Elements of Surgery (part 5 of 5)

Elements of Surgery (part 5 of 5)

There is no great risk of the bone again escaping from its situation. I have but once witnessed such an accident. A female suffered luxation of the hip nearly a month previously to her admission into the Royal Infirmary, and reduction was unavoidably deferred for three days more. It was accomplished without difficulty, and the usual precautions were afterwards adopted; but next day it was discovered that luxation had again taken place. The patient had cunningly contrived to have ardent spirits brought to her, and indulged freely in these, got out of bed, and slipped down. Replacement was again effected, more easily than before; the limbs were firmly secured to each other, confinement to bed and no farther indulgence in liquor were strictly enjoined, and after thirteen or fourteen days the limb fully regained its functions.

Luxation of the hip downwards and forwards, the head of the femur lying in the thyroid foramen, is generally produced by a fall under a heavy load, the thigh being at the same time forcibly abducted. I have also seen it occasioned by a fall with a restive horse. The limb is elongated considerably, and advanced a little forwards; the trochanter major is depressed, the toes are inclined neither outwards nor inwards; the limb is immoveably fixed, and this most unequivocally marks the nature of the accident.

The limb is lengthened when the trochanter major is split off, as also when severe bruise of the glutei has been inflicted without breach of continuity in any part of the bone, and without displacement. In the first stage of morbus coxarius, too, a somewhat similar appearance and position of the limb is presented; there is lengthening, but then there is also more or less wasting of the muscles, more mobility than in the dislocation, and a marked history attached. Complicated cases occasionally occur—as when a patient who has been labouring under hip-joint disease, perhaps not in an aggravated form, falls heavily, and on being lifted up is found to be incapable of moving the joint, the limb at the same time being elongated, and having a distorted appearance. An instance of this nature impressed strongly upon me the great necessity for accurate diagnosis in the first instance, and that such was to be acquired only by taking every circumstance into consideration. A young man was engaged in cleaning a slaughter-house, standing on two blocks of wood with his legs considerably apart. One of the blocks suddenly slipped from under him, and he fell with his limbs spread. He was carried home in great pain, and next day I was asked to visit him. The limb was elongated, and the hip flattened; the joint was stiff, and attempts at motion produced great pain; but by perseverance the limb could be put in various positions, and the trochanter was not so much depressed as in luxation downwards. By cross-examination it was discovered that the patient had halted in walking for many weeks previously, had felt as if the limb was longer than the other, had pain in the groin and knee; in fact, morbus coxarius had been advancing, and the pain, immobility, and greater elongation had been occasioned by the fall, causing violent excitement of the morbid action previously in progress. Dreadful consequences must have resulted from mistake in diagnosis and practice founded upon it. I have observed, in other cases, great and rapid elongation of the limb in consequence of injury to the hip-joint previously diseased; and I have known instances in which persevering and forcible efforts were made to reduce the supposed luxation.

The reduction is in many cases difficult. In young and muscular individuals, after the lapse of some hours, when reaction has occurred, the muscles are rigidly contracted, and the head of the bone is not easily dislodged. Extension, made to a certain extent and continued, is not so useful or essential here as in other forms of luxation of this joint. Adduction, carrying the injured thigh quickly and forcibly over the other, is generally successful; and the reduction is favoured by at the same time raising up the neck of the bone, by means of a towel or wooden roller passed under the upper part of the thigh. There is also no such advantage from rotating the bone as in other luxations. It is very often necessary, even in recent cases, to adopt measures to weaken muscular exertions; and again, in cases of three weeks’ duration, I have found no difficulty.

The head of the bone, when dislodged from the foramen obturatorium, may slip past the cotyloid cavity, for it is impossible to regulate its direction; it comes to be acted upon by muscles which have been displaced, some being compressed and partially paralysed, whilst others are excited; they have been put out of their usual condition and relation, and act irregularly. The head of the bone may, from this cause, get into the sacro-ischiatic notch. This has occurred to me; but I have found no difficulty in removing it from thence, and effecting reduction satisfactorily.

Displacement into the sacro-ischiatic notch is attended with great and remarkable inversion of the toes, slight shortening of the limb, the prominence of the head of the bone felt under the gluteus maximus. It is the least common form of luxation. Reduction is attempted by extension and rotation outwards, at the same time pulling the head of the bone towards the acetabulum by means of a towel passed under the thigh.

Luxation of the head of the femur on the pubes is perhaps more frequent than any other, excepting that on the dorsum of the ilium. The limb is not much shortened, the toes are everted, the trochanter major is depressed, and nearer to the anterior superior spinous process of the ilium than usually, and the head of the bone is both seen and felt prominent in the groin. Much pain, swelling, and sometimes more or less paralysis of the limb, are occasioned by this displacement; the femoral artery and vein lie immediately interior to the head of the bone, and are compressed, and the crural nerves are stretched over it. In attempting reduction, rotation inwards should be employed during extension, accompanied with endeavours to lift the upper part of the bone towards the acetabulum.

[Congenital Luxation of the Hip-joint is sometimes met with, though on the whole a very rare affection, especially in this country. Female children are more apt to suffer from it than males, and it is also more common in such as are of a scrofulous habit than in such as are endowed with a good constitution. Of twenty-six cases of this malformation observed by Dupuytren, not above three or four were males; a disproportion probably not altogether dependent upon chance. The immediate causes of this variety of displacement are, first, shortness, total absence, or extreme obliquity of the neck of the thigh-bone; secondly, partial or entire obliteration of the cotyloid cavity; thirdly, deficiency, extraordinary elongation, or complete absence of the round ligament.

The characters of this malformation are, shortening of the affected limb, unnatural projection of the great trochanter, ascent of the head of the femur into the iliac fossa, inversion of the leg, and obliquity of the pelvis. The motions of the joint, particularly those of abduction and rotation, are constrained and imperfect; the muscles of the upper part of the thigh are retracted, or drawn towards the iliac crest; the limb is thin, wasted, and out of all proportion to the rest of the body; the tuberosity of the ischium is almost uncovered, and consequently unusually prominent; the upper part of the trunk is thrown backwards, while the lumbar portion of the spine projects forwards, being concave behind; the pubes is placed almost horizontally on the thighs; and the ball of the foot alone touches the ground when the child stands erect.

In the recumbent posture, when the weight of the trunk is taken off, and the muscles are relaxed, most of the symptoms of the luxation disappear, and the limb may be shortened or elongated at pleasure. In walking, the body is inclined towards the sound side, and the head of the dislocated bone sinks towards the cotyloid cavity by its own weight. As age advances, the limb becomes shorter, in consequence of the femur ascending higher and higher on the ilium; the obliquity of the pelvis augments; and the power of locomotion, already so much impaired, is completely destroyed.

Congenital dislocation of the hip-joint may, in general, be easily distinguished from other accidents or maladies, by the affection being observed at or soon after birth, by the obliquity of one or both thighs; by the absence of pain, swelling, and ulceration; by the head of the femur being displaced without any external violence; and by the ability of the surgeon to lengthen or shorten the limb at pleasure. In disease of the hip there is always more or less pain, with a feverish state of the system, and gradual failure of the strength; the parts about the joint are tense and swollen; the limb, at first somewhat lengthened, becomes afterwards shortened, and cannot be extended without the greatest suffering; and the motions of the ileo-femoral articulation are forever impaired.

The post-mortem appearances vary. In general the cotyloid cavity is partially obliterated, or entirely deficient, being replaced by a small, irregular, osseous prominence, devoid of cartilage and synovial membrane; the head of the femur, often flattened at its antero-internal aspect, rests in a sort of superficial fossa on the dorsal surface of the ilium; the round ligament, as was before remarked, is elongated, partially worn away, or even altogether absent; and the surrounding muscles are either atrophied, transformed into a species of yellowish fibrous tissue, or preternaturally developed. In the latter case, their action is preserved; in the former, it is very much restricted, or totally impeded.

The prognosis is always unfavourable, as the patient dies either young, or remains permanently lame and deformed.

The treatment can be only palliative; and as the weight of the trunk is the main agent in aggravating the displacement, repose is obviously indicated: but it is not necessary to confine the patient to the recumbent posture; since, in the act of sitting, there is no stress on the femur, the body resting principally on the tuberosities of the ischia. Dupuytren thought favourably of the cold bath: it should be strongly impregnated with salt, and the body immersed for three or four minutes at a time. He was also in the habit of using a well-stuffed belt, about four inches wide, for surrounding the pelvis and fixing the great trochanters; thus binding the ill-adapted parts together, keeping them at the same height, and preventing that continued motion to which they are otherwise so much exposed.]

Luxation of the Bones of the Leg.—separation of them from the end of the femur—seldom occurs. It can be the effect only of great violence and great laceration. Most frequently fracture is concomitant, perhaps with wound; and such accidents require amputation, either primarily or secondarily. Subluxation, from laceration of the internal lateral ligament, is not so unfrequent. It is most common in females, the natural conformation of their thigh-bones disposing them to bend inwards; and from falling awkwardly, particularly if carrying a weight, the ligament is apt to give way. The limb is pained, deformed, and unable to support the body, and swelling to a considerable extent soon follows. Reduction is extremely easy; and the parts are retained in site by the application of a wooden splint, to either the outer or the posterior side of the joint, the leg and foot being previously bandaged. The joint remains long weak, and never recovers entirely; a sustaining apparatus, fitted on the outside, retained by straps, and with a joint opposite to the articulation, is required to be constantly worn when the patient wishes to use the limb.

Luxation of the Patella is spoken of by some as common. Others of much experience have not met with a single instance of it. I have never seen this accident. The bone, it is said, may be displaced outwards, inwards, or upwards. The first form of luxation is the most frequent, and is caused by a severe fall, with the foot twisted outwards and the knee inwards. Displacement inwards is produced by direct violence applied to the outer part of the bone, or by the foot being turned inwards in a fall. Displacement upwards can occur only after laceration of the ligamentum patellæ, the bone being then drawn up by the unresisted action of the muscles on the fore part of the thigh. In dislocation outwards, the bone has been found “resting with its inner edge upon the outer surface of the condyle, the fore part facing obliquely forwards and inwards.” In this last form of accident, sudden, forcible, and complete flexion of the limb is said to produce immediate reduction. In dislocation outwards or inwards, the muscles are to be relaxed by raising the heel, extending the limb, flexing the thigh, and then forcing the bone to its proper site by manipulation. In the dislocation upwards with rupture, the limb is to be kept extended and raised, and the bone is brought as nearly into its place as possible by bandaging. When a peculiar laxity of the apparatus about the joint exists, whether as a cause of luxation or not, the support of a well-made knee-cap is required.

As formerly stated, Dislocation of the Ankle cannot take place inwards or outwards, without fracture of the end of the tibia or of the fibula, either above the articulation, or where they project by the sides of the astragalus for the greater security and strength of the joint. Subluxation, however, or sprain, may occur without injury of the bones: in this accident, should the parts not have spontaneously resumed their original situation, no difficulty is experienced in putting them to rights; simple manipulation is sufficient. Occasionally, the foot is luxated forwards, by force applied either to the heel or to the fore part of the leg whilst the limb is fixed. The heel is shortened, the foot elongated; indeed, the marks of the injury are so distinct, that comparison of the limbs is sufficient for diagnosis. Luxation may also take place backwards; and in this case the heel is elongated and the foot shortened. In these accidents it is not unfrequently found that one or other malleolus has given way, or that the lower end of the tibia is split. Reduction is sometimes difficult. Extension is to be made by grasping the foot and pulling whilst the limb is fixed, at the same time making pressure either backwards or forwards, as may be required. To retain the bones in their proper situations, it is always necessary, at least prudent, to apply a paste-board or leathern splint to each side of the limb, particularly when fracture of the malleoli is conjoined.

Displacement of the Bones of the Tarsus may result from great force; for example, when the foot is squeezed under a heavy weight, one or more bones may escape from their connections, and project. Reduction of such displacement is exceedingly difficult at any period, and becomes almost impossible when inflammatory action is allowed to supervene previously to attempts being made. The astragalus is sometimes pushed out of its place; though it is difficult to conceive how, to a bone so hid and so firmly connected, such force should be applied as to cause protrusion of it from its natural situation. It has been found lying on the dorsum of the foot, causing swelling, lameness, great pain, shortening and deformity of the limb; and the shape of the bone can, in such circumstances, be distinctly felt and seen through the integument. As already observed, reduction is almost impracticable, and, with the view of remedying deformity, it has been proposed to cut out the displaced bone; but as to the expediency of such practice I can give no opinion.

I have seen but one instance of displacement of this bone backwards, and most probably another will never occur to me. A heavy young man, in a state of utter intoxication, fell backwards down a stair, and in the fall his foot became entangled in the railing. The astragalus was found lying betwixt the back of the tibia and the tendo-Achillis, its upper articulating surface facing forwards, the lower in contact with the tendon. All attempts to reduce the bone proved fruitless. Violent inflammatory action followed, but was reduced by active measures; and the limb ultimately became very useful; in fact, though not till after many months, little lameness or shortening was perceptible.

