth and nostrils. The mouth is opened with
difficulty and pain; deglutition is seriously impeded, or altogether
impracticable; the voice is weak and indistinct; and the countenance
is swollen and discoloured. Life is endangered by the risk of the
purulent matter bursting out suddenly during the painful and laborious
efforts at respiration, and escaping into the air passages; fatal
results have thus taken place, and to prevent such the abscess should
be opened early. When the swelling is large, and attended with alarming
symptoms, the matter is most conveniently evacuated by a flat and long
trocar and canula. If the abscess be small, and the breathing not
affected, there will be no danger in allowing the collection to burst
spontaneously. Suppuration may also occur in the external glandular
tumour, or in the surrounding cellular tissue. When sloughing to any
extent takes place, it is in patients of an extremely debilitated habit
of body, or when the affection is attendant on disease of a malignant
character. Metastasis may take place to the larynx, to the trachea,
or to the lungs, either spontaneously, or in consequence of repellent
applications.

_Chronic abscesses_ are occasionally met with in these parts, or
behind the upper part of the pharynx, unconnected with disease of the
subjacent bones. The matter must be evacuated as soon as its existence
is ascertained. No great accumulation should be allowed to take place
in any situation, far less in the immediate neighbourhood of important
parts.[36]

Scarification of the tonsils and surrounding membrane is seldom
required. A lancet concealed in a canula, with a spiral spring
to withdraw its point, is used for this purpose, and for opening
abscesses; but dangerous and fatal results may ensue, and have actually
followed such incisions of these parts. A sharp instrument directed
outwards, made to penetrate either by the rash thrust of an ignorant
and careless practitioner, or by a hurried movement of an unsteady
patient, may reach the common trunk of the temporal and internal
maxillary arteries, or even the internal carotid. The sheathed lancet
may be useful in the hands of such as are not habituated to the use
of instruments; but scarification of the parts and puncturing of
abscesses can be effected safely by a straight, sharp-pointed bistoury,
covered with a slip of lint to within three-quarters of an inch of its
point. The patient’s head is steadied by an assistant, the point of
the instrument directed backwards, not at all outwards, and its edge
upwards so as to avoid wounding the tongue, which is also to be kept
out of the way by the forefinger of the left hand.

New formations about the isthmus faucium are rarely met with. Small
warty excrescences, and small pendulous, fatty, or polypous tumours,
are occasionally seen. These, if productive of inconvenience, can be
easily removed by cutting instruments.

Enlargements of the uvula and tonsils are common, impeding deglutition,
and producing indistinct and burring articulation. If large,
respiration is interfered with.

_Elongation and Enlargement of the Uvula_ attends inflammatory attacks
in the fauces, but may continue for a long time afterwards. The
organ is increased in volume, both in length and in breadth, from
interstitial deposition of new organised substance, and from unusual
vascularity. The inconvenient size produces nausea and cough; it is
even said that the tumour has, in some instances, got entangled in the
rima glottidis, suffocating the patient, or at least giving rise to the
most alarming symptoms. In some cases the elongation appears to have
kept up cough and expectoration for months or years.

The parts may be touched with a bit of sponge, dipped in the tinct.
muriatis ferri; but a more useful remedy is the powder of alum, applied
either on a spatula, or by insufflation. Astringent decoctions, or
solutions, are of little use. But in cases of large and long continued
enlargements, the swelling cannot be expected to subside under
such treatment, and recourse must be had to curtailment by cutting
instruments, of which the best for this purpose are long blunt-pointed
scissors and forceps, with hooked points. The patient is made to open
his mouth wide; the surgeon then introduces the instruments into the
month, and watching an opportunity when the uvula is nearly stationary,
suddenly seizes and clips off a sufficient portion. This is followed by
instant relief.

Frequently an œdematous swelling of the uvula, of a crystalline
appearance, resembling a large grape, accompanies ulceration in the
neighbourhood; puncturing of the part, and attention to the cause of
the affection, are sufficient for the cure. When the bloodvessels of
the uvula are in a state of chronic enlargement, scarification is also
employed with advantage.

_Chronic Enlargement of the Tonsils_ occasionally takes place in
children, but generally in persons from eighteen to twenty-four
years of age, or in such adults as are subject to irritations in the
neighbourhood of the organs. A delicacy of constitution is supposed to
be indicated by the affection. One or both tonsils may be enlarged,
usually both. The surface of the tumour is irregular; the mucous
follicles are enlarged, and often filled with sebaceous matter. The
swellings in each side gradually approach each other, meet, and by
narrowing the isthmus, seriously interfere with the functions of the
parts. Little pain is felt, and that is dull, occasionally shooting
through the ear. Respiration is at all times fettered, and during
sleep noisy. Occasionally the swellings exceed their usual size,
from some accidental excitement of the circulation. They may subside
very considerably on the removal of the cause, or abatement of its
operation, for there is nothing malignant in their nature. It is true,
as I have seen, that the tonsils may be involved in malignant disease
spreading from the neighbouring parts; but in the affection under
consideration, no mark of malignancy appears, as far as I know. There
is mere enlargement and opening out of the texture, without much, if
any, change in structure or consistence; the part may be cut into
without the risk of exciting unhealthy action, and the divided surface
cicatrises readily.

Deobstruents, and iodine, as the most efficient, may be given, with
perhaps some effect. In the adult, when the affection is troublesome,
permanent, and of long duration, the exuberant matter must be removed,
and this is accomplished either by ligature or by incision. The
former method is the more difficult, tedious, painful, inconvenient,
and dangerous. It is seldom that one ligature, with a simple noose,
suffices; it is necessary to transfix the tumour, and, separating
the portions of the ligature, to include the upper and under halves
in distinct nooses. The latter method is the preferable. It is not
requisite to cut out the whole tonsil, and there is risk in attempting
such a measure, but that part only is removed which projects beyond the
arches of the palate and the natural level of the gland. Long curved
scissors may be employed, but the straight probe-pointed bistoury
is more convenient; and this, to insure security, may be blunted to
within an inch and a half of its point, or rolled so far in lint.
To facilitate incision, the tumour is laid hold of by a sharp hook,
or, what is better, by a vulsellum. Occasionally violent attempts
at retching occur during the operation; but there is little pain or
hemorrhage. The complicated machines invented for this purpose are
worse than useless. The healing of the sore is hastened by fomentations
and mild gargles, and by either stimulating or soothing applications,
as circumstances require.

Excision of the tonsils is said to produce the bad effect of changing
the pitch of the voice—taking from the high, and adding to the
low notes. I have performed the operation, as above described, on
professional vocalists, to remedy indistinctness of articulation and
constant hoarseness, with the desired effect, and without altering
either the pitch, quality, or compass of the voice. No doubt,
unpleasant results might follow extensive incisions of the parts, as
division of the anterior fold of the palate, and removal of the whole
tonsil; but by paring off the prominent parts of the glands no risk is
incurred.


_Ulcers of the Palate, &c._, are said to have arisen almost uniformly
from contamination of the system, following sores on the genital
organs. Now, at least, they seldom and scarcely ever occur from this
cause, unless most execrable practice has been resorted to. Foul and
extensive ulcers of the membrane of the mouth, of the tongue, of
the gums, and of the folds of the palate, are common in those who
have used mercury recently; and those whose constitutions have been
saturated with mercury, or who have taken only alterative doses for a
considerable time, are for a long while liable to ulcerations of these
parts on exposure to moisture and cold—one set of sores healing, but
others soon breaking out. It is, indeed, very rare to meet with sores
in these situations that are not thus accounted for: certainly such
as are by recurrence deep, extensive, and troublesome, are not seen
unless in those who have suffered from mercurial medicines. Slight
excoriations are not uncommon in individuals of the soundest and most
untainted systems; but even in very young subjects, if the sore is of
considerable size, and slow in healing, it will generally be found
that some preparation of mercury, probably calomel, had been given
previously, and perhaps without precaution and care. Calomel, as well
as other forms of the mineral, is too often and too freely given,
and without proper consideration; the ruin of many good constitutions
is attributable to this cause, and to this cause alone. How long
mercurial poisons continue to exercise a prejudicial influence on
the constitution, is a question not easily determined. In many, its
dominion is long and powerful. Frequently its effects are developed
years after its exhibition, from accidental circumstances, such as
change in the mode of living, derangement of the stomach and its
appendages, exposure to inclement weather, change of climate, &c.

Sores form in various situations, between the pillars of the fauces—in
the site of the tonsils—on the uvula, and by its side—on the posterior
and anterior surfaces of the pendulous velum; sometimes the ulceration
appears to have extended from the nostrils. Often the uvula is entirely
lost; it is not long since I saw two uvulæ, in one day, as black as a
bit of coal, surrounded by ulceration, and just about to drop away.
Ulceration of the posterior surface of the velum is marked by dark
redness, and swelling of the anterior. Sometimes it happens, that
by deepening of the ulcers, the velum is perforated at one or more
points, and the edge of the opening healing, a permanent deficiency
remains. The whole of the soft palate may be destroyed, either by one
extending ulceration, or by repeated attacks. When cicatrisation takes
place, the posterior nares are narrowed, deformed, or even completely
closed. Along with ulceration of the fauces, abscesses frequently form
in the coverings of the hard palate; they are either the consequence
or the cause of necrosis of part of the bone. Whatever their origin,
more or less of the bone with which the matter is in contact, dies and
separates; and thus openings are established between the cavities of
the mouth and nostril. This is productive of great inconvenience, the
patient speaks very indistinctly and, when taking food, a part of the
more fluid ingesta returns by the nostrils. During the progress of the
exfoliation, the breath is intolerably fetid.

Such is an outline of mercurial products in the mouth. Eruptions and
ulcers on the surface of the body often accompany or follow them;
and the patient gets into a bad state of health—becomes, in short,
cachectic.

The state of the system must be ameliorated if possible; and chiefly
by attention to the digestive organs. These may be improved by such
medicines, as ipecacuan, taraxacum, gentian, rhubarb, scammony,
aloes,—given in various doses and combinations, according to the
circumstances of the individual case. The first two possess many of
the good qualities of calomel, in regard to the biliary secretion, and
leave no evils behind them. Sarsaparilla is a most important remedy,
and the form of its exhibition should be varied when its effects begin
to diminish. The different applications which may be made to the sores
have been mentioned formerly; of them all, the nitrate of silver is
the most generally useful, either in solution or in substance. It is
used at intervals of two or three days, not to destroy living texture,
but to diminish irritability and dispose to heal. If there be no great
loss of substance, deficiency in the soft parts may be repaired by
operation after the ulcerative disposition has ceased. In deficiency
of the palate—during the progress of the ulceration in the bone and
the parts investing it, and for some time after it has ceased—the
inconvenience is lessened by filling the opening with crumb of bread
softened, and made into a paste by kneading; this must be frequently
renewed, otherwise it collects discharge, and becomes offensive.
After cicatrization of the margins, and contraction of the opening, a
metallic plate may be fitted in.

[Illustration]

_Ulcers of the Tongue._—Such as are not of a malignant kind are readily
healed on improving the state of the digestive organs and general
health. The state of the organ indicates that of the chylopoietic
viscera, it enjoys intimate sympathy with the other parts of the
alimentary canal, and why it should suffer from derangements of them is
readily understood. The sores may be continued by local irritations, as
by friction on encrusted tartar, or sharp or decayed portions of teeth,
or by repeated application of heat, as in smoking. In consequence of
long-continued irritation, like similar ulcers of the lips, they take
on malignant action. The malignant ulcer generally occurs in patients
past the meridian of life. Yet I have seen the greater part of the
tongue involved in carcinomatous swelling in young subjects; from one
girl, twelve years of age, I was obliged to remove one-half of the
organ vertically. Stony induration surrounds the exposed surface to
a considerable extent, and the sore presents all the characteristic
appearances of cancer. In many cases the induration precedes
ulceration, in others follows it. A most extensive and dreadful disease
of the organ is here represented; along with induration of the whole
organ, ulceration had penetrated like a tunnel from the apex to the
base; œdema of the glottis supervened. Sooner or later the absorbents
are affected, becoming swollen, painful, and hard; and, as in malignant
affections of other parts, the disposition and action is not limited to
those in the immediate neighbourhood of the primary disease. The tongue
is subject to simple induration, which is totally unconnected with
malignant disposition, and subsides on improvement of the digestive
organs; occasionally repeated leeching of the part accelerates the cure.