By Sprain is understood subluxation or partial displacement of a joint, with stretching, and more or less laceration of the articulating apparatus—ligaments, tendons, sheaths, and bursæ, being all involved in the injury. Sometimes small portions of the processes of bone are separated, being torn away, attached to ligament or tendon. All joints, both large and small, are liable to the accident. In the proximal, or in the middle joints of the finger, for example, one or other lateral ligament is stretched or torn; the finger is twisted to a side; the joint is swelled; and this swelling, with pain, is of long continuance, perhaps increased by repeated twists, or by imprudent use of the joint. The elbow and shoulder are frequently sprained, as also the hip and knee; but the injury most frequently occurs in the wrist and ankle. It is generally occasioned by a fall, the foot or hand coming awkwardly to the ground, the muscles being at the time relaxed and unprepared; by over-exertion in lifting heavy weights; by entanglement and twisting of the limb, &c. The ankle is often sprained by what is called a false step; the fore part of the foot comes in contact with an obstacle unexpectedly, the foot is twisted under the limb, the weight of the body is thrown on the apparatus of one side of the joint, and this is in consequence immoderately and unnaturally stretched. Violent pain immediately occurs, and the patient is sick and faint. Discoloration and rapid swelling take place from extravasation of blood into the cellular tissue, into the sheaths of the tendons, and perhaps into the synovial pouches, in consequence of laceration of the bloodvessels. Effusion of serum and increased secretion of synovia afterwards occur, from incited action of the vessels. Thus the joint is deformed. Attentive examination is required to guard against mistakes; the existence or non-existence either of displacement or of fracture must be at once ascertained by determined and perfect manipulation; the parts must be pressed and moved, to such an extent as is necessary, notwithstanding the pain thereby occasioned, and notwithstanding the resistance afforded by the patient. It has been already stated that luxation of the wrist is not uncommon; that separation of the one bone of the forearm from the other, and transverse fracture or splitting of the radius, at the distal extremity, are accidents by no means rare. Great disfiguration follows simple sprain, much swelling taking place on the fore part of the limb from effusion under the fascia, and there is also much serous and bloody infiltration of the cellular tissue on the back of the hand and forearm. In the ankle, the ends of the bones must be carefully examined, and also the fibula in its whole extent, that the existence or non-existence of fracture may be ascertained, and that the surgeon may be guided to a correct mode of treatment. If the joint is not put at rest immediately, the extravasation is increased, and, in consequence, the pain and inflammatory swelling also; and parts of the joint at first not involved in the injury may thus be made to suffer. Many diseases of synovial membrane and articulating cartilages are attributable, and can be traced, to badly managed sprains; and in some constitutions, but slight injury, combined with a little bad treatment, suffices to destroy a joint. When, the case is well managed, the pain is never great, and soon abates; the swelling after a few days slackens; the discoloration becomes greater, the serum being absorbed, and the effused blood shining through the skin; the integuments appear green, blue, red, purple—these hues either being present all at the same time, or occurring successively; the discoloration often extends far from the joint. The mobility and strength of the joint are recovered gradually.

Perhaps no injury is more frequently mismanaged, by those both in and out of the profession. Every old woman thinks she can cure a sprain; most absurd and hurtful measures are resorted to; the injured parts are kept in motion; cold lotions and cold effusions are employed, and at the same time stimulating frictions: probably attempts are made, either by leeching or by puncturing, to extract the effused blood; and many similar follies are committed. The proper treatment certainly appears to consist principally in absolute rest and position. If there is any displacement it must be rectified immediately. If there is any fracture; or if there is a tendency to redisplacement after reduction; or if the patient is restless either from folly or from insensibility, as when the head has been injured by the accident, when the patient is under the influence of strong liquors, or when he labours under delirium tremens,—a splint or splints must be applied to secure immobility of the parts, at the same time without such compression as may interfere with swelling from effusion; the effusion is a salutary process, and should be encouraged, not repressed. By absolute rest and elevation of the limb, the extent of the swelling is limited, and inflammation warded off. Fomentations, properly employed, afford much relief; at first they probably encourage the serous effusion. The integuments soon become relaxed, during the regular use of fomentation, and tension and vascular action subside, as also pain. The swelling then abates, and is no longer hard; it pits on pressure, and the skin has a puckered appearance. Then gentle friction becomes advantageous, and uniform support should be afforded by the application of a flannel roller. The longer the limb is disused, the more perfect and rapid is the recovery, provided the rest of the cure be properly conducted. In general nothing more than what has been stated is required. But if the limb be moved, or stimulated in any way, early, then necessity will arise for antiphlogistic measures—perhaps venesection, certainly copious and repeated abstraction of blood by leeches, accompanied with fomentations, and the internal exhibition of antimonials, purgatives, &c. When such is the case the cure is tedious, the joint long remains swelled and stiff, the patient is lame and incapable of exertion.

Leeching or puncturing at an early period, with the view of allowing extravasated blood to escape, is useless and hurtful. The effused and coagulated blood cannot be evacuated, and suppuration, followed by destruction of the cellular tissue, has often been the consequence of such ill-advised proceedings. Friction with stimulating liniments, or even simple friction, at an early period, is also hurtful, as tending to excite vascular action, and to convert simple swelling into inflammatory. The application of cold at any period is of little use, and ought certainly to be avoided immediately after the injury, as adding to the sufferings of the patient, and interfering with the natural processes which have commenced for the reparation of that injury.

In limbs that have remained stiff after severe and mismanaged sprain, the dashing of water, either cold or tepid, has been strongly recommended. The practice is not ineffectual; the vessels of the surface are excited, perhaps as by other friction, and perhaps by the reaction which follows the chill. But the limb is apt to become rheumatic; and, on this account, the state of matters will not be improved by this proceeding, unless it be resorted to with proper precautions.

In severe sprains there is reason to think that sometimes even the tendons yield a little—that many of the fibres give way, and that thus the tendon is thinned and elongated. Such injury happens often in horses, in what is called breaking down. In them the tendon is occasionally snapped entirely through, and the ends widely separated. The same occurs in the human subject. Separation of the muscular fibres, however, is rare; laceration of the tendon itself, or separation of the tendon from the muscle, is more common. The yielding of the broad tendons on the upper and fore, lateral and under parts of the abdomen, affords an example of laceration of tendinous fibre from violent exertion. The tendons of the limbs are more frequently injured, and in the lower oftener than in the upper. I have more than once seen the tendon of the biceps torn in violent exertion. In the thigh, too, some fibres occasionally give way from a similar cause. The supra-muscular fascia in the arm and thigh is apt to give way at one or more points during powerful exertion of the muscles, causing deformity by protrusion of muscle through the torn space. But it is in the apparatus for extending the foot, and raising the weight of the body, that laceration of tendon most frequently takes place. The accident is uncommon till after the middle period of life, when the body has become heavier, when muscular exertions have been less habitually practised, and when the fibre has grown more rigid. The person in raising himself over some slight obstruction in walking, perhaps attempting to pass a small ditch or stile, suddenly “breaks down.” Or in dancing,—an amusement which he has long discontinued—a sudden snap is felt, with immediate lameness and slight pain in the back of the limb; swelling and discoloration follow; and these symptoms and signs vary in intensity according to the extent of the injury. Laceration may have been slight; the pain, swelling, and lameness are proportional, and at first an inconsiderable void can be felt at the upper part of the tendinous termination of the gastrocnemii. Sometimes no change is perceptible, and in such cases some have been of opinion that the slender tendon of the plantaris has given way and caused the lameness; but this is doubtful, and it seems more probable that stretching and yielding has taken place in some part of the tendon of the gastrocnemii, which had been in powerful action—probably, the tendinous and muscular tissues have been separated to a slight extent. Occasionally the tendo-Achillis is found completely torn through, and its upper end retracted; in such cases a large space is occasioned at the injured part, when the knee is extended and the foot bent. Sometimes the tendo-Achillis is cut through; I have seen both completely divided in the same individual—he received a wound by a cutlass across the back of both limbs, while endeavouring to escape from the mate of a vessel, in which he had been stealing. In rupture without breach of surface, the torn bloodvessels pour out their contents into the cellular tissue to a considerable extent, and if a proper mode of cure be not adopted immediately, inflammation quickly supervenes; and this is apt to terminate very unfavourably in the infiltrated tissue.

The tendon is united by the deposition of new matter, and the conversion of this into substance resembling the original structure from the vessels of which the deposit has taken place. The quantity of new formation necessarily depends on the extent of laceration and the space thereby occasioned. That such reparation of tendon does take place, and that to a very great extent occasionally, is placed beyond all doubt by the results of veterinary practice. “Knuckling over” in horses is occasioned by contraction of the flexor tendon; the heel does not reach the ground, and in order to effect this the tendon has been in many instances completely divided. The cut ends immediately separate, to the extent of some inches, and after a time this large space is filled up by a substance similar to tendon; so similar, indeed, that on post mortem examination, some years afterwards, a careless observer could scarcely distinguish any difference in the appearance of the various portions of the tendon. The same is observed after the operations for deformity of the foot in the human subject.

The treatment of lacerated tendon consists in placing the parts so as to relax the muscles whose tendons have suffered. In rupture of the tendo-Achillis, the knee should be bent and the foot extended, relaxing the muscle and approximating the separated ends. This is readily and conveniently affected by placing a slipper on the foot, and attaching to its heel a firm band, which is then fastened to a ring or strap placed on the thigh. This apparatus must be worn for six or eight weeks. Afterwards a high-heeled shoe should be used for some time; or if the union be still weak and imperfect, a splint may be placed on the fore part, resting on the dorsum of the foot and the fore part of the leg.

Bruise.—The effects of bruises or contusions are, separation of the cellular connexions, rupture of bloodvessels, and effusion of their contents into the cells; a cavity, often large, is thus formed partly by the direct injury, and partly by the subsequent effusion, and this is quickly filled with blood, partly fluid and partly coagulated. Immediate tumour forms; and the integument is discoloured, often beyond the principal swelling. The injury may, or may not, be attended with division of the integuments, or with fracture or displacement of the bones; but all injuries of the hard parts are attended with more or less bruising of the soft. Bruise is most frequently produced by a blow, and is most severe when the violence is resisted by an unyielding part, as by bone; a squeeze between two bodies, particularly if they be in motion, also inflicts extensive contusion. The swelling continues to increase for some time, and then gradually disappears along with the pain. As the tumour subsides, the discoloration increases; the thinner parts of the effusion have been absorbed, and the clot then shines through the skin, imparting to it various hues.

Bruise may be followed by inflammatory action. Then effusion is increased, bloody fluid is poured both into the cavity and into the unbroken cellular tissue, the whole parts become extremely tender, the surface inflames, and the excited action is apt to terminate unfavourably in the various tissues. Not unfrequently sloughing takes place, both of the skin and of the cellular tissue and fatty matter, with unhealthy suppuration and infiltration; and constitutional disturbance accompanies. All this is likely, nay, certain, to follow admission of air into the cavity filled with effused blood, whether by accidental wound or by intentional division of the integument. Meddlesome surgery is unfortunate here, as well as in many other cases. After scarifications, punctures, leechings, or incisions, the blood often seems to undergo a putrefactive process, and unhealthy suppuration is quickly established.

Sometimes the clot is not entirely absorbed, and considerable swelling remains for a long time, perhaps with slight tenderness of the part; a foundation is thus laid for abscess, either chronic or acute. Frequently the inflammatory action following on bruise is not so violent and rapid as that above described, but is limited in its consequences chiefly to the effusion of coagulable lymph. This may not be altogether absorbed along with the other effusion, it may become organised, and be the nucleus or germ of a new growth, of a tumour contrary to nature—deposit increases in and around the nucleus, and this formation, though at first of a simple nature, may become rapid in its growth, and may assume a troublesome or even a malignant action; and sometimes all this may occur at an early period, before the attention either of the patient or of the practitioner has been drawn to the action or to its effects. Many tumours can be traced to the effects of a bruise.

In the treatment of bruise, the parts should be placed in a state of absolute rest, and methodically fomented. Local bleeding is seldom required, and is of little use; at first it is hurtful. When, from the extent or number of the bruises, fever follows, general antiphlogistic measures must be resorted to. Cold and astringent applications, and other repercussives, as also stimulants, are pernicious in the first stage, and are not very useful at any time. Opening of the cavity must be carefully avoided, excepting when absorption has ceased, when the tumour has increased and become painful, and when the effused blood is putrescent, and unhealthy suppuration has commenced. Then the cavity should be opened freely, and by poulticing the clots and sloughs are got quit of; afterwards the parts must be supported, as also the strength of the patient. When from long want of use, in tedious cases, the parts have become cold, shrunk, and weak, as also happens in sprain, friction, champooing, tepid affusion, passive motion, and voluntary motion short of giving pain, will all be of use as tending to restore the circulation, the nervous energy, and the muscular development. If œdema remain, bandaging or a laced support will be required.

Amputation.—Every endeavour, which skill and experience can suggest, must be made before mutilation of the body, by the removal of even the smallest portion of one of its members, is resorted to. But there are cases in which mutilation, though a harsh remedy, is still indispensable for the saving of life. There are others in which it is prudent and proper to resort to operation, in consequence of a member becoming perfectly unserviceable, and likely to impair the usefulness of the individual. Such are very bad and complicated fractures and luxations—laceration of the soft parts of a limb to such an extent as to impress the experienced surgeon with a certainty that in a short time gangrene must ensue, and render the success of any attempt to save life very problematical. When the extent of injury is such that, though gangrene may not be dreaded, yet it is plain that extensive suppurations and exfoliations must necessarily take place, a question may arise as to whether immediate amputation is to be performed or not. This will be decided by the circumstances in which the patient is placed, and often also by his own feelings upon the subject. He may choose to run some risk, and endure much suffering, with even a very slight chance of ultimately preserving his limb. In cases of traumatic gangrene of the chronic form, amputation is not only justifiable, but imperative; as also in those cases of severe fracture in which the patient is sinking under profuse discharge, with disunited bones. And the same absolute necessity for operation exists in many diseased joints, and in some diseased bones, when the patient’s safety would otherwise be endangered, or when, on mature consideration, it is evident that the member, if retained, must for ever be an encumbrance, and worse than useless. Certain tumours of bones, tumours involving joints, tumours and ulcers of the soft parts of a malignant nature, and without appreciable disease of the lymphatic system, will also demand recourse to the amputating knife. Patients, too, will be met with, who, after undergoing all the suffering attendant on disease of long duration—as exfoliation of bone and sloughing of tendons, following deep suppuration—will, to get rid of the annoyance of the stiff and deformed member, or part of a member, not only submit to, but urge and insist on, the removal of the offending part. Amputation will also occasionally be required for badly-formed stumps, as those in which the end of the bone protrudes through ulcer of the integument, and is necrosed—or those in which the bone has been sawn of an inconvenient length.

Many precautions are to be observed in this operation. It is not to be commenced without due consideration as to the position of the operator, and of his assistants—their several duties—the form of incision—the length of the stump—the difficulties, if any, which may be expected, and the best means of obviating them. The most prominent objects are, to save undue effusion of blood, to effect the incisions with as little suffering to the patient as possible, and to make them of such a form as to cover the end of the bone effectually— so that pressure may, after a time, be borne without risk of ulceration of the soft parts, or exfoliation of the bone.