Enough has already been said about removing the local irritating cause,
when such can be discovered; and the maxim, though most important,
need not be formally repeated in regard to affections of the tongue.
The simple ulcer heals under the usual applications to sores or mucous
surfaces, the general health being at the same time attended to. For
malignant disease, nothing but very early removal of the part can
avail. But this is not always either advisable or practicable: the
disease may have involved the organ too extensively, and the lymphatics
may have too widely participated in the action. When the diseased
part is small, and nothing contraindicates surgical interference, it
may be removed by the bistoury; usually the bleeding is very slight,
but if troublesome it is easily arrested by the cautery. When the
disease is extensive, ligatures are to be employed. During the process
a vulsellum is useful for grasping the morbid part, and securing the
organ. The ligatures should be strong, and are introduced by needles
in fixed handles. They may either be passed at once, or be preceded by
finer ones, by which they are afterwards drawn through. The tongue is
transfixed beyond the induration, and, if one ligature is sufficient,
its noose is divided, and the parts tied separately, so as to include
the mass. But frequently several ligatures are required, and their
portions must be so disposed as not only to isolate all the indurated
and ulcerated part, but also some of the neighbouring sound structure.
They are tied firmly, to cut off vitality as completely as possible,
and at once. Considerable swelling and profuse salivation follow, but
gradually subside. In a short time fresh ligatures are passed through
the old perforations, and drawn from time to time, till the part
sloughs and drops away. This will not be found necessary if incisions
are made betwixt the parts of the ligature in the first instance, so as
to permit of their being tightly drawn. The swelling may be relieved
by hot fomentations, and opiates mitigate the pain. The discharge is
profuse and fetid. A weak solution of the chloride of soda, vinegar
with honey, or a solution of the mel boracis, may be used as gargles.
The healing of the wound is to be promoted by applications suited to
the appearances which it may assume.


_Inflammation of the Tongue_ occasionally occurs during certain
eruptive diseases, and sometimes in consequence of accidental
circumstances, as stings in the part from venomous insects; but it
is not a common, affection, and is generally produced by the abuse of
mercury. When that poison was used more freely than now, the disease
in question was by no means rare. It was then customary to see
patients who were made to spit some gallons in a day, for the cure of
a venereal affection, supposed or real, with their faces swollen, and
their tongues protruding from their mouths, enormously enlarged. This
consequence of the exhibition of mercury is more apt to occur in some
constitutions than in others, and I have seen it produced in a violent
form by the patient’s taking only two Plummer’s pills. In this case
the patient, an old gentleman of broken constitution, had been filled
brimful of mercury, over and over again, for one disease or another in
warm climates.

[Illustration]

The tongue swells rapidly, fills the mouth, and protrudes of a brown
colour, from effused serum, with great enlargement of the papillæ.
The patient is unable to speak, deglutition and respiration are much
impeded, and thirst is excessive. In some instances the inflammation
proceeds to suppuration, but the more general termination is resolution.

In the more mild cases, a cure will generally be procured by
evacuating the bowels freely by means of saline purgatives, and by
local abstraction of blood; the blood may be obtained either from
the application of leeches, from opening several of the enlarged
superficial veins, or from slight scarifications. Afterwards astringent
lotions may be employed. But in more severe cases of glossitis, the
tumour is productive of very great inconvenience to the patient,
and is not unattended with danger; the difficulty in breathing may
amount almost to suffocation, and in such the treatment must be
active. Several free incisions are to be made longitudinally on the
dorsum of the tongue; from these the effused fluids are evacuated, a
considerable quantity of blood escapes, and consequently the tumour
speedily subsides. Superficial incisions are not sufficient, and
the practitioner should not shrink from cutting tolerably deep; for
although the wounds may appear ghastly in the engorged and tumid
condition of the organ, yet when the swelling subsides, and the tongue
regains its usual bulk, their size, as in other situations, is so
remarkably diminished, that they resemble trifling scarifications, and,
in some instances, are almost imperceptible. Their extent and number
must vary according to the size of the tumour, and the urgency of the
concomitant symptoms. If such practice should fail in diminishing
the swelling, and affording relief to the respiration, it may become
necessary to perform tracheotomy. If the inflammation terminate in
suppuration, the abscess must be treated on the same principles as
those occurring in other parts of the body.

The tongue is also subject to gradual and permanent enlargement. A
remarkable case of this nature occurred to me some years ago, and I
shall here detail it shortly. The patient was a male, aged 19. The
tongue was of a very large size, compressible and elastic, projected
three or four inches from the lips, and completely filled the cavity
of the mouth. It was of a dark brown hue, in some places livid; its
surface was rough, at some points granulated, at others fissured,
and at many traversed by large venous trunks. At the back part of
the dorsum, the papillæ were much enlarged, granulated points were
numerous, and several plexuses of dilated blood vessels ramified
immediately beneath the investing membrane. There was occasional
bleeding from an ulcerated fissure near the centre of the dorsum,
and also from the lateral parts of the protruded portion: in the
latter situation, several cicatrices were visible. Saliva flowed in
a continuous stream from the apex of the tumour. The lower jaw, much
separated from the upper, was elongated and unusually narrow; the
teeth, particularly those in front, were placed at a distance from each
other, were covered with tartar, and projected almost horizontally
from the sockets. A depression was felt at the symphysis mentis, as
if the two portions of the jaw were asunder, and the intervening
space occupied by ligamentous matter. The enlargement was congenital,
and the organ swelled rapidly, it was stated, every three months to
a much larger size, and subsided gradually. The bleeding was most
frequent and profuse when the swelling was greatest, and then too he
suffered much pain in the part. Articulation was very indistinct,
and could be understood only by those who were accustomed to be
near him. He swallowed, and even masticated pretty freely. From the
periodical enlargement and diminution, from the repeated hemorrhages,
and from erectile tissue being visible on many parts of the surface,
I considered the structure of the tumour to be in part similar to
that of aneurism by anastomosis, and to be throughout extremely
vascular. I therefore did not attempt removal by incision, but in the
first instance intercepted its vascular supply by tying both lingual
arteries. The tumour was not affected immediately on the application
of the ligatures, but soon began to diminish gradually. Everything was
proceeding favourably; but, on the seventh day, the tongue was attacked
with inflammatory swelling, which advanced unsubdued, notwithstanding
the most active treatment. Sloughing commenced at the apex, and
appeared extending backwards; I then isolated the protruded portion
of the organ by ligature, and thus removed it in three or four days.
At that time he complained of no pain, and felt very comfortable.
But his system became much disordered soon after; abscesses formed
rapidly over both wrists and on the hands, unhealthy infiltration of
the cellular tissue took place at the root of the tongue, and amongst
the deep muscles at the upper part of the neck, the parts became
gangrenous, and he died. Dissection showed that the greater part of
the tumour was composed of erectile tissue. A sketch of the lower jaw
is here appended, in order to show the alteration in form, both at the
symphysis and in the rami, which had resulted from the pressure of the
organ and the necessarily constant open condition of the mouth.

[Illustration]

Enlargement of the tongue occasionally takes place in young subjects,
a sort of simple hypertrophy, which often proceeds to a very great
extent. The increase goes on in a remarkable manner after the organ is
extruded beyond the lips, so that the patient is incapable of covering
it. Portions of the swelling of a V shape have been removed in such
cases, and the edges of the wound put together. But by well managed
and continued pressure the absorption of the swelling has been brought
about, the organ has been reduced within the oral aperture, and a cure
has then rapidly followed.


_Division of the Frænum Linguæ_ is sometimes, though rarely, required.
Division can be necessary only when the frænum is so short as to
confine the point of the tongue, prevent free motion of the organ,
and thereby cause indistinctness of articulation. Infants are often
supposed by anxious mothers to have their tongues unduly confined,
when no such malformation exists; in such circumstances, it is
almost needless to observe that the part ought not to be interfered
with. And even when there is confinement, division should not be had
recourse to, unless the child is prevented from taking nourishment. The
operative procedure is simple and safe. The tongue is raised towards
the palate, either by a spitula or split card—or, what is better, by
the fingers—and the frænum is cut across to a sufficient extent by
blunt-pointed scissors.


_Ranula_ is a swelling produced by accumulation in, and distention of,
the extremity of the combined ducts of the sublingual and submaxillary
glands. The extremity of the duct contracts, or is completely closed,
and in consequence of the saliva and mucus (the one the secretion of
the gland, the other of the duct) collect, distend the canal, and cause
thickening of the parietes. Thereby a tumour is formed, which, in
some instances, attains a very large size, displacing in some measure
the neighbouring parts, and incommoding the tongue in particular.
Indistinct utterance and impeded deglutition result.

The orifice of the duct, if discovered, is to be dilated gradually
by occasional introduction of variously sized probes. Often it is
necessary to make a small incision in the situation of the orifice, and
introduce a bit of gum-elastic bougie, by continuing the use of which
for some time, permanency of the opening may be obtained.


_Deposition of Earthy Matter_—principally phosphate of lime—not
unfrequently takes place in the extremity of the submaxillary and
sublingual ducts, and the concretion so formed is often of considerable
size; some are larger than an almond. The colour is either white or
yellowish, and the surface either smooth or roughened by nodules;
in all the calcareous matter is friable, and disposed in concentric
layers. They are of the same nature as the earthy deposits, called
tartar, which form on those teeth opposite to the extremities of the
salivary ducts. The foreign body produces uneasiness in the mouth,
swelling, and indistinctness of speech; occasionally painful swelling
of the salivary gland and surrounding parts takes place. Concretions
also form, though very rarely, in the extremity of the parotid duct,
and are attended with like inconvenience; of this I have seen only two
cases.

The foreign body is easily removed; an incision is made through the
membrane of the mouth, and the concretion dislodged by forceps, a
scoop, or the fingers. The saliva regains its course, and irritation
subsides. Sometimes the foreign body is exposed by ulceration, and
might ultimately escape from its bed spontaneously.

[Illustration]

A figure of a salivary calculus of considerable size is here given.
When the concretion is small, its extraction is not so easily
accomplished as might be supposed. It is apt to slip back out of reach,
so that it cannot be seized, brought forward and extracted either by
scoops or forceps. The flow of saliva must be promoted by giving the
patient something to masticate; the probability is, that the foreign
body will then be presented, and perhaps expelled, if the opening of
the duct has been previously dilated. A young lady was brought to me
lately suffering great uneasiness from the presence of a concretion,
not larger than a millet-seed. She complained of great pain under the
jaw on seeing anything savoury, that, as the vulgar phrase is, made her
mouth water. Various unsuccessful attempts had been made to remove it.
A small incision of the surface of the duct was made, but the foreign
body eluded the grasp of the forceps, and completely disappeared. The
patient was given a bit of bread to chew, and almost immediately the
concretion was expelled.


_Tumours_, unconnected with the salivary ducts, occasionally form
in the loose cellular tissue under the tongue. They may be either
sarcomatous or encysted; the former are rare. I have removed several
solid tumours, principally adipose, from this situation. They were
loosely connected, and taken away without almost any dissection; indeed
they were lifted out with the fingers, after division of the membrane
of the mouth and of the cellular cyst which surrounded them. One was
as large as an orange, and of a flattened form. The tongue had been
displaced by the swelling, and articulation, deglutition, and breathing
impeded. The patient, an old lady, had a good recovery. The case had
been by some mistaken for ranula; and I mention this circumstance, lest
others may reckon more on the situation of a swelling, than on its feel
and other external characters. A sketch of the tumour is given at page
137.

Encysted tumours below the tongue are common. The cysts are generally
thin and adherent, the contents albuminous and glairy. They attain a
large size, and prove very inconvenient. Occasionally the cysts are
thick and more loosely attached; such usually contain atheromatous
matter. I removed one uncommonly large, from the inner surface of which
numerous hairs were growing.