In all cases, and in all situations and circumstances, hemorrhage can be restrained during completion of the incisions, and during the employment of means to close the cut ends of the vessels, by means of very slight but exact pressure on the trunk of the principal vessel. The point at which this is to be applied should be at as short a distance as possible above the place of incision, and at the same time above the origin of any branches which must be cut. Not the slightest pressure should be made until the instant when the incisions are about to be commenced, so that no venous congestion may take place in the limb. All the blood in the limb, below the incisions, must necessarily be lost. The veins are more easily compressed than the arteries, and pressure, made a short time before the operation, may arrest the return of the blood, whilst it may not completely stop its influx; thus engorgement of the lower part of the limb is produced, and the quantity of blood that must be lost is increased. For a similar reason, pressure, sufficiently firm to stop arterial hemorrhage, is to be continued till the principal branches are tied, and then entirely removed; for the continuance of even slight pressure will increase the flow from the surface of the stump—blood, flowing in, and being arrested in its venous return, trickles out through the open ends of the veins. If a circular band be used for the compression, such as the screw tourniquet, it should be put on quickly, and screwed up at once, and then the incisions should not be delayed one instant after; there should be no relaxation of the pressure at any part of the operation; and as soon as the principal vessels have been secured, the apparatus should be altogether removed—otherwise, as already stated, rapid oozing will continue from the face of the stump. It is my confirmed opinion, that much more blood is lost from the use of a tourniquet than without it. I would rather trust to a no very efficient assistant, than put on a tourniquet. It is evident that compression on the whole circumference of a limb must completely interrupt venous return, and cause the increase of hemorrhage already mentioned; whereas pressure on only two points of the same circumference, as is effected by the hand of an assistant, is not liable to this objection. Besides, the latter mode is more quickly applied, and more readily removed, causes infinitely less pain to the patient, and is equally effectual in arresting the flow in the main arterial trunk. Neither does it interfere with the due contraction and retraction of the divided tissues. The incisions should always be made rapidly; and after their completion, the surgeon, if distrustful of his assistant, or if his hand has become cramped and tired, may himself grasp the limb and compress the vessel, giving the forceps or ligatures to another.

The first step in the operation is to arrange the measures for temporary arrestment of the bleeding. The patient is placed in a favourable position, either sitting or lying, as may be most convenient for the particular amputation, and is firmly secured by one or more assistants; all the apparatus must be in good order and conveniently placed, and an assistant should be stationed to attend to them, and hand those required. The compressor and the operator are each at their post, and ready to act in concert. The incisions may be made either from without inwards, or from within outwards, after transfixion of the limb. The latter mode is to be preferred when practicable, as requiring less pressure; the parts are more stretched than in the former method, are therefore more easily and rapidly cut, and consequently less pain is inflicted. To the inexperienced transfixion may appear cruel, it may appal them, but in reality it is almost unattended with pain; it is rapidly executed, and renders the operator capable of completing his work with great quickness and little suffering, and at the same time with neatness and precision. The knife should be of a size and length proportioned to the incisions, straight-backed, and with a good point; of a form to pass through readily, yet strong, and not too broad. With one sweep of this, the incisions are made at once, through the muscles, through the cellular and fatty tissues, and through the integument—or vice versâ if the mode from without inwards be preferred. By these parts being cut rapidly and at once, their connexions with each other are not separated, the cut surface is smooth, and the parts are in the most favourable state for becoming agglutinated and consolidated; the bone is more deeply covered, and the stump of a handsomer and more useful shape, than when the parts are cut successively and with detachment.

The operator places himself so that he may grasp the part to be removed, during the sawing of the bone, without change of position. The incisions are made with the left hand free; but as soon as the saw is in the right, the left should take firm hold of the limb below the wound. During the operation, the limb is supported by an assistant, either sitting or kneeling before the patient; but the regulating of the position of the limb, during sawing, is not to be intrusted to him alone. He may, from anxiety to facilitate the action of the saw, snap the bone and splinter it when it has been little more than half divided; or, from dread of this, he may lock the instrument, and so delay completion of the operation. The management of the lower part of the limb should always be by the person using the saw. This instrument should have its teeth well set, and be provided with a workmanlike handle. It is worked steadily and not hurriedly, with very slight pressure, and that pressure employed only when pushing forwards. Before its application, all the soft parts must necessarily be divided completely; and this is done by carrying the knife, after formation of the flaps, round the bone, with its edge rasping on it, and as high up as possible. The instrument is then placed accurately on the point thus exposed, close to the soft parts, and during the sawing the flaps are well retracted by the hands of an assistant. The saw may be worked either horizontally or vertically; the latter direction is to be preferred, for thus, when the section is nearly completed, the uncut part of bone is deep, and less likely to snap on the weight of the limb being allowed to operate, or when undue pressure is made downwards. If splintering of the bone have occurred, whether from neglect of the foregoing precautions, or by other accident, the sharp projecting parts should be taken away, and the cut surface made quite smooth by means of the bone pliers; and with this instrument also, the sharp edge of the bone may be rounded off, in cases where subsequent pressure might cause ulceration or sloughing of part of the integument of the stump.

The arteries are tied close to their connexions. Their cut ends are laid hold of with the dissecting forceps, or by those represented at page 170, and pulled out; a small firm thread, either of linen or silk, is then applied tightly, and one end immediately cut away close to the reef-knot. Separation of the ligatures generally takes place from the sixth to the tenth or twelfth day; they produce little discharge or irritation during their presence, and no source of irritation connected with them is left behind. But when both ends are cut away close to the knot, separation is often long of taking place, and though the parts may heal over them kindly enough, the stump never can be considered sound till all are discharged. Probably several of these knots remain deeply imbedded after cicatrisation of the integument, and when the patient considers himself cured, and is moving about the room or ward, actively and cheerfully, painful hardness forms deeply, part of the stump reddens and swells, matter forms, and at length the insignificant origin of the mischief is discharged; and this may occur more than once. Generally such suppurations are limited, and soon cease; but occasionally the abscess formed round the knot is extensive, deep and free incision is required, the filling up of the cavity is necessarily slow, the cure is long protracted, and both practitioner and patient are disappointed and annoyed. Besides, the suppurations thus occasioned, though slight in extent, may, when in the neighbourhood of a principal arterial branch, cause ulceration of the coats of the vessel, producing troublesome hemorrhage at a late period. All these untoward consequences of cutting off both ends I have experienced in a series of cases, and from the results of a faithful comparative trial of both methods, I am now fully determined always to leave one end of the ligature hanging from the lips of the wound.

No one now, it is presumed, dreams of the absorption of ligatures, whether composed of animal substance or not; therefore the catgut ligature, at one time much recommended, has no superiority over the linen or silk thread,—besides it is not so convenient of application.

Twisting or bruising the cut ends of arteries has been long known as effectual in arresting bleeding. Vessels of a large size can be so treated with sufficient facility, and they may not bleed after; but well-tied ones are much more secure. The smaller cannot be pulled out and twisted, ligatures must be used for them; and the application of one or two more ligatures, namely, to the large arteries as well as the small, will add to the patient’s safety, and to the operator’s comfort and peace of mind, and can have little effect in increasing irritation. I have made trial of the method of torsion after amputation, and for the above reasons, and because the manipulations are more tedious, I disapprove of the plan, and decidedly prefer the ligatures. I am not aware that the proposal of leaving the vessels both untwisted and without ligature has been tried in this country; one would think that it must always be troublesome, and not unfrequently hazardous.

In some cases, as when the incisions are made in the neighbourhood of diseased bone, the soft parts are so condensed that the vessels cannot be pulled out by means of the forceps; they are to be transfixed by a sharp hook or tenaculum, and a ligature is then applied round the parts which the instrument holds; or the vessels may be encircled by a thread passed round by means of a curved needle; in both methods more or less of the surrounding tissues must necessarily be included in the noose, though always as little as possible. Sometimes an artery of the bone, whether sound or inflamed, bleeds sharply; in such circumstances the application of ligature is impossible, and I have occasionally been obliged to insert a wooden peg into the opening; to this a chord is attached by which it can be removed after a few days.

When bleeding has been satisfactorily arrested, the surface of the wound is to be cleaned of coagula, either with the fingers or with a warm and soft sponge, the ligatures are brought to the margin at convenient points, and the edges of the integument are then put together by interrupted sutures—two, three, or more, according to the extent of the wound. They need not be numerous, for they are only temporary, effecting partial approximation, and showing the line in which the parts are to be brought together by the after dressing. The stump is then covered with lint soaked in cold water, and this application is renewed frequently so long as any trickling of blood continues. Farther dressing is delayed for six or eight hours, when the oozing has entirely ceased, and the visible cut surface become glazed. Under this management, there is less chance of bleeding breaking out afresh than when the limb is encompassed by bandages and pledgets of lint, perhaps compressed so as to interfere with the return of the blood, and heated by superfluous dressings. If bleeding to any extent should occur, as there is always a risk of, after the patient has become warm and comfortable in bed, and reaction has been established, there is but little pain or annoyance in reaching the bleeding point, and taking measures to stop the flow; the few stitches are soon clipped away, and then the surface of the wound is completely exposed, and ligatures can be applied to those vessels which require them. Then, after removing all coagula, sutures are placed in the same perforations, and the stump is in as favourable a state as previously. I now generally leave the wound quite open, until all risk of hemorrhage has ceased, and, if one or two stitches are required, these are put in at the time of applying the plaster.

After six or eight hours, as already stated, any clots that have formed are to be taken away gently, and the glazed edges of the wound are then brought accurately and neatly together by the adhesive composition already recommended,—with the difference of its being spread upon slips of oiled silk, which I have found to be more pliable, and altogether preferable to the glazed riband. Interstices are left for the sutures and the ends of the ligatures, and the latter may now be abridged slightly. This mode of keeping the edges in contact I can confidently recommend from experience. The plasters are much more adhesive than those in common use, do not irritate, and are not loosened by discharge. After twelve or twenty-four hours, often much earlier, the sutures are clipped through and removed. No other dressing is required till the end of the cure, provided this proceed favourably. The part is kept cool, and the slight discharge which occurs in a day or two is wiped up from time to time, if it be in such abundance as to reach the oiled cloth over the pillow on which the stump is laid. No disturbance of the parts is necessary as when ointments, bandages, and compresses are employed, or straps that require frequent removal and reapplication. The patient suffers comparatively nothing; and the surgeon is saved much troublesome and dirty work,—for union by the first intention seldom fails.

Bleeding within a few hours after the operation, before excited action of the vessels has commenced, is easily arrested by exposure of the surface, removal of all clots, for by these hemorrhage is encouraged, and by including the open vessels in ligatures. For the accomplishment of this, the period and mode of dressing, above recommended, afford great facility, as has been already observed. Hemorrhage at a later period is not common. It happens occasionally in consequence of the stump having acquired an unhealthy condition, from sloughing,—or from abscess, as when this occurs round ligatures which have been retained, along with the slough of the vessel and cellular tissue, both ends having been cut away. The matter formed during separation of the ligature in the usual way, escapes readily along the protruding end, but when there is merely a knot, the integuments have most probably closed over, there is no direct outlet; the matter is confined, and causes ulceration of the coats of the vessel as well as of the surrounding tissues. In this kind of hemorrhage, it is needless to attempt finding the bleeding point by tearing open the stump, separating any adhesions that may have formed, causing much pain and retardation of cure. And even though the bleeding vessel or vessels could be found, they are not in a state to hold a ligature. The artery is surrounded by sloughing cellular substance, its coats are tender, and in no condition to assume a healthy action necessary for permanent closure after deligation. If ligature is applied, the included part quickly separates, and then the vessel is as open as before. Astringents, and even the cautery, are useless. Ligature of the main arterial trunk, above the origin of branches supplying the stump, so as to weaken for a time the circulation, is found to be effectual. I have had recourse to this in many cases, and uniformly with success. Some years ago, several occurred in the Royal Infirmary, within a very short time of one another; it was during rather an unhealthy season, and at the time I was making trial of cutting off both ends of the ligatures. They were all after removal of the lower limb; one patient died—the amputation was high, through the trochanter minor, and the vessel tied secondarily was the common iliac; this had the effect of completely arresting the hemorrhage, but the previous loss of blood proved too much for the system to recover from; transfusion was had recourse to, and produced temporary benefit. The others, cases of amputation below the knee, made most favourable recoveries after ligature of the superficial femoral, and in more than one the stump healed very rapidly after its readjustment. Indeed, it is not unfrequently found that when the flaps are separated, from whatever cause, and replaced when the granulations have appeared, there follows a rapid union and cure.

When healing by the first intention has failed, fomentation and poultices are generally the most grateful and beneficial applications for a day or two. Afterwards, when suppuration has been fairly established, and the stump begins to be flabby and œdematous, simple dressing and uniform support by bandaging are required, sometimes along with compresses on particular points to prevent lodgement of matter.

Sometimes the secondary hemorrhage is not an arterial and rapid flow, but a slow and continued oozing from a cavity, ulcerated, dark, and angry, round the end of the bone; this seems to arise from diseased action in the cancellated tissue of the bone. Removal of the coagula, stuffing the cavity with dry lint, and the application and continuance of firm pressure, generally suffice for its arrestment.