Encysted tumours here can seldom be removed by dissection; the depth of
their situation, their firm connexion, the awkward situation in which
the patient is necessarily placed, and the risk of hemorrhage, forbid
the surgeon from attempting regular extirpation. A more simple and
equally effectual procedure is as follows:—The membrane of the mouth
and the cyst are divided by the point of a bistoury; and if the tumour
be large, and the distention great, an oval portion of the parietes
may be cut out. The contents are thus evacuated. The bleeding is
allowed to cease, and the cavity having been wiped out clean, a stick
of caustic potass is applied to the surface, so as to annihilate the
cyst effectually. This I believe to be the only radical and safe mode
of removal; after any other, the tumour is certain to be reproduced.
It has been recommended to pass a seton, so as to excite inflammatory
action, and lead to obliteration of the cyst. I have made trial of this
practice, but most dangerous swelling ensued, the mouth was rapidly
filled, and the system alarmingly shaken; after all the disease was not
eradicated.

Tumours beneath the tongue, however originating, occasionally inflame,
and become the seat of unhealthy abscess. A large and painful swelling
forms, and projects under the chin. The matter gradually approaches
the surface, and perhaps evacuates itself imperfectly into the mouth,
or the integuments give way, and afford an external issue. In such
cases, an early incision from the mouth may prevent the internal
mischief, and the disfiguration of the countenance which would
otherwise ensue may, in short, limit the suppuration; at a later period
a free opening requires to be made below the chin, in the mesial
line, and in the direction of the muscular fibres. A ready drain is
thus obtained for the matter, and the cavity of the abscess gradually
contracts.


_Tumours of the Gums_ are usually hard, and not inclined to increase
rapidly. They are of the same consistence as the parts to which they
are attached, and grow either inwardly, outwardly, or both. They
surround one or more teeth, which at last become loose, the alveolar
processes then soften, and form part of the swelling.

These may degenerate, and grow rapidly, or the tumour may be soft
(tumor mali moris) from the first. The attention of the patient is
directed to the part by the occurrence of discharge from about the
teeth, which loosen one after another. A soft tumour arises from the
sockets after either extrusion or extraction of the teeth, it grows
rapidly, and involves more and more of the gums and alveolar processes.
Angry ulceration attacks the prominent parts of the swelling; the
bone is softened to a considerable extent around; the discharge is
thin, bloody, and profuse. Ultimately the lymphatics become affected,
neighbouring parts are contaminated, malignant action acquires a firm
footing, and extends, the patient becomes hectic, and dies.

Each kind of tumour should be removed freely and early; the untoward
results of the latter have been already mentioned; and I believe
that, if the former be allowed to proceed unchecked, the tumour may
ultimately extend to the bone, and osteosarcoma of the jaw, more or
less extensive, be established. The disease must be attacked at an
early period of its existence, and teeth, sockets, and soft parts taken
freely away, by means of a strong knife and saw, or cutting forceps.
After excision, the actual or potential cautery should be applied,
otherwise the disease is apt to recur. Portions of involved bone, which
may have escaped the knife, are by the caustic made to exfoliate. When
the potassa fusa is used for the purpose of destroying what cannot be
readily reached by the knife, and when it is pushed into the alveoli
and applied to the altered gum, its action must be limited by the
immediate use of vinegar, diluted or not.


_Inflammation of the gums_ and neighbouring parts is attended with
violent pain, swelling, and throbbing, difficulty in opening the mouth,
headache, and fever. Inflammation of the soft parts runs its course
speedily, and, as the cause is seldom removed during the existence
of the inflammatory action, generally terminates in suppuration, so
giving rise to what is termed _parulis_ or gumboil. Frequently the
inflammation extends to the sockets of the teeth, which seldom resist
the action long, but from their low degree of vitality soon become
necrosed; and by the presence of the dead portions of bone, a fresh
accession is given to the disease. Severe pain is experienced on
touching the teeth whose alveoli are affected; they project and become
loose; purulent matter is secreted, and oozes out between the loosened
teeth and diseased gums. Abscesses form, and point in different
situations; the gums are tumid and spongy; through the openings in them
the bone can be felt bare, and the purulent matter is situated within
or around the alveoli, and under the mucous membrane and cellular
tissue which invest them.

When the inflammation has been either intense from the first, or of
long duration, it not unfrequently happens that abscesses form within
the substance of the jawbone, and occasionally to a considerable
extent—a portion of the bone having become inflamed, and the action
terminating in suppuration and partial caries. This is more apt to
occur in the inferior than in the superior maxillary bone; and,
if allowed to proceed, the osseous cyst containing the purulent
matter gradually enlarges, the plates of the bone are separated and
expanded, the parietes become attenuated, and the affection is termed
spina ventosa. Purulent collections in this situation also seem, in
many instances, to arise from, or at least to be preceded by, the
formation of a cyst around the decayed root of a tooth. Such cysts
are generally of small size, and pyriform shape; externally they are
smooth, membranous, and of rather a delicate texture; internally,
they are lined by lymph of soft consistence, and contain purulent
matter. In fact, they are purulent depôts, which form in consequence of
inflammation around the fangs of the teeth, and from which the matter
is occasionally discharged through a small aperture at the upper part
of the cyst, and by the side of the affected tooth. They sometimes
attain a very considerable size.

[Illustration]

Mercury is perhaps the most common cause of this disease; but it is
also produced by certain operations on the teeth, and by the presence
of carious teeth or of stumps.


_Caries of the teeth_ is an extremely common affection, and in some
instances seems to arise from an unhealthy state of the constitution;
but it is most frequently produced by the teeth having suffered from
chemical agents, as when the mineral acids have been taken for a
considerable time as medicines, or when the individual is in the habit
of consuming sweetmeats, and confections. Sometimes the disease remains
almost stationary, and may give little or no annoyance for a number of
years; in other instances, its progress is very rapid. A portion of the
tooth gradually decays, and this is at first unattended with any uneasy
sensation; but when, from continuance of the destructive process, the
central cavity has been exposed, the pain is excruciating, attended
with headache, and swelling of the surrounding soft parts. In general,
the progress of the disease may be arrested by removing the diseased
portion, and stuffing the cavity, before any pain has been felt.
But after the central cavity of the tooth has been exposed, filled
with fungous mass, as here seen, or from their growing in a faulty
direction, and pain consequently experienced, the most effectual
remedy is extraction. The patient from whom the specimen below was
obtained, perished in consequence of the extensive abscesses of the
mouth and neck, consequent upon the awkward position of the wisdom
tooth.