Hitherto, these general observations on amputation have regarded the operation by flaps only; the circular method has not been mentioned. The reason is, that the circular amputation has been, it is hoped, in a great measure abandoned in this country. And its inferiority to the method by flaps is so obvious, and so generally acknowledged, that detail of the different steps of the operation is, I conceive, here altogether unnecessary. It is more tedious in performance, more painful to the patient, does not afford so good a covering for the end of the bone, and consequently not so convenient and useful a support for an artificial limb, and the cure of the wound is protracted. The stump is almost always conical, the end of the bone is, ultimately at least, covered only by integument, and from even very slight pressure this is apt to ulcerate; exfoliation of the bone follows to a greater or less extent, or unhealthy nicer of the soft parts continues, along with caries of the bone, and partial death of its surface; and at length it becomes necessary either to perform a second amputation or to curtail the length of the bone. It may sometimes succeed tolerably well when there is but one bone: when there are two, it is altogether inadmissible. In very muscular limbs, when amputation is demanded on account of destruction of the bones and joints, with laceration of the soft parts, as when the patient is not required to have pressure made on the stump, it suits well to make the flaps of integument only, and to cut the muscles short, as will be noticed more fully afterwards. The advocates for the circular amputation, my excellent friend Sir George Ballingall, and others wish it to be believed, (and this is their main argument,) that the exposed surface of the flaps is much greater than that in their favourite method. Some of the philosophers of the Modern Athens have been appealed to, and have measured, it is said, the area of the one and the other, and given their verdict in favour of the round about incision. The accompanying drawings from nature, and the corresponding diagrams, speak pretty plainly in favour of the other method. In the first there is a cone formed by the cut skin and muscles, with a corresponding hollow and ragged cavity; and the second set shows two smooth, nearly triangular surfaces, which the said philosophers may measure and report upon at their leisure.

Various accidents and diseases require removal, either primary or secondary, of the fingers, or of parts of them. Amputation is most easily accomplished at the articulations, and ought therefore always to be performed at these points, when the circumstances of the case permit. The last phalanx may require removal either on account of severe injury, or from incurable disease, as onychia maligna, necrosis, caries, &c. The operation is one by single flap, and may be conducted in one of two ways. The doomed phalanx is grasped, on its anterior and posterior aspects, by the fore and middle fingers of the left hand; and the articulation is flexed almost to the full extent, in order that incision into it may be facilitated. A straight, narrow, and sharp-pointed bistoury is carried in a semicircular sweep over the back part of the joint, so as to divide the integuments, and open completely the articulating cavity. The remaining ligamentous investments of the joint are divided by one or more additional touches of the knife, so as to loosen the base of the phalanx. The fingers of the left hand are then changed from the fore and back parts of the phalanx to its sides, the edge of the knife is passed behind the base of the bone, and the surgeon, by carrying the blade forwards and downwards, forms a flap of sufficient dimensions to cover the wound, and removes the offending part. There is seldom any trouble from hemorrhage; no ligatures are required. The flap is turned up so as to form a cushion over the exposed surface of the middle phalanx, and is retained so by the adhesive composition formerly mentioned, or by one or two turns of a linen bandage. The other method of operation is the reverse of the preceding. The joint is extended, the bistoury is made to transfix close to the joint and at its anterior part, and by then carrying it downwards and forwards, as before, a similar flap is formed; this is retracted by an assistant, and with one sweep of the knife the articulation is divided from before backwards. By either method the flap is the same. By similar procedure the amputation at the middle articulation is performed.

It is sometimes an object to save as much as possible of the proximal phalanx, when amputation is rendered necessary by disease of the middle articulation, or of the distal extremity of the bone. In such cases, two semicircular flaps are made by cutting from without, either on the lateral, or on the thenal and anconal aspect, and the bone is divided either by a small saw or by the cutting pliers. The flaps are retained in apposition, and the bleeding arrested by bandaging.

Amputation at the proximal articulation is also performed by double flap. In the previous operations an assistant steadies and supports the hand; in this he has likewise to bend the rest of the fingers, and to separate as widely as possible those neighbouring to the one about to be removed. The operator seats himself before the patient, grasps the finger so as to manage its movements with the left hand, and holding the knife perpendicularly, with its point upwards, lays it over the knuckle, and carries it obliquely upwards so as to open that side of the articulation. He then pushes the finger towards the opposite side, and with the point of the knife completes the loosening of the articulation; for this the blade of the instrument should never be employed, otherwise the integument will be cross-cut and mangled. After separation of the base of the phalanx by the point, the blade is passed behind, and carrying it downwards and outwards, a flap is formed similar to the first—both proportioned to the size of the wound which they are to cover, and the bone which they are to protect. The fingers may also be removed by the oval method, as described and delineated in the Practical Surgery. The flaps are retained in contact by bringing the neighbouring fingers towards each other. This also suffices, in general, to suppress the bleeding, but sometimes one or both digital arteries require ligature. At first, cold cloths are probably the best applications, with the view of stopping the oozing, and warding off inflammatory action. Vascular excitement is very apt to follow this amputation, when performed for disease of the finger, as after neglected or severe whitlow; the soft parts in which the incisions are made are generally infiltrated and condensed, and prone to inflammation. The surface around is red, tense, and shining, on the second or third day; the back of the hand, the palm, and perhaps the forearm, are then involved in inflammation of the surface, and infiltration of the cellular tissue; and in all probability, free incisions, followed by poultice and fomentation, will be necessary to restore the parts to quietude. Such consequences are to be guarded against as much as possible, by attention to the system, and by avoiding all irritating dressing.

The phalanges of the thumb are removed in the same manner as those of the fingers. Amputation of the metacarpal bone is accomplished thus. The thumb is grasped by the fingers of the left hand, and so managed. The bistoury, held in the same manner as for amputation at the proximal articulation of the finger, is placed with its point on the web betwixt the thumb and forefinger, and carried in one sweep rapidly upwards in a slightly oblique direction, till it is stopped by the os trapezium. The point is used to effect disarticulation, the member being at the same time pushed steadily outwards; the blade is then placed behind the base, carried downwards close to the side of the bone, and is not to be brought out till sufficiently low down for forming a flap to cover the whole wound. The flaps may be formed otherwise, and much more handsomely, by transfixion of the ball of the thumb, as shown in the Practical Surgery, p. 360. After arresting the hemorrhage, the flap is laid smoothly down, and retained in its proper position by bandage or slips of the adhesive plaster. The metacarpal bone of the little finger is removed by the same method of incision as for the thumb.

In amputation of the fingers, the incisions sometimes require to extend beyond the proximal articulation, on account of disease having involved that part; in other words, it may be necessary to remove more or less of the metacarpal bone along with the finger. The method of incision will vary according to the extent to which the bone is diseased. When the operation is required for disease of merely the distal extremity, the incisions are made in the same form as for amputation of the joint, only they are on each side sufficiently high to be beyond diseased bone. They may either be made from below upwards in the usual way, or be commenced at their highest point on the dorsum of the metacarpal bone. After the soft parts have been separated from the bone, by a few touches of the knife after formation of the principal incisions, removal is completed either by the cutting pliers or the metacarpal bow-saw—the former I have found the more convenient instrument. It is applied perpendicularly, and should always have its smooth surface in contact with the part to be retained, otherwise the cut part will be rough and irregular. Section is completed more rapidly than by the saw, and, by attention to the above precaution, the stump is equally smooth, if not more so. The wound is brought and retained in contact by approximation of the fingers. But in taking away any considerable portion of the metacarpal bone, it is of importance to preserve the palm uninjured. With this view, the knife is entered over the centre of the bone on its dorsal aspect, above the diseased part, and carried straight downwards till near the articulation, when it is made to diverge for the formation of lateral flaps; the integuments in the track of the longitudinal wound are then dissected backwards, so as to expose the bone completely, and the bistoury is passed round the bone throughout its whole extent, the edge being kept close to it,—in order that the soft parts may be separated, and that without unnecessary width of wound or implication of the palmar arches and branches proceeding from them. Then the bone is clipped at the proper point by the cutting pliers; or the section of the bone may be performed before separation of the soft parts from its under surface, as, by raising the cut end, this part of the operation may be facilitated. Here the metacarpal saw is inapplicable.

Before quitting this part of the amputations, it may be observed, that no good can result from taking away a metacarpal bone and leaving a finger, or from removing a proximal phalanx and leaving the distal. The parts so left can be of no use, they have no support, and the muscles cannot act upon them: they must prove an incumbrance, and as such will either form the subject of a second amputation, or remain a proof of the unsuccessful result of the first.

Amputation in the forearm, may be necessary at various points, on account of accident or disease, but should never be resorted to, in either case, so long as part of the hand can be saved. The preservation of even a small portion of this useful member, even of one finger or a part of one, is of great importance to the patient. When, however, this is hopeless, all must be removed; and, if the wrist be sound, amputation may be performed at that joint. Hitherto, no mention has been made of the temporary suppression of bleeding, for in the amputations detailed there is scarcely ever any necessity for adopting such measures; but in those of the forearm and arm, a steady assistant must be placed ready to compress the humeral artery as soon as the incisions are commenced; in the case of the forearm, the pressure is made on the lower portion of the artery; in the arm, the point of pressure will necessarily depend on the point of removal. The patient may be either seated or recumbent. One assistant compresses, another steadies the limb in the supine position. The surgeon holds the hand in his left, standing on the inside of the right limb, and on the outside of the left. Suppose the right wrist is to be operated on,—the end of the ulna is felt for, and at that point the knife is entered, and drawn across the wrist on its dorsal aspect in a semilunar direction, the convexity of the curve of course pointing towards the fingers. The joint is opened by retracting and dissecting back the flap so formed; the knife is then passed behind the scaphoid and lunar bones, which are exposed and turned out by division of the ligaments, and by rapid and gentle sawing motion downwards and forwards, a flap of sufficient size is then formed on the palmar aspect. The dorsum of the hand may be so diseased or injured as not to afford sufficiency of sound parts for a posterior flap; in such circumstances the anterior must be made proportionally large, that it may alone cover the ends of the bones. After suppression of the bleeding, the flaps are approximated by one or two points of suture; these are afterwards removed, and their place supplied by the adhesive plaster.

Amputation, at any point between the wrist and elbow-joints, requires, in all, the same method of incision, but the nearer to the elbow the better is the stump; at the wrist the flaps are composed principally of integuments and tendons, and the cushion so formed for the bones is very inferior to one of muscle. Compression is made and the limb steadied as before; the surgeon with his left hand grasps the wrist, and places the forearm in the middle state between pronation and supination. In the right forearm, the knife, held perpendicularly, is entered over the centre of the radius, and its point, after reaching the bone, is inclined inwards so as to pass round it; transfixion is then made, the knife passing close to the palmar surface of the bones, and emerging at a point opposite to its entrance; and then by rapid motion downwards and inwards, a proper flap is formed. The instrument is again introduced over the radius, at a little distance from the upper part of the first wound, and passed on the opposite side of the bones, emerging also in the first incision and at a similar point; another flap is made. These are retracted, the knife is swept round the bones, and passed freely between them, to divide the remaining muscular substance, and after this has been completed, the saw is applied. During the sawing it is well to preserve the limb in the same position as during the incisions, and to apply the instrument perpendicularly; thus both bones will be divided at once, and the risk of splintering diminished. In transfixion, great care is required that the point of the knife pass across, not between, the bones, and with this view a slight change of position is useful; during the transfixion for the inner flap, the surgeon, as soon as he feels the knife rounding the radius, rotates the forearm gently inwards, and in transfixing for the outer flap similar rotation is made outwards. In this situation, and others where the soft parts are less thick in one aspect than the other, it is by much a preferable plan to make a flap first, by cutting from without inwards, as already described in regard to the wrist, and then to transfix for the formation of the second flap. This is delineated in the Practical Surgery, p. 367. Sometimes slight difficulty is experienced in tying the interosseal artery. The flaps are brought together, and treated in the way already mentioned.

In all amputations of the upper extremity, it is of importance, and indeed a rule scarcely to be departed from, to leave as much of the limb as possible; for here the longer the stump, the more useful is it to the patient. In accordance with this maxim, amputation at the elbow-joint may be required, when either disease or injury extends too high for amputation in the forearm, but not too high for the formation of an anterior flap over the joint. The limb is steadied in the supine position, compression being made near the middle of the humeral artery; the knife is passed horizontally across the condyles close to the bone, and brought downwards and forwards to a sufficient extent for the production of a flap, which is alone to form the protecting cushion. The joint is then cut through, the knife is passed down till obstructed by the olecranon, and with one sweep a semicircular incision of the posterior integument is made. All soft parts in this line are divided, and then the saw is applied to the olecranon process. This amputation is easy, rapid, and beautiful in execution; and, when the flap is sufficiently large,—as it always may be, for there is no want of soft parts in front,—the stump is well formed and useful. The flap is laid down, and attached by suture to the integument posteriorly; in due time the adhesive dressing is applied. The circumstance of a secreting surface forming the stump does not seem detrimental, either here, or in the wrist-joint. The synovial fluid soon ceases to distil, and union is not interrupted by it. There is no necessity for scarification, or scraping the cartilage, with the view of hastening cessation of secretion and granulation of the surface.

Amputation of the arm is performed by the formation of lateral flaps, at any point below the insertion of the deltoid muscle. Compression is made on the upper part of the humeral, or on the axillary artery. The limb is held well separated from the side; and care should be taken that, when so raised, its height be convenient to the operator. The knife is entered perpendicularly to the shaft of the bone, passed fairly down to it, and then inclined along its side; the operator now grasps the limb below the line of incision with the left hand, and pulls the muscles towards him—it is supposed that the right arm is being amputated, the surgeon standing on the inside, and an assistant supporting the forearm—and then completes transfixion, inclining the handle of the knife towards himself, in order that its point may pass round the bone and emerge at as distant a point in the circumference of the limb as possible. By a rapid sawing motion, downwards and inwards to the proper extent, the inner flap is formed; and by attention to the grasping of the muscles and the inclination of the knife, its base is so large as to admit of the more easy performance of accurate transfixion for the outer—that is, the instrument is more easily brought through the same incision. The assistant seizes the extremity of the inner flap as soon as formed, and retracts it, but only to a slight extent; it is simply held out of the way. If it be pulled backwards, as in retraction during sawing, the formation of the second will be much impeded. The knife is again entered about half an inch below the commencement of the first incision, and by inclining the handle the point is brought round the bone, and made to appear on the opposite side also in the first incision; this is facilitated by pulling the soft parts outwards with the left hand. Then the outer flap is completed. The knife is swept rapidly round the bone, so as to expose it completely at the upper part, the assistant at the same time retracting the flaps fully. The saw is applied, the arteries tied, the flaps approximated, and the operation completed.

In performing the second transfixion, the reason why the knife is entered lower than in the first, is, that cross-cutting of the corners of the wound is thereby avoided. For a long time I was surprised and annoyed to find many stumps present an unseemly cross-cutting of the integument at the upper parts, particularly after approximation of the flaps, although the incisions seemed to have been made smoothly and accurately. It is occasioned by the sawing process for making the second flap, and when this is commenced at the same height as for the first, irregularity of incision at the upper part is unavoidable. The precaution, however, of making the second transfixion considerably lower than the first I have found quite effectual. The disparity between the bases of the flaps is readily and quickly remedied, after their formation, by a sweep of the knife upwards on the lower side.

Irritable and painful stumps are more frequently met with after the amputations of the arm and forearm than any other. The occurrence, however, is less common than formerly, and this may be fairly attributed to the improvements in the operation—to the method by flaps having superseded the circular, and nothing but the arteries being surrounded in ligature. Still the affection is occasionally met with, and there can be none more painful and troublesome. Generally, no obvious cause can be found for the attack of this malady; but in some of the cases there would seem to be a constitutional and innate tendency, as it were, towards this irritability of the cut and bulbous extremities of the nerves—as in the following case:—A gentleman, aged 53, underwent amputation of the thumb, in consequence of laceration of the hand. Amputation was very soon afterwards performed at the middle of the forearm, on account of hemorrhage and infiltration of the hand, after fruitless attempts to secure the arteries. After cicatrisation of the wound, he complained of great pain in the stump, and in the situation where the tourniquet had been applied. Amputation of the arm was then performed, but the stump was not well made. The pain returned, and he applied to me, with the view of again submitting to amputation. It was performed nearer to the shoulder-joint, and in order to guard against recurrence of the disease, the nerves were laid hold of, pulled outwards, and cut across as high as possible. The patient was relieved of many of his sufferings, and continued tolerably comfortable for nearly two years; again, however, the painful symptoms have returned, though in a slighter degree. On examining the removed stump, all the nerves, particularly the musculo-spiral, were found greatly enlarged in their extremities, and intimately adherent to the cicatrix and the ligamentous covering of the rounded extremity of the humerus. More desperate operations have even been performed to free patients from irritable stump. The lower limb has been hacked off bit by bit, even to the coxo-femoral articulation, without much, if any, relief. Such operations are hardly warrantable.

Amputation at the shoulder-joint is more frequently required for accident than for disease. It has always been the custom to trust for suppression of bleeding, during this operation, to the hands of an assistant; and when the method has been found effectual in the case of the large axillary artery, why should it be objected to, on the score of inefficiency, in the minor amputations? particularly when it is evident, putting efficiency out of the question, that it is preferable to compression by the tourniquet, or any other circular apparatus;—more quickly applied and relaxed; less painful, less formidable; always ready, and independent of the instrument-maker. The compression is made above the clavicle, so as to secure the subclavian, where it passes over the first rib. The thumb of a steady assistant is placed deeply into the cavity of the lower triangular space of the neck, immediately above the first large sinuosity of the clavicle. The pressure thus made is quite effectual; but as it requires to be firm and uniform, and as there is always a risk of the thumb giving way from exhaustion, it is better to interpose some mechanical contrivance when the assistant is either diffident or inexperienced. The best apparatus for this purpose is a common door-key. A bit of lint or cloth is wrapped round the handle, and this part is then pressed down on the vessel. As in other amputations, the pressure is not commenced till the knife is about to enter.

The flaps may be double, on the outer and inner aspects, or one may be made sufficiently large to cover the whole wound. The patient is seated on a chair, and secured by a person placed behind. The arm is raised a little from the side, and supported by an assistant. Two oblique incisions are made, commencing high on each side of the shoulder, and converging gradually till they meet near the insertion of the deltoid. The triangular flap, so marked out, is dissected rapidly upwards, close to the bone, and kept raised by an assistant. The person supporting the arm then uses it as a lever, carrying it downwards and backwards; the joint, thus made more palpable, is cut into by a semicircular sweep of the knife across it; the head of the bone is now dislocated, and the rest of the capsule and fibrous tissue exterior to it divided; the blade of the knife is insinuated behind the head of the bone, and carried rapidly through the remaining soft parts. In no amputation can I conceive any necessity for suspending the incisions, in order to secure vessels, provided the pressure is well applied, and the knife used dexterously. Here very little blood should be lost. The vessels divided in the formation of the flap are small, and the axillary is not cut till the incisions are nearly completed; as soon as the limb has dropped, the surgeon places his finger on the mouth of the artery, and then applies his ligature as quickly as possible; the pressure may now be removed, and the minor vessels secured leisurely. The flap covers the wound completely, and is easily retained.

Or two flaps may be made by transfixion. In operating thus on the right limb, the surgeon, standing in front of the patient, enters the knife a little below the point of the acromion, passes it across the outer aspect of the joint, and by inclination of the handle outwards, makes its point to appear on the inside of the outer margin of the axilla; by carrying it downwards and outwards to a sufficient extent, the outer flap is formed. This is immediately elevated by an assistant, and then the arm is pushed upwards, and across the chest, so as to render the joint more accessible; the ligaments are cut, the bone disarticulated, the knife passed beyond its head, and placed with the edge parallel to the shaft of the humerus, and the arm restored to its former position; the inner flap is then made by carrying the instrument downwards and inwards. In the left limb, the knife is entered on the inside of the outer border of the axilla, and brought out below and in front of the extremity of the acromion, reversing the order of the former incisions; after the outer flap has been so formed, the joint is cut across, the knife passed beyond the head of the bone, and the inner flap made as before.

Accidental injury, as already stated, is the most frequent cause for amputation at this part, and this will always influence the method of incision. There is nothing peculiar in the after-treatment of the stump. But it ought always to be remembered, that the operation is one of great severity; that a large part of the body has been suddenly removed; that, consequently, there is risk of the mere shock being dangerous, and of an untoward constitutional condition supervening—and, therefore, the after-attendance should be zealous and careful.

The phalanges of the toes are removed in the same way as those of the fingers. This latter operation may be required on account of bad onychia, large exostosis or injury. This and the other must also be removed on account of diseased bone, such as here represented with affection of the interposed joint. The osseous shell formed by the enlargement of the original tissue encasing a segmentum is well represented. In the amputation at the proximal joint, it is to be recollected that the extremity of the metatarsal bone lies more removed from the web of integument betwixt the toes than the metacarpal bone does from that of the fingers. The incision upwards, therefore, requires to be deeper; but in other respects the operations are precisely the same.

In amputating at the proximal articulation of the great toe, there is often a difficulty in obtaining a sufficient covering for the wound, on account of the presence of the sesamoid bones, and the general bulging of the heads of the bones. The knife is entered on the dorsum of the metatarsal bone, about half an inch above the joint, and then inclined to each side, marking out lateral flaps of considerable length; these are then reflected,—in making the outer, the instrument being dextrously passed round the sesamoid bone,—and the disarticulation completed.

In removing the great toe, along with the metatarsal bone, the bistoury is entered over the articulation of the metatarsal bone with the tarsus, and carried straight downwards, along the centre of the dorsum of the bone, till near its extremity; it is then inclined to each side, in the manner described for amputation of the metacarpal bones. The integuments are dissected off on each side of the longitudinal incision, and the knife run up along the inside of the bone, till stopped by the tarsus. The surgeon now presses the toe outwards, so as to assist the disarticulation; and after this has been completed, the bistoury is carried downwards, close to the outside of the bone, and not brought out till past the lower articulation. The external flap thus formed is then laid accurately down, so as to cover the wound, and retained. The preferable mode of making the flap, so as to expose the metatarsal bone for division or disarticulation, is well illustrated in the Practical Surgery, p. 375. The entire bone must be removed in such cases as that here sketched. In cases in which the shaft is comparatively sound, and the disease is principally seated in the articulation with its distant extremity, the shaft may be divided with the cutting forceps at a point sufficiently removed from the disease. The operations on the other metatarsal bones are the same as those on the metacarpal. They may be removed, either entirely or in part, along with the corresponding phalanges, by operative procedure similar to that practised on the hand.

Sometimes disease of the foot is not so extensive as to require or justify removal of the whole organ; the metatarsal bones are not involved throughout their whole extent. The same remark applies to injury by accident. In such circumstances, amputation is performed at the articulation of the metatarsal bones with the tarsus. The operator first ascertains the exact site of these joints, and then transfixes the foot at that point, passing the knife close along the plantar aspect of the bones; carrying the instrument downwards, a sufficient flap is formed to cover the stump, or a semicircular flap may be made and reflected by cutting from without inwards. The integuments on the dorsum are then divided in the line of articulation, the joints divided successively, and the parts removed. The flap is raised, adjusted, and retained. In dividing the articulations, it is to be recollected, that the base of the second metatarsal bone, reckoning from that of the great toe, is lodged considerably higher than the others; and, therefore, the knife must be inclined upwards at that point, or else the use of the saw is requisite. The stump thus formed proves exceedingly useful: the subsequent lameness is not great; the heel and tarsus compose a very efficient support for the weight of the body, and the flexion is unimpaired; by attention, too, the deformity may be in a great measure concealed. In short, the surgeon who amputates above the ankle, for disease or injury not extending to the articulation of the metatarsus with the tarsus, is guilty of a serious error.

The disease may reach higher than is compatible with the preceding operation, and yet it may be possible to save the heel. In such cases amputation is performed in the articulations of the os calcis with the os cuboides, and of the astragalus with the os naviculare. The plan of the incisions is the same as that for the operation at the bases of the metatarsal bones.

No amputation is more frequently performed than that of the leg. Operation near the ankle is inadmissible; sufficiency of soft parts, for the protection of the stump, cannot be procured lower than the calf. Incision is completely limited to two points, either immediately below the tuberosity of the tibia, or in the bellies of the gastrocnemii. The former is the situation to be preferred in hospital practice, and amongst the lower orders generally; the latter is suitable to the better classes of society, that is, to those who can afford to purchase an expensive artificial support. The amputation below the tibial tuberosity being the most frequently required, will, with propriety, be described first. Suppose the right leg is to suffer:—The operator places himself on its inner side, according to the general rule formerly inculcated, and grasps the lower part of the limb with his left hand, an assistant supporting the foot at a proper height, and controlling motion. The knife is entered over the fibula, on its outer aspect, and carried upwards along that bone for an inch and a half, or two inches; it is then brought across the limb in a semilunar direction, the convexity of this incision pointing towards the foot, and after reaching the inner and lower part of the tibia transfixion is performed, the instrument being pushed along the posterior surface of the bones, and made to emerge at the upper part of the fibular incision. By then carrying the knife downwards, a posterior and larger flap is formed sufficient to cover the stump. All this is effected by uninterrupted sweeps of the knife, that is, without ever removing the point or edge from the track of incision. The integuments on the fore part are then dissected upwards a little, by a few touches of the knife, so as to form a small semilunar flap; at this part of the operation there is no necessity for laying down the knife and using a bistoury. The muscles in the interosseous space are then completely divided, and the knife swept round the bones to detach the soft parts still uncut. The saw is applied, either in a horizontal or perpendicular direction; I prefer the latter for reasons already assigned. The vessels are secured, and there are generally but three—the popliteal, and two sural. I now generally aim at cutting the vessel before it divides, and seldom fail in doing so. There is then possibly the popliteal only requiring ligature, and there is less chance of secondary hemorrhage. This has occurred, so as to prove fatal at a considerable period after the operation, in consequence of the posterior tibia being cut close to its origin, and no clot having formed in it. Before adjusting the flap, it is well to assist nature in rounding off the end of the tibia, and thereby prevent danger to the integument; with this view the sharp anterior ridge of the bone is cut away and rounded off by means of the pliers. This must be done sparingly if at all, and with great caution. The nipped surface is liable to exfoliation, or the medullary web is apt to be injured, and this is inevitably followed by more or less death of bone. To some the fibular incision may appear unnecessary; but I have long practised it from conviction of its advantage. It is an excellent mark for transfixion, and assists greatly in preventing entanglement of the knife betwixt the two bones; besides the soft parts in this situation must be divided at one or other step of the operation, and hence the procedure cannot be objected to on the ground of causing unnecessary wound. In operating on the left limb, there is not the same danger in transfixion, and consequently so long a preliminary incision on the inside is not requisite; in other respects the steps of the operation are the same as for removal of the right. In muscular subjects two semilunar flaps had better be made, one from the anterior aspect of the limb, the other from the posterior, the muscles being cut short in the ham, and the incision made to reach the popliteal artery.

It has been proposed to excise the head of the fibula after formation of the flap, instead of sawing it across at a corresponding point with the tibia. At one time I put this modification into extensive practice, with the effect of improving the appearance of the stump very considerably; but in several cases, untoward consequences took place. Discharge of synovia occurred on the second day, followed by very profuse suppuration, which proved of long continuance, and very exhausting; in more than one case, the joint became anchylosed, rendering the stump very inefficient as a means of support, in consequence of being fixed at an inconvenient angle; and one patient sank, exhausted by the profusion of the discharge. I then found, from repeated examination of the parts on the dead subject, that it was very difficult, nay impossible, to excise the head of the bone without dividing the capsular ligament, and wounding the synovial pouch, or opening a bursal cavity, beneath the popliteus muscle, communicating with that of the knee-joint. It is scarcely necessary to add, I have since wholly abandoned this method of operation.

It has been already observed that high amputation of the leg is preferable amongst the working classes. The limb is of much greater use to the patient than were the stump longer; he is able to follow his occupation with greater ease and security, and at less expense, by resting on the knee, than by using the artificial limb applied to the middle of the leg. The wealthier patient, however, can afford a more expensive support, and a less efficient, though more handsome continuation of the limb suffices. In such circumstances, amputation is performed at the middle of the leg; after cicatrisation, the artist supplies an artificial support resembling the natural limb; and thus the motion of the knee is preserved. The same directions apply to this operation as to that immediately below the knee.