[Illustration]

From the presence of carious teeth, or decayed portions of teeth, many
evils both local and general ensue, besides inflammation and abscess.
They are frequently the cause—and the sole cause—of violent and
continued headaches; of glandular swellings in the neck, terminating
in, or combined with abscess; of inflammation and enlargement of the
tonsils, either chronic or acute; of ulcerations of the tongue or lips,
often assuming a malignant action from continued irritation; of painful
feelings in the face, tic doloureux, pains in the tongue, jaws, &c.;
of disordered stomach, from affection of the nerves, or from imperfect
mastication; and of continued constitutional irritation, which may give
rise to serious diseases.

Along with abscess of the gums, purulent matter often collects in the
cellular tissue of the cheek or of the chin. In the latter situation,
the inflammation and suppuration are often caused by the teeth in
the front or side of the lower jaw being too much crowded together.
When the teeth are crowded together, the patient, of course, cannot
be effectually benefited till one or more of them are extracted, and
sufficient space allowed for development of the others. The abscess
gives way, and discharges its contents often both externally and
internally, and a fistula remains, which cannot be got rid of, unless,
as in most other affections, the cause be removed. The cavity of the
abscess must be opened into either from without or within, and after
the subsequent irritation has subsided, the cause must be removed;
carious teeth or stumps are not to be taken away during the inflamed
state of the parts, but after the pain and inflammation has subsided in
consequence of free evacuation of the purulent matter. After these have
abated, and not till then, the offending bodies are to be extracted,
both in order to procure a more speedy and effectual cure, and with
a view to prevent recurrence of the disease. If a portion of the jaw
has become necrosed, the sequestra are to be extracted as they become
loose, and openings and counter-openings must be made, according to
circumstances, so as to afford a free outlet to the matter.

The extraction of teeth, the crowns of which have not been destroyed,
is accomplished most readily by the dexterous use of variously shaped
forceps. Stumps may be occasionally extracted also by forceps, but
the lever is generally required to loosen them from their sockets.
The old key instrument and pelicans are now superseded by those above
mentioned.[37]

[Illustration]

_Spina Ventosa of the Jaw_ often originates, as before mentioned, in
a small cyst at the root of a decayed or dead tooth. An enormously
large one extracted along with the stump attached is here shown: it is
sketched from a specimen in the collection of Mr. Nasmyth, of Edinburgh.

The disease is usually situated on one side of the lower jaw; but
sometimes occurs in the upper, and is at first unconnected with the
cavity of the antrum. Inflammation has taken place in the internal
structure of the bone; matter is secreted by the medullary vessels, and
collects in the cancellated texture. Purulent formation advances, the
cancelli are broken down, the external laminæ of the jaw are extended,
protruded, and attenuated; and then the internal cavity enlarges,
containing pus, perhaps mixed with other fluids, and with disorganised
particles of bone. Sometimes the collection proceeds slowly, and the
expansion of the bone is gradual and uniform; in other instances, the
swelling rapidly attains a large size. As the disease advances, the
bony parietes become remarkably thin and delicate, particularly at
the more prominent parts of the tumour; and at many points bone is
deficient, and its place supplied by membranous expansion. Occasionally
alteration of structure takes place in the cyst; solid matter is added,
either bony or fibro-cartilaginous, and morbid action proceeds in the
new deposit. In acute cases, in which the secretion and distension
are rapid, severe pain is felt in the part at the first, and usually
continues but little unabated; when the swelling is slow and gradual,
considerable pain is experienced during the inflammatory stage, but
soon diminishes, or ceases entirely. In every instance, the features
are deformed, and the functions of the mouth more or less impeded.

Osteosarcoma may supervene on spina ventosa—morbid action occurring
in the parietes, and morbid deposit ensuing, as in the following
instance:—The patient was a male, aged twenty-one. Swelling had
existed for a considerable time at the posterior part of the lower
jaw on the left side. The wisdom tooth and last large grinder, their
pulps probably having been blighted, never appeared, and the swelling
occupied their situation. The bone was expanded on each side; the upper
surface of the tumour was soft, its growth had been gradual, and no
great pain or uneasiness was experienced. I cut out an oval portion of
the cyst where it projected into the mouth, and well-digested matter
was evacuated; a seton was then passed out near the angle of the jaw,
and worn for some weeks. The plates of the bone approximated, the
cavity contracted, and the discharge ceased. Two years afterwards rapid
swelling took place in the same situation, suppuration occurred, and
the matter was again discharged by incision; the tumour then subsided.
Again inflammatory swelling occurred twelve months afterwards; the
same course was followed and the patient relieved. A hard swelling
now occupies the jaw from its angle to the canine tooth, it is
increasing in size; the necessity for its removal is apparent, and has
been decided upon. Very shortly after writing the above, the patient
submitted to the disarticulation and removal of fully half of the jaw,
represented here. He made a rapid recovery, and showed himself to me
and the pupils at the hospital a short time since, and fully five years
from the time of the operation, in remarkably good health, and very
little deformed by his loss. His whisker effectually conceals the mark
of the incisions.

[Illustration]

But in general, after free evacuation of the purulent matter from a
bony cavity, even of very large size, the space between the parietes
diminishes rapidly, the distended and attenuated bone contracts and is
condensed, the new deposition is absorbed, and the parts regain their
natural and healthy appearance.