In amputation of the thigh, the same method of incision is followed as in amputation of the arm. But, according to the point of removal, the direction of the flaps varies. If in operating high in the limb the flaps be made laterally, there will be imminent risk of the bone protruding through the upper part of the wound; for the patient uniformly raises the stump towards his abdomen. No antagonist muscular power is left to oppose the action of the muscles inserted into the trochanter minor, and the elevation of the stump is involuntary: it always occurs to a remarkable extent in young persons. On this account, anterior and posterior flaps are here far preferable to the lateral; for then the more the stump is raised, the better is the end of the bone covered—the anterior flap folds over it. Transfixion is therefore made horizontally; and the posterior flap should be a little longer than the anterior. But in the lower part of the limb, lateral flaps are not only not liable to the same objection, but preferable to the anterior and posterior. In the neighbourhood of the knee-joint, the soft parts consist almost entirely of ligamentous tissue on the fore and back part, and proper cushions can be obtained only from the sides. Transfixion is therefore made perpendicularly. Thus the bone will be well covered by parts likely soon to adhere; and there is no risk of protrusion, for muscles are left to counteract the elevators, and there is sufficient lever in the limb whereby to control its motions. And it may be here mentioned, that after all amputations, when startings of the muscles are not only painful, but disturb the position of the stump, the limb should be bound down by a broad band, passed across it a short way above the wound, and fastened firmly at each end to the bed or pillow; at the same time anodynes are to be administered. I have long since come to the conclusion that the femur in amputation should not be sawn lower than its middle; the method by anterior and posterior flap is therefore the only one applicable.

Amputation at the hip-joint is deservedly ranked amongst the most formidable operations in surgery. It ought, therefore, never to be performed but as a last and necessitous resource for the salvation of life. At the same time, when necessity for it is obvious and acknowledged, and no other means can be of any avail, hesitation and delay should never take place; otherwise the last and only chance of saving the patient will pass away, and the operation, when at length performed, will but hasten his exit from this world,—and besides inflict an injury to science, by intimidating practitioners, and affording subject of reproach and ridicule to the thoughtless and uninformed part of the public. I prefer the formation of anterior and posterior flaps,—as follows:—The patient is placed recumbent on a firm table, his nates resting on, or rather projecting a little over, the front edge. The sound limb is separated from the one to be removed, and held aside by an assistant. Or it is secured to the foot of the table by a towel, the necessity for an additional assistant being thus done away with, and more freedom in his movements afforded to the operator. Indeed, in all amputations of the lower extremity, this is the preferable method of fixing the sound limb. The other limb is supported by an experienced and intelligent assistant, who understands, and is able to perform, the movements to facilitate the different steps of the operation. The compression is intrusted also to an experienced and steady assistant, who, standing by the patient’s side, presses firmly with one or both thumbs on the femoral artery, where it passes over the pubes; and in this more than in any other operation should the pressure be delayed till the instant of incision, for otherwise the blood lost in the limb will be immense. Transfixion, by a knife proportioned in size to the dimensions of the limb, is made horizontally, the instrument being passed in a somewhat semicircular direction, so as to include as much of the soft parts as possible; an anterior flap is made by cutting downwards. During the passage of the knife across the joint, the assistant rotates the limb a little, so as to facilitate the bringing of the instrument out with its point well inwards; in the left limb the rotation will be inwards, in the right outwards. After formation of the flap, the assistant abducts forcibly, and presses downwards; the joint is opened, the round ligament cut, the capsule divided, and the blade of the knife placed behind the head of the bone and the large trochanter; the posterior flap is then made rapidly. After transfixion for the superior flap, and when the sawing motion downwards has advanced but a little way, the compressing assistant shifts one of his hands into the incision, immediately behind the back of the knife, and so obtains a firm grasp of the femoral artery previously to its division. He retains this hold, at the same time retracting the flap, during the rest of the operation. As soon as the limb has been separated, the surgeon secures the vessels on the posterior flap, partly by his fingers, partly by compression with a large sponge, and ligatures are applied as quickly as possible. The femoral is secured last; for, as long as the assistant retains his hold, hemorrhage from it is not to be dreaded. Thus, when both surgeon and assistants are quick and cool, the operation may be completed with the loss of much less blood than might be expected. I have had occasion more than once to perform this operation, and thus speak from experience. In cases of accidental injury requiring this operation, the lever use of the limb must frequently be wanting; and in such cases, too, the parts may be so injured as not to afford flaps anteriorly and posteriorly. In these circumstances, the surgeon must be guided by experience and judgment in adopting the mode of procedure which appears most applicable; in ordinary cases the operation above detailed appears the preferable.

Excision of diseased portions of bones, is practised occasionally with the view of removing a source of irritation and exhaustion from the system, without sacrifice of a limb. When the operation proves successful, the beneficial effect on the general health is as remarkable and rapid as after removal of the hectic cause by amputation; the pulse falls and grows firmer, diarrhœa and sweating cease, the hectic flush leave the cheek; in short, the constitution makes a complete and successful rally. It is had recourse to in order to take away disease in the following situations,—in the cancellated articulating extremity of a long bone, in part or the whole of a short bone, and in part or the whole of long bones. Even a long bone, from one articulating surface to the other, may be removed; the metacarpal bone of the thumb, and the metatarsal bone supporting the great toe, may, for example, be taken away in their whole extent. I have seen these bones so treated, but the result was unsatisfactory. As has already been observed, the part of the member that is left is without support, and not under the influence of muscle; it is consequently loose and useless.

Operation for the removal of necrosed, or softened and ulcerated portions of the carpal and tarsal bones, is sometimes successful. But operative interference, either with these, or with more extensive and formidable articulations, is not advisable unless the soft parts are not largely involved, and when the general health is tolerably good—the patient either having suffered less than usual, or having rallied and begun to gain strength after exhaustion by discharge and fever. If the ligaments, bursæ, and cellular tissue are much affected, as is often the case, there is no chance of discharge ceasing, and the patient regaining health, even though the bone be removed to any extent—a second operation will be required, namely, amputation above the diseased parts. And when this becomes requisite, after failure of the first to restore or even improve the health, the patient is apt, as has too often been the case, to sink under the accumulation of suffering. He might, even though much exhausted, have been able to bear up against the shock of one and a successful operation, but he cannot endure that of a second, or perhaps third, serious and protracted attack of the knivesman. The disappointed hope of a cure from the first operation is a secondary, though nevertheless a sure contributor towards the unfortunate issue.

No particular rules can be laid down for the operative procedure. By converting two or more natural openings into one, extending the incisions as much as possible in the direction of the limb and of the muscles and tendons, and avoiding the course of the larger bloodvessels and nerves, room is made for an accurate examination of the diseased parts. A strong and firmly pointed knife is required for these incisions, for the soft parts are much consolidated, and are cut with difficulty. The extent of disease is ascertained both by the probe and by the finger, and farther measures, if necessary, are then adopted for complete removal. Loose portions of bone are taken away; and often large sequestra of the cancellated tissue are found lying in the cavity, either loose or easily separable; for extraction, forceps and the fingers, and sometimes a lever, are required. A firm scoop is useful for removing such portions of diseased cancellated tissue as are still continuous with the shaft of the bone. When an opening in the cancellated tissue, leading to an internal sequestrum, is minute, enlargement is effected by means of either the trephine or the cutting pliers: afterwards, gouges, gravers, &c., may sometimes be useful in operating on the soft texture underneath,—but they are seldom requisite. The bleeding from the soft parts is free; the vessels do not retract, and may require the application of a needle and ligature. That from the bone is easily arrested by pressure: the cavity is filled with charpie or with dossils of lint, and these are supported by a bandage. Some days after, this dressing is removed, having been previously softened and loosened by fomentation and poultice. The cavity should now be examined carefully, to ascertain whether or not all the diseased parts have been taken away; it is then dressed daily from the bottom. If parts of the surface assume an unhealthy aspect, the granulations being either backward or flabby, to these escharotics should be applied—the most suitable is the red oxide of mercury. Gradually the cavity fills up, and a depressed, firm, and permanent cicatrix is obtained. It need not excite surprise, however, if, in not a few cases, after matters have proceeded apparently very favourably for some time, the surface become pale, soft, and glistening; the discharge thin, acrid, and profuse; the integuments around tumid and discoloured,—if, in short, the disease be in no long time fully reëstablished.

The tarsal and carpal bones are often the subjects of this operation. In a few cases I have removed several, in others one or a portion of one, with success. In one instance the greater part of the astragalus was taken away, along with the ends of the tibia and fibula. There remained, in consequence, a large opening across the joint, through which a cord was passed, to facilitate gradual and piecemeal discharge of remaining portions of diseased bone. The articulation could actually be seen through. The seton was gradually diminished and the aperture closed. The foot was thus preserved, and the leg was but little shortened; the limb proved strong and extremely useful, but the ankle-joint retained little or no power of motion. I have also again and again trephined the os calcis, and removed large portions of it; the cuboid likewise has been taken away, along with the base of the metatarsal bone or bones in connection with it; in some of these cases an excellent cure followed, in others amputation of the foot was afterwards necessary.

Some have ventured to cut away the articulating ends of the bones composing the knee-joint. This may be accomplished without much difficulty. The patella is either removed entirely or turned to a side, the ligamentous and tendinous attachments are divided, and the ends of the bones thus exposed; by cutting close to and towards them, little risk is incurred of wounding the bloodvessels and nerves in the popliteal space. The saw is readily applied in a horizontal direction. After tying the vessels, and approximating the edges of the wound, the limb is placed in the straight position, and retained fixedly so by the application of splints. Much constitutional disturbance is to be expected, as well as profuse and tedious suppuration. There are few surgeons so rash as to have recourse to this operation. One or two patients, it is true, have lived in spite of it, retaining the limb in a tolerably useful state. But in others,—and these constitute the majority,—amputation was after all required, and that proved insufficient to save the patient. In short, the results of excision of the knee-joint do not justify its repetition.

The articulating ends of the bones composing the shoulder-joint have been removed; and this may be done with advantage on account either of disease or of injury. This joint is, like others, liable to ulceration of the cartilages, either primary, or in consequence of abscess and degeneration of the soft parts around. The disease is attended usually with painful feelings increased by motion, and the patient is indisposed to attempt motion. Sometimes merely weakness of the limb is complained of, and the attention is drawn to the wasted appearance of the muscles, particularly of the upper arm; the deltoid seems shrunk almost to nothing. The motions above the shoulder are lost; and abduction is impracticable. Much pain is produced by pushing sharply the articulating surfaces into contact, and is further increased by rotation. The enforcement of strict and absolute rest of the joint, the establishment of a drain in the soft parts immediately neighbouring, and attention to the general health, often prove sufficient to arrest the progress of this disease. If, however, it is neglected, abscess forms sooner or later. On cutting into this, and introducing the finger, the joint is discovered to be open; the head of the bone is found detached from the soft parts, and unsupported. Or this state of parts may be ascertained to exist by examination through a sinus, either with a probe, or with the finger after dilatation. In these circumstances, an attempt may be made to check disease, and preserve the arm, by excision of the obnoxious parts of the bone. And this kind of operation is also justifiable when the head of the humerus has been shattered by musket-shot; or when it has been exposed and injured by a splinter, or by a large shot, and the joint laid open. The situation and course of the incisions will be so far regulated by the openings or wounds already existing. They should always be made in the direction of the fibres of the deltoid, and the posterior aspect of the articulation is preferable to the anterior. One incision, from the back of the acromion process to near the insertion of the muscle, is sufficient to expose the head of the bone, to allow all its remaining attachments to be separated, and to admit of its being turned out so as to be conveniently acted on by the saw. The head of the bone merely is taken away. In separating the soft parts from its neck, the edge of the knife should be always directed to the bone, to avoid the nerves and vessels on the inside. In some cases of injury, very little additional wound may be requisite. The glenoid cavity may, in consequence of being seriously involved in disease, also require removal; this is best accomplished by large cross-cutting pliers. Few vessels require ligature. The edges of the wound are brought together; the elbow is supported, and the arm fixed to the trunk, in order to keep the bones in apposition, and prevent motion. This position must be retained during the rest of the cure; and when the wound is on the outside of the shoulder, as recommended, the dressing of it does not interfere with the retentive apparatus. The discharge gradually ceases, and cicatrisation is obtained, though not till after a considerable time, at least in general. The cut ends of the bones accommodate themselves to each other, and a sort of new joint is formed—but never strong. The motions of the forearm are perfect, though perhaps weakened; those of the upper arm are very incomplete. I have both performed and assisted in the operation repeatedly, and never experienced any difficulty; a cure has not always followed, but in some cases the limb has become very useful.

The elbow-joint, on account of its exposed condition, is generally regarded as the most favourable for excision. The affections of the joints of the upper extremity are much more manageable than those of the lower, and may generally be prevented from proceeding so far as to end in destruction of the apparatus. By care and good management, disease will be arrested, and the functions and motions of the parts restored and preserved; or the articulation may become stiff, and even though the anchylosis be complete, the limb will be very useful if the joint have been kept in a good position. The health, if previously undermined, is renovated, so soon as the local disease is arrested. But some bad cases are met with, in which all the parts surrounding the articulation are involved, and the strength wasted; in these amputation is the only safe and effectual procedure. It is only when the soft parts are not much diseased, when it is ascertainable that the affection of the bone is only to a limited extent, and when the usual means of cure have had a fair trial and failed, that excision is admissible. In determining on the operation, the time of life and the worldly circumstances of the patient are to be considered: a poor man requires his limb to be serviceable in labour; handsome appearance without utility is to him of no value. The motion and usefulness of the arm may be in a great measure preserved, if only a part of the bone of the arm, or a part of those of the forearm, entering into the articulation, be removed; but if large portions of all of these be taken away, the muscles will lose their support, the motions will never be restored to any extent, and the motion that is of it will be weak and vacillating. The joint will remain loose and powerless, and the limb will prove to be but a useless incumbrance. Such, at least, is the result of my experience on this subject; and I am sorry to add, that all which has been written on it is not deserving of unreserved belief. Many patients have, after long and severe suffering, preserved the arm to little purpose; others have been necessitated to submit to another operation—amputation after all; some have died after the first, others after the second mutilation. The operation is attended with no difficulty in execution, and this in some measure accounts for its frequent, and it is to be suspected, indiscriminate, performance of late years. The incisions are made on the posterior aspect of the joint. One is placed in the mesial line, extending from about two inches above the olecranon to the same distance below it; and from this flaps are raised, by making either a cross-cut in the middle, or one at each extremity; in the one case the flaps are four, and triangular; in the other two, and quadrangular; by either method the bones are readily exposed. A more simple form of incision, as described in the Practical Surgery, will often be found to suffice. The joint is opened and dislocated, and the soft parts separated to the necessary extent from the bones. The ulnar nerve is avoided by dissecting close to the bone. The diseased portions are then sawn off. The wound is closed, and the arm kept bent. This operation I have performed pretty often, the cases being carefully chosen for it, and the success has been highly satisfactory. By the sanguine supporters of this operation, the after-treatment is advised to be conducted so as to secure motion in the new articulation. From this I would dissent, for if the articulating ends of the bones have been actually cut off, the motion may be extensive enough certainly, but both joint and limb will be almost altogether impotent. It would be better to procure anchylosis in the bent position, than to have the arm dangling like a flail; in the one case the limb will be useful; in the other, ornament, and that too of an equivocal kind, is all that it can boast. Even anchylosis, in most cases, can be brought about only after the lapse of a long period. In the more severe affections of this joint, amputation of the limb is the operation which must ultimately be had recourse to, if the patient survive; and it is better to perform this at once, than after the experiment of excision has been tried and found wanting. I know that parents have too often had to regret and mourn bitterly their having departed from sound advice, and lent themselves to such experimental trials on their offspring.