In the slighter cases of spina ventosa, removal of the offending teeth
or portions of teeth, is generally sufficient; the matter escapes
freely enough from the sockets, and the discharge soon ceases. When the
cavity is considerable and its parietes thin, a counter-opening at the
base of the jaw is required; and it is often of advantage to introduce
a small cord from the opening in the mouth through the counter-opening,
and to continue its use for a short time, drawing it backwards and
forwards in the cavity occasionally. For making the counter-opening
and placing the seton at the same time, a strong needle in a fixed
handle is most convenient. This practice I have employed in a good many
instances, and can confidently recommend as successful. In a large
spina ventosa, not complicated with solid growth, the parietes may be
removed freely and with safety; the cavity is dressed to the bottom,
and gradually fills up by granulation. The division of the integuments
to expose the tumour must vary according to the circumstances of the
case; the incision of the bone will generally be accomplished by a
strong bistoury. Such procedure will seldom fail in procuring a cure,
and is less severe, less dangerous, and productive of less deformity,
than division of the jaw and entire removal of the diseased portions,
an operation which can very seldom be warranted for spina ventosa. In
the following case, the tumour was the largest of this kind which I
have met with in the jaw, and yielded to the treatment just noticed.
The patient was a male, æt. 48; he applied to me in 1821. The tumour
had been of three or four years’ duration, equalled a large fist in
size, and involved the left side of the lower jaw at the junction
of the ramus with the body of the bone. The sac extended behind the
coronoid process, and downwards, through the substance of the jaw,
amongst the hyoid muscles. Several carious teeth and stumps were
imbedded in the swelling; the projection was chiefly lateral, the
parietes were yielding, and the line of the jaw could be traced from
below. There was occasional slight discharge of purulent matter from
the neighbourhood of the involved teeth. The cheek was laid open, and
the bony and cartilaginous parietes of the cavity completely removed;
the bleeding from the bony surface was arrested by cautery and pressure.

The soft parts united kindly, and the patient obtained a rapid,
perfect, and permanent cure, returning home with the cheek united in
ten days after the operation.


_Solid Tumour_ of the Lower Jaw—_Osteosarcoma_—commences in the
internal structure of the bone, frequently in the neighbourhood of
stumps. The origin may be traced to external injury of the part; or the
disease may take place in the jaw, either along with osteosarcomatous
tumours of other bones, or subsequently to their development; in such
circumstances a peculiar disposition of the system is the only cause
that can be assigned. The tumour generally occupies the lateral parts
of the bone. Its growth may be either slow or rapid, and is attended
with dull uneasiness, rather than acute pain. At first the morbid
deposit is confined to the cancellated texture, but as it increases
the external laminæ are distended, and at last give way at one or
more points, and the tumour protrudes fungous into the mouth. The
consistence of the mass is various, it may be soft and brain-like,
or cartilaginous, mixed with bone and fibrous matter in various
proportions; but the anatomical characters of these tumours have been
already detailed, and need not be here repeated. The features are much
deformed, the swelling seriously incommodes the neighbouring parts;
the teeth loosen and drop away, and fungi arise from the sockets; a
fetid, thin, sometimes bloody discharge is secreted copiously, and the
health declines. The part protruding around the gums is deeply indented
by the teeth of the upper jaw; it separates the jaws to a greater or
less extent, prevents closure of the lips, induces salivation, and
impedes the taking of nourishment. The tumour is one of those which
are apt to be reproduced, and if unmolested, gradually undermines the
system, and ultimately the patient perishes very miserably. At one time
every instance of it was regarded as hopeless; but of late a great
many tumours, in various stages of advancement, have been removed
successfully by British and foreign surgeons. In some instances,
the portion of the jaw containing the morbid growth has been sawn
out; in others, one half of the bone, or more, has been removed by
disarticulation, after being divided beyond the diseased part. A very
few weeks ago, I had occasion to remove fully three-fourths of this
bone, from the site of the first large molar on the left side to the
condyle of the right. The patient, an elderly female, is convalescent.
The operation is severe, and to a spectator shocking enough; but it can
be undertaken with safety, and in most cases with almost a certainty of
favourable termination. In no other way, assuredly, can the disease be
eradicated. Partial excisions, applications of the cautery, &c., only
hasten the malignant process.

To expose the tumour and admit of the bone being readily divided,
incision of the soft parts requires to be extensive. And previously to
determining on the plan of operation, the extent of the disease must
be ascertained accurately. If, for example, the tumour is included
between the lateral incisor tooth and last molar on the same side—these
teeth must be extracted to permit division at these points. A semilunar
incision may then be made along the base of the jaw, the horns of the
incision pointing upwards and passing over the space which was occupied
by the extracted teeth. The flap is dissected up, and the membrane of
the cheek divided along the line of incision. The bistoury is then
carried along the inside of the bone so as to divide the membrane of
the mouth and separate the attachments of the muscles. The tongue is
pushed aside, and a copper spitula placed under the jaw at the part to
be divided, in order that the soft parts may not be injured during the
sawing. A small narrow saw, or one commonly known by the name of Hey’s,
is applied to the bone at the points where the teeth were extracted,
and by a few motions of this instrument a notch is made of no great
depth; a pair of strong cutting pliers are placed in the track, and by
them division of the bone is accomplished with equal neatness, and
much more rapidly than if the use of the saw had been continued. The
pliers should be strong in every point, and the handles long, to afford
the advantage of a powerful lever. In edentulous subjects, as the one
alluded to above, there is no necessity for using the saw at all: the
bone is at once and easily cut by the forceps. The chain saw has been
recommended for performing the section of the bone, but I have not yet
seen one to be depended on; it is not only slow, but uncertain, in its
operation.

The incisions may be made otherwise. The cheek may be divided by
passing through it a long narrow bistoury, close to the anterior edge
of the masseter muscle, and carrying the instrument forwards and
through at the angle of the mouth. From each extremity of this incision
another is made downwards, the anterior one inclining forwards, the
other backwards. By reflection of the flap thus formed, the bone is
exposed more easily, rapidly, and perfectly, than by the former mode
of incision. The objection to this mode of procedure is the deformity
occasioned by the scars, though, if care is taken in putting the edges
together, this is very slight indeed, and not remarkable.

In either method, no artery, except the facial, requires to be secured
by ligature. After division of the bone, the attachments of the
tumour, which may not have been separated previously, are cut with the
bistoury, the cavity is filled lightly with charpie, and the incisions
are carefully and neatly put together, and retained by points of
interrupted and twisted suture; the latter form of suture being adopted
at those points where accurate coaptation is most important.