FOOTNOTES:

[1] [In the cellular tissue the pain is acute and throbbing; in the pleura, sharp and lancinating; in the lungs and glandular organs, obtuse and heavy; in the skin, prurient and smarting; in the bones, dull and gnawing. Sometimes it is persistent, sometimes intermittent, sometimes periodical; and occasionally, again, it is felt at parts very remote from the one originally and mainly affected. Of the latter variety we have a familiar instance in the hip-joint disease of children, in which the earliest symptom complained of is pain in the corresponding knee. In hepatitis, the right shoulder is often the seat of the suffering; in cystitis, the head of the penis.—ED.]

[2] [Mr. Hunter endeavoured to settle this point by experiments on the inferior animals. With this view, he made a wound in the right side of the chest of a dog, and placing the thermometer in contact with the diaphragm, ascertained that the temperature was 101°. A large dossil of lint was then thrust into the opening, when the edges were drawn together with adhesive strips. On the following day, when the parts were in a state of inflammation, the foreign substance was removed, and the instrument being again introduced, no difference of heat was found to exist. Similar experiments were made on the rectum and vagina of an ass, with like results. Hence Hunter concluded that there was no real increase of temperature. From more recent researches, however, it is obvious that this inference of the great English surgeon is at variance with facts. Thus, in erysipelas, furuncle, and anthrax, the thermometer has been observed, in numerous instances, to rise as high even as 107°, being an increase over the average heat of the blood of eleven degrees. Results of a similar nature have been noticed in tetanus, acute rheumatism, and other maladies.—ED.]

[3] [Leeches may be applied to almost any region of the body, excepting such as are abundantly supplied with loose cellular substance, as the eyelids and scrotum; or traversed by large subcutaneous veins. Parts in a state of high inflammation must also be avoided, otherwise gangrene may be induced, an effect which I have several times witnessed in hospital practice: in a case of this kind they should be placed in the immediate vicinity of the disease.

Previously to applying them, the skin should be thoroughly cleansed with a wet sponge, and moistened with a few drops of milk, blood, or sweetened water. Dipping the leeches in table beer is very effective in rendering them lively and active. Having been withdrawn from the water in which they are kept for a quarter of an hour before, they should be held to the part by means of a glass tube, a roll of pasteboard, or a piece of linen. When there is plenty of space, as on the abdomen, chest, or back, and it is designed to use great number, they may be confined by an inverted tumbler or a wire-gauze cage. They should not, however, be crowded too closely together, as erysipelatous inflammation is apt to arise when this is done; and they ought not to be touched until they drop off of their own accord. If they remain on too long, their separation may be facilitated by sprinkling them with a little salt or vinegar: pulling them away is painful and liable to occasion irritable sores. The subsequent flow of blood, which is generally considerable, especially in children, is to be promoted by cloths wrung out of warm water, and reapplied every ten or fifteen minutes for several successive hours.

If the bleeding be profuse or continue longer than is desirable, it may be arrested by some styptic powder or lotion, either alone or assisted by a compress and roller. In obstinate cases, it may be necessary to apply the nitrate of silver or chloride of zinc; or, what is better, because more effective, to use the twisted suture made with a very fine needle and ligature passed through the sides of the little wound.—ED.]

[4] [Scarification is a very efficient mode of abstracting blood, and one which, in my own hands, has often been attended with the happiest results. It is performed by drawing a sharp thumb-lancet rapidly and lightly over the affected surface, in as many places as may be deemed necessary, and afterwards encouraging the bleeding either by means of a wet sponge or by immersing the part in warm water. Scarification is mainly used in chronic ophthalmia, attended with great vascular turgescence of the lower lid, in scrofulous swellings of the joints, in chronic enlargement of the testicle and epididymis, in irritable ulcers of the leg, in tonsilitis, and in erysipelas.—ED.]

[5] [All practitioners are aware how much the formation of the buffy coat is influenced by extraneous circumstances. Of these the most important are the shape and capacity of the receiving vessel, the degree of motion to which the blood is subjected, and the size of the orifice in the vein. Dr. Belhomme, of Paris, who has minutely investigated this matter in a series of one hundred and fifty experiments, has come to the conclusion that a narrow basin, a large orifice, and a full, rapid stream, in the form of an arch, are the external conditions most favourable for producing the buffy coat. The results of these researches have since been verified by those of Gendrin and other observers, and they are well worthy of recollection, as they are calculated to exert an important bearing on the practice of our profession. See my Elements of Pathological Anatomy, Vol. I., p. 207. A cupped state of the blood most commonly occurs in association with inflammation of the serous membranes and parenchymatous organs, and may generally be regarded as evincive of a high degree of vascular excitement. Still, not too much stress should be placed upon this appearance, as it is sometimes present in states of the system the very reverse from that just mentioned, in persons, for example, who have been repeatedly bled or whose strength has been otherwise very much reduced.—ED.]

[6] Throughout the Elements, the edition of Practical Surgery referred to is that of 1842. Philadelphia.

[7] To prevent mortification blisters have long been a favourite means with American surgeons. The practice originated, I believe, with the late Dr. Physick, of Philadelphia, early in the present century. To do good, they should be large enough to cover, not only the whole of the inflamed part, but a considerable portion of the surrounding surface, and to be kept on until they have produced thorough vesication. Blisters are scarcely less serviceable to arrest mortification, after it has made some progress, but in this case they should be placed in contact with the sound skin, not with the dead, as they cannot, when this is done, be productive of any good.

To expedite the sloughing process, allay the unpleasant fetor, and promote the formation of healthy granulations, I know of no remedy that will answer so well as the nitric acid lotion. It should vary in strength, according to the exigency of the case, from four to twelve drops of the acid to the ounce of water, and a cloth wet with it should be constantly kept in contact with the affected part, taking care to wash it occasionally to rid it of the foul discharges with which it becomes from time to time impregnated. If necessary, a poultice can be placed over the rag. Under this treatment, particularly when aided by the liberal use of carbonate of ammonia, wine, brandy, and other cordials, I have often been astonished to witness the rapid changes that have taken place, in cases apparently of the most desperate character.—ED.

[8] In this country no remedy is perhaps more frequently employed in the treatment of erysipelas than blistering. In my own practice I have constantly resorted to it for the last fourteen years, and in no instance has it disappointed my expectations. Not only do I consider it as perfectly free from danger, an objection which has sometimes been alleged against it, but I know of no measure so well calculated to afford prompt and effectual relief. My practice is to apply the blister directly to the inflamed surface, together with a small portion of the healthy skin, and to keep it on until it produces thorough vesication. The vesicles are then opened with a needle, and the part covered with a light emollient poultice or the warm-water dressings. In children, and persons of a nervous delicate constitution, or whose health has been previously much impaired, the blister must be removed in from three to six hours, otherwise serious local mischief may be induced. This treatment, although applicable to every species of erysipelas, is particularly valuable in the phlegmonous form, no matter where situated, whether in the face, eyelids, scalp, trunk, or extremities.

Another remedy which has been extensively employed in this country, is the mercurial ointment, first recommended to the notice of the profession by Dr. Dean and Dr. Little, of Chambersburgh, Pennsylvania. My own experience, however, does not enable me to offer anything in its favour. Indeed, if at all useful, it can only be so, it seems to me, in the milder forms of the complaint: in the more severe grades it should never be resorted to, as it is far inferior to blistering, or scarification, as practised by Mr. Liston. The ointment should be perfectly fresh, and be applied upon soft linen, at least twice a day. Professor Velpeau has recently recommended methodical compression by means of the roller, and from some cases which he has published in illustration of his method it would seem to be entitled to further trial.—ED.

[9] [Dr. Physick (American Journal of the Medical Sciences, Vol. VII., p. 304) was always in the habit of commencing the treatment of hip-joint disease by the administration of a mercurial purge. The preparation which he commonly used was calomel, of which he gave to a patient from six to ten years two or three grains at bedtime, followed the next morning, unless it should have previously acted well, by a dose of oil. If, after having kept the patient perfectly quiet for a few days, he found the parts inflamed, swollen, and tender to the touch, he abstracted from six to eight ounces of blood, by the application of a sufficient number of leeches. Unless the inflammation was very acute, with a good deal of febrile disturbance, he did not prescribe much reduction in the diet, which was generally of a light wholesome character. His next object was to institute a course of steady and systematic purging, which he regarded as far superior to emetics, fomentations, blisters, setons, and caustic issues, so much employed by other practitioners. The articles which he selected were cream of tartar and jalap, which were given every other day in sufficient doses to procure several copious evacuations. These medicines were occasionally changed, either as they lost their effect, or as the patient took a dislike to them.

Having pursued the above plan for a few weeks, and accustomed the patient to his confinement, the next object was to insure perfect rest to the diseased joint, the most essential item of the whole treatment. To this end, a carved splint, long enough to extend from the middle of the side of the chest nearly to the external malleolus, and sufficiently wide to reach nearly one-half round the parts into which it was to lie in contact, was adapted to the shape of the limb, carefully padded on the inside, and secured by two rollers, one of which was passed round the trunk, the other round the limb from the ankle to the top of the thigh. When the limb is much bent or distorted, it should by no means be forced into a straight position in the first instance; on the contrary, the splint should be angular, to accommodate itself to hollows and projections of the parts, and, as the cure progresses, another less crooked should be substituted. It is rarely that more than two splints are required, though Physick was sometimes obliged to use as many as three or even four in the same case. During the whole treatment the patient should lie upon a hair mattrass, and the apparatus kept steadily applied until all the symptoms of the disease have vanished, which is seldom under twelve months.—ED.]

[10] [The treatment of this affection must be chiefly of a local nature, although it may sometimes be necessary to resort to constitutional means, especially mercurial purgatives. When dependent upon a gouty or rheumatic state of the system, the different preparations of colchicum may be exhibited with a prospect of advantage, as also the hydriodate of potash in large doses. As a local remedy, blistering is by far the most prompt and effectual, and worth all the liniments and unguents that have ever been devised. The discharge from the vesicated surface may be maintained by savin or tartar emetic ointment; or, what is preferable, the fly may be reapplied as soon as the sore becomes dry. The operation of the blister should be aided with a bandage and a piece of oiled silk, or strips of adhesive plaster, to support the distended ligaments. Should these means fail, or the accumulation be so great as to impede the motions of the joint, and render it probable that absorption cannot take place, a small valvular incision may be made into the most dependent situation of the swelling, to draw off the fluid. Such a step, however, although justifiable under the circumstances here indicated, should not be taken without due reflection.—ED.]

[11] [Rachitis is emphatically a disease of infancy, being most frequently witnessed from the eighteenth to the twentieth month; it is occasionally congenital, and sometimes, though rarely, it takes place after puberty. Of three hundred and forty-six cases examined by Mons. Guerin, of Paris,[12] three occurred before birth, ninety-eight during the first year, one hundred and seventy-six during the second, thirty-five during the third year, nineteen during the fourth, ten during the fifth year, and five from the sixth to the twelfth. Of these cases one hundred and ninety-eight were observed in the female sex, the remainder, or less than one-half, in the male.—ED.]

[12] Memoir on the General Characters of Rachitis, translated by Dr. T. W. Colescott, of Louisville, and published in the Western Journal of Medicine and Surgery, for January, 1841.

[13] [The symptoms which characterize this affection are generally well defined. The face has a yellowish, sallow appearance; the eyes are large and brilliant; the nostrils unnaturally expanded; the lips, especially the upper, tumid and everted; the head big, and sunk between the shoulders; the chest narrow and contracted; the curvature of the clavicle increased; the articular extremities of the bones unusually prominent; the muscles thin and flabby; the motions constrained and difficult; the whole body has a short, stunted appearance, and the little patient exhibits all the marks of premature decay or old age. The respiration, short and laborious, is performed chiefly by the diaphragm; the abdomen is tense and tumid; and the skin, which is constantly moist, is often bathed during the night with acid perspiration. The appetite is weak, the digestion difficult, the thirst considerable, and there is nearly always diarrhœa, or diarrhœa alternating with constipation. The alvine evacuations are of a thin, watery character; the urine is copious, but not high coloured; the pulse is small and frequent; the action of the heart feeble, the sensibility remarkably keen, and the mind uncommonly active. The child feels averse to use his limbs, and the bones are so soft as to be bent with the greatest facility.