The _symphysis_ of the lower jaw has been removed, and its extirpation
may again be rendered necessary, either on account of tumour commencing
in its internal structure, or from disease of the sockets extending
deeply and approaching the base. I removed it in a case of malignant
disease, by which, and by the applications used as remedies, great
ravages had been made on the under lip; the gums and alveoli were
involved, as also the bone, to a considerable extent, without any
apparent affection of the lymphatics. Nothing untoward occurred in the
operation, and the case was proceeding favourably; but after some weeks
the patient was seized with violent erysipelas of the face and head,
and perished. One objection to the operation is, that the muscular
attachments of the tongue to the symphysis cannot be divided without
some risk; the antagonist muscles are unrestrained; the os hyoides
and root of the tongue may be drawn backwards upon the forepart of
the vertebræ, so as to close the air-passage, and cause suffocation.
This is guarded against by the introduction of a thick ligature. The
disposition to retraction soon ceases.

Disarticulation of one side of the jaw is not unfrequently necessary;
it is absolutely required when the tumour encroaches upon and involves
the angle and ramus. It is a more severe operation than excision
of part of the bone, and attended with greater risk; yet it may be
advised and undertaken with a very fair and probable chance of ultimate
success. The incision of the cheek is made to incline more upwards
than those recommended for partial excision, and is extended to over
the articulation of the jaw; from this point, another is made in
the direction of the ramus, and prolonged an inch or more beyond the
angle. A third incision is made perpendicular to the first, or to the
lower lip, over that part of the bone in front which is to be divided.
The flap is turned down, and the muscles and membrane of the mouth
separated from the bone opposite to the last incision; after which,
the finger is passed through to complete the detachment. A preferable
form of incision along the posterior border of the ramus and under the
base of the jaw and tumour to over the point at which the bone is to be
sawn, but without division of the lip, is recommended in the _Practical
Surgery_. This method I have practised repeatedly; the cicatrix is
then completely out of sight, and in the male is entirely covered and
concealed. During the cure, also, the discharges escape more readily,
the opening being quite dependent. The bone is then divided at that
point by the saw and pliers, the tooth in the line of the track having
been extracted previously to the commencement of the operation. The cut
end of the jaw is laid hold of by the left hand, and depressed, and
the bistoury carried backwards along the internal surface, to effect
detachment as far as the angle. The bone is still more depressed, and
the temporal muscle cut from the coronoid process. The mass is thus
loosened, and forced downwards and backwards on the neck; the forepart
of the capsule is then cut, and the bone twisted out. Separation of
the remaining attachments is completed by a few rapid strokes of the
knife, and the whole mass removed. Hemorrhage is then to be permanently
arrested, but instead of immediately tying every open mouth which
presents itself, it is sometimes better to expose the common trunk of
the internal maxillary and temporal arteries—which is easily effected,
as it emerges from under the digastric muscle—and to pass a ligature
beneath it, by means of an aneurism needle. This is more quickly done
than the applying of ligatures to the many branches of this trunk
which have been divided. The other vessels—the facial, branches of
the lingual, &c.—are then tied, the cavity is filled with charpie,
and the incisions of the soft parts are carefully closed. In these,
union by the first intention usually takes place nearly throughout the
whole extent; suppuration occurs from the deep wound; the charpie is
dislodged gradatim, and removed; granulations spring up; and, after
some time, the cavity is obliterated. The cheek must necessarily fall
inward very considerably, but the deformity is not to be compared to
that caused by the tumour. During granulation, the patient is made
comfortable by the frequent use of tepid gargles, lodgement of pus in
the mouth being thereby diminished. Articulation and mastication are
not so perfect as when the jaw was entire and sound; but the patient
gradually becomes accustomed to the want, and these functions improve.
A contrivance described in the _Practical Surgery_ is used to prevent
the remaining portion of jaw from being drawn towards the mesial line,
and to keep the teeth opposite to those of the corresponding side of
the upper jaw. Partial paralysis of the side of the face necessarily
follows, for there is no possibility of accomplishing disarticulation
of the jaw without dividing many branches of the portio dura.

Supposing that the portion of the jaw between the angle and
symphysis had been removed on account of osteosarcoma, and that the
ramus subsequently became affected, it is no easy matter to effect
disarticulation, as I have experienced.—The patient was a female, aged
30, of delicate constitution, and subject to toothache from infancy.
I removed an osteosarcomatous tumour, extending from the angle to
the canine tooth, on the right side. Division was made wide of the
existing disease, and the sawn surfaces appeared quite healthy; but
about five months afterwards, symptoms of return occurred in the
ramus, and ten months after the first operation disarticulation was
indispensable. The operation was accomplished with very considerable
difficulty, on account of there being no lever to overcome the action
of the temporal muscle. After separating the attachments as much as
possible, an attempt was made to force down the coronoid process, from
under the zygoma, by pushing the lower end of the bone backwards, in
order to divide the insertion of the temporal muscle; but this proved
ineffectual. The capsular ligament of the joint was then divided, and
the bone with difficulty turned over from behind, forwards. It was then
detached underneath the coronoid process, pulled down from under the
zygoma, and the temporal muscle at length divided at its insertion.

In none of these operations is there a necessity for preliminary
exposure and ligature of either the carotid artery or its branches; by
so doing, a great addition is made to the patient’s sufferings, the
real operation is only commenced when the patient supposes it should
have been finished, and he is thus annoyed and worn out. The flow of
blood is easily moderated, or altogether arrested, by the pressure of
an assistant’s fingers against the forepart of the vertebræ, below the
angle of the jaw.

The position of the patient is either recumbent, with the face turned
from the operator, or sitting with the head supported and steadied.

The instruments required are, a very strong, sharp-pointed bistoury,
for division of the soft parts; saws, of which Hey’s is to be preferred
for notching the bone; strong and long pliers, for completing its
section; an aneurism needle, for securing the common trunk of the
temporal and internal maxillary artery; dissecting and artery forceps,
hooks blunt and sharp, narrow copper spatulæ, ligatures, &c.


_Wounds of the Face and Neck._—Accidental wounds of the face may
involve the more important blood vessels and nerves, and interfere