The alterations of the osseous tissue have been divided by Mons. Guerin, to whom we are indebted for the most able and elaborate account of this disease that has yet been furnished, into three stages. In the first, the bones seem to be saturated with a reddish, watery fluid; a considerable quantity of which is also interposed between their outer surface and the periosteum, on the one hand, and between the medullary membrane and their internal walls, on the other. At a more advanced period, this fluid is replaced by a sort of gelatiniform substance, that is particularly conspicuous in the situations here specified, becomes gradually organized and vascular, and ultimately adheres with great firmness to the parts with which it lies in contact. The periosteum is thickened and injected, the nutrient vessels are remarkably enlarged, and the medullary membrane is sensibly altered in its character; the changes which it has undergone being similar, though less in degree, to those of the fibrous envelope just mentioned. The lamellæ of the long bones, naturally so hard and compact, are a good deal softened, and the areolar structure greatly rarefied, many of the cells being more than double or even triple the natural size. Similar alterations are observed in the short and flat bones.

In the second stage, a peculiar spongoid substance is formed between the periosteum and the outer surface of the bones, varying from two to three lines, or upwards in thickness; and which, by the pressure which it exerts upon the lamellæ of the compact tissue, sometimes forces them inwards upon the medullary canal, thus greatly reducing it in size, or even entirely obliterating it. Simultaneously with these changes the bones are rendered so soft that they may be easily bent, cut, or even indented with the finger. In the third stage—that of resolution—the recently formed substance in the long bones, as well as in some of the flat and short, assumes a compact character, and becomes gradually identified with the pre-existing tissues, which at the same time regain their primitive solidity. Owing to the presence of this new matter, the bones are much larger than in the natural state, and their firmness—especially in the adult—resembles that of ivory. Hence the term eburnation is sometimes applied to this state of the skeleton.—ED.]

[14] [Of sixty-three cases recorded by Mr. Hodgson, in his work on the Diseases of the Arteries, fifty-six were noticed in the male, and seven only in the female. The reason of the more frequent occurrence of aneurism in men than in women is found in the circumstance of the former being more exposed to all sorts of violence and disease than the latter.—ED.]

[15] [This disease is much more frequent in old than in young persons. Of one hundred and eight cases, collected by Dr. Bizot, of Geneva, from the writings of Morgagni, Corvisart, Laennec, Scarpa, Boyer, Hodgson, Richard, and S. Cooper, only a single one occurred before the twentieth year. Fifteen were noticed from the age of twenty to twenty-nine; thirty-five, from thirty to thirty-nine; thirty-one, from forty to forty-nine; fourteen, from fifty to fifty-nine; eight, from sixty to sixty-nine; two, from seventy to seventy-nine; and two, from eighty to eighty-nine. Thus it would appear that more persons suffer from this malady from the age of thirty to fifty than during all the other periods of life put together. (Elem. of Path. Anat. vol. i., p. 288.)—ED.]

[16] [The following table, extracted from the Cyclopædia of Practical Surgery, will place this subject in a clearer and more accurate point of view. It exhibits the relative frequency of spontaneous aneurism in the different arteries in 179 cases, excluding those of the aorta: it was drawn up originally by Mons. Lisfranc:—

1. Popliteal 59 { at the groin 26 2. Femoral { { at other points 18 3. Carotid 17 4. Subclavian 16 5. Axillary in the arm-pit 14 6. External iliac 5 7. Innominata 4 8. Brachial 3 9. Common iliac 3 10. Anterior tibial 3 11. Gluteal 2 12. Internal iliac 2 13. Temporal 2 14. Internal carotid 1 15. Ulnar 1 16. Fibular 1 17. Radial 1 18. Palmar 1

In another table, constructed by Mr. Hodgson, and founded upon sixty-three cases, including, however, twenty-nine of the aorta and innominata, the results are as follows:—

Carotid 2 Subclavian and axillary 5 Inguinal 12 Femoral and popliteal 15.—ED.]

[17] [This aneurismal diathesis occasionally exists in an astonishing degree. Thus, Pelletan relates an example in which there were upwards of sixty tumours of this kind; and a still more remarkable one is recorded by Mons. J. Cloquet. In this case the number of dilatations exceeded two hundred, the largest of which were not bigger than a common pea. (Elements of Path. Anat., vol. i., p. 283.) An instance similar to that in the text occurred at Cincinnati two years ago, in a man between thirty and forty years of age, in whom Professor Mussey secured the right femoral artery for popliteal aneurism. Three years previously the same operation was performed on the left limb for the same affection by Dr. Speer, of Pittsburgh.—ED.]

[18] [This is commonly called Brasdor’s operation, after the surgeon who devised it. Mr. Wardrop, of London, is its greatest advocate. It has proved successful only in a few cases out of upwards of twenty in which it has been performed.—ED.]

[19] [For some very interesting examples of this hemorrhagic tendency, the reader is referred to Mr. Wardrop’s excellent little work on Bloodletting, and to the first volume of my Elements of Pathological Anatomy. A few years ago a case came under my notice in which fatal hemorrhage was caused by lancing the gums over the two central incisors of the upper-jaw, in a male child between five and six months old. He was labouring at the time under an attack of cholera, so prevalent in our early summer months; and the day after the operation purpuric spots appeared in different parts of the body, the largest being situated on the abdomen and the scalp, just behind the ear. The bleeding was at length arrested by the twisted suture, made by transfixing the gum with three very small needles, the points of which were broken off close to the jaw, and the threads applied in the usual manner. Notwithstanding this, the child died exhausted on the fifth day, hemorrhage having, in the meanwhile, taken place from the stomach and bowels. It may be proper to add, that the infant had been delicate from his birth, and that there was no hereditary predisposition to the singular affection which carried him off.—ED.]

[20] [In one instance I succeeded perfectly in effecting a cure with the seton. The tumour, about the size of a twenty-five cent piece, occupied the vertex, and possessed all the properties of the erectile tissue. The child was eighteen months old, and the swelling had made its appearance a few weeks after birth. Half a dozen coarse silk threads were passed, by means of a curved needle, under the base of the tumour, where it was allowed to remain for nearly a month. Considerable suppuration supervened, followed by the complete obliteration of the enlarged vessels. In the hands of Mr. Wardrop, of London, the caustic potash, applied to the surface of the tumour, as in making issues, appears to have been attended with great success. The practice of tying the principal arterial trunks connected with the swelling almost constantly fails, and is rarely resorted to except by ignorant and reckless surgeons.—ED.]

[21] [The first accurate account of osseous aneurism was published in 1826, by Mons. Breschet, in the second volume of the “Répertoire Générale d’Anatomie et de Chirurgicale.” It has since been noticed by other surgeons, particularly by Professor Lallemand of Montpelier, and Mr. Bell of Edinburgh, and there is reason to believe that it is of more frequent occurrence than is generally imagined.

The disease is most commonly seated in the head of the tibia. It has been observed also in the scapula, as in the case mentioned in the text, the femur, wrist, and ankle. The male is more liable to it than the female, and it rarely makes its appearance until after the period of puberty. The cause of the disease has not been satisfactorily explained. In some cases it is produced by external violence, as a blow or fall; in others, especially when seated near a large joint, it is traceable to gouty and rheumatic affections.

The enlargement, even in its early stage, is tense and painful; being attended with distention of the superficial veins, swelling of the surrounding structures, and slight discoloration of the skin. In a short time a deep-seated pulsation, or throbbing, synchronous with that of the left ventricle, and similar to what is witnessed in some erectile tumours, may be perceived in the affected part. In the advanced stage of the malady the beating is accompanied by a sort of undulating movement, and is easily interrupted by compressing the main artery of the limb, between the tumour and the heart. The enlargement varies in size. In a case mentioned by Mr. Bell, it was more than nine inches in circumference, by upwards of six in length. In some instances, pressure applied to the tumour with the finger imparts a peculiar crackling sensation, not unlike that of dry parchment or an egg-shell. The soft parts around the disease are generally œdematous, the whole limb is apt to be swollen, and the motions of the contiguous joints are constrained and painful. Towards the last the general health always seriously suffers.

On inspection, the outer table of the bone is found to be considerably attenuated, in many parts destroyed, and in some so flexible and elastic as to be bent with the same facility as cartilage. Frequently the bone is extremely brittle, and may be crushed like an egg-shell. The areolar texture is partially absorbed, and the medullary canal filled with coagula, which are often arranged in concentric layers, as in old aneurismal sacs in other situations. The investing membrane in the immediate vicinity of the disease is thickened, as well as preternaturally dense and firm, and the vessels ramifying through the tumour are greatly enlarged.

The only effectual remedy for this disease, provided its location be favourable, is amputation. In the early stage relief may possibly be afforded by securing the main artery of the limb. Lallemand relates a case in which ligature of the femoral artery completely arrested an aneurismal affection of the head of the tibia; but this must be regarded as an exception to the general rule.—ED.]

[22] [In this country we have a number of insects, the sting of which is sometimes attended with considerable pain and swelling, or even high inflammatory excitement. Of these, the most common are the bee, wasp, hornet, yellow-jacket, and humble-bee, which all secrete a subtle poison contained in a reservoir in the abdomen, from which it is projected by the barbed dart when in the act of stinging. Severe and even dangerous wounds are occasionally thus inflicted; indeed, in a few instances death has been known to follow, especially in persons of a nervous, irritable temperament. Another insect, from the bite of which a good deal of irritation often results, is the musketoe, which abounds everywhere, during the hot summer and autumnal months, along the water-courses of the western and southern states. The little punctures made by this animal I have known in several instances to degenerate into unhealthy sores, furnishing a thin, sanious discharge, attended with more or less itching, and exceedingly difficult to heal. The late Professor Dorsey mentions a case—that of a lady who previously enjoyed good health—in which the bite of the musketoe terminated in gangrene and death.

Of the great number of serpents inhabiting this country, only two—the rattlesnake and copperhead—are known to be venomous. Both are very active in warm weather, are furnished with long teeth, and secrete an acrid, virulent poison, of a yellow-greenish colour, which is lodged in a bag or reservoir at the roots of two of the teeth of the upper-jaw. When this poison is fairly infused into a wound of the skin and cellular tissue, it often proves fatal in a few minutes; in other cases, the patient either recovers, or death does not occur until a later period.—ED.]

[23] [The wounds made by the stings and bites of insects are best treated by stimulating lotions, such as salt-water, vinegar, alcohol, hartshorn, and camphorated spirits. These remedies generally afford prompt relief, and they possess the additional advantage of being always near at hand. Bleeding, purging, and opiates, may become necessary, when, besides much pain and swelling, there is a great degree of constitutional disturbance. When bees and wasps find their way, as they sometimes do, into the œsophagus, causing violent suffering and nervous agitation, almost instantaneous relief may be afforded by making the individual drink large draughts of vinegar or salt and water.

When a person has been bitten in one of his limbs by a venomous serpent, a ligature should be immediately applied, as tightly as possible, at a short distance above the wound, which is then to be carefully excised together with a portion of the surrounding structures. A cupping-glass is next applied, and after this has remained on for several hours, the sore is to be dressed with an emollient poultice or some simple unguent, or fomented with cloths wrung out of warm water and laudanum. The only internal remedy upon which the slightest reliance is to be placed, is arsenic, in the form of Fowler’s solution. It should be administered, as was first suggested by Mr. Ireland, an English surgeon, in doses of two drachms every thirty minutes until an ounce or upwards is taken, or until free vomiting and purging ensue.—ED.]

[24] [The above symptoms, together with deep-seated tubercles of the skin and mucous membrane, constitute what Mons. Ricord has lately described under the name of tertiary syphilis. They seldom make their appearance under fifteen or eighteen months after the formation of primary sores, and some cases occur even after the lapse of many years. From two to three years may perhaps be considered as the average period for the development of the tertiary form of the disease. This, however, is still an unsettled point.—ED.]

[25] [It is somewhat surprising that the author has made no mention, in connexion with this subject, of the iodide of potassium, so justly lauded by Mons. Ricord and some other French surgeons. For the last two years or more I have been constantly in the habit of employing this article in tertiary syphilis, in mercurial disease of the bones, and in chronic rheumatism, in which, I am convinced, it is as much of a specific as quinine is in intermittent fever and miasmatic neuralgia. The medicine, to produce its full effects, should be administered in much larger quantities than are recommended in our treatises on the Materia Medica. In my own practice, I usually commence with ten grains, repeated three or four times a day, and gradually increased until it amounts to a scruple, or even half a drachm. Exhibited in doses of this size, it is truly surprising how rapidly, in most instances, it affords relief. Patients who have laboured under nodes and nocturnal pains for months, whose health has become greatly impaired, and who have not slept soundly perhaps for weeks together, have often perfectly recovered under this treatment in less than a fortnight. A very decided improvement generally takes place within the first forty-eight hours, the local uneasiness diminishing, and the sleep being rendered more refreshing. The medicine should not be laid aside as soon as the patient experiences relief, but be continued for several weeks after the symptoms of the malady have subsided. By neglecting this precaution a relapse will occasionally occur. The best vehicle for it is distilled water with a small quantity of simple syrup. Mons. Ricord administers it dissolved in hop-tea, made with an ounce of hops to a pint of boiling water; this is allowed to stand for four hours, when thirty-six grains of the salt are added, and the whole drunk during the course of the day. When given in the large doses above mentioned, it is said to be sometimes productive of diarrhœa or gastric irritation; but no such effects have followed its employment in my own hands, and I presume therefore that they are exceedingly rare. Should they take place, the quantity must be lessened, or the medicine entirely suspended for a few days.

In obstinate cases of tertiary syphilis it may be necessary to exhibit along with this medicine the compound decoction of sarsaparilla, or some of the preparations of mercury, such as the proto-ioduret, deuto-chloride, or cyanuret. The first may be given in doses of from one-half a grain to a grain, the second, from one-eighth to a fourth of a grain, and the last, from one-sixteenth of a grain to a grain, twice or three times a day. How the iodide of potassium acts in producing its beneficial effects in the diseases in which it is now so extensively used by our French brethren, as well as by some of the practitioners of our own country, has not yet been explained. That it is a powerful alterant must be admitted, and that it greatly improves the condition of the digestive organs is equally certain.—ED.]

[26] [As there are no facts in surgery so valuable as those of a statistical kind, I shall offer no apology for transferring to these pages an abstract of a very able article on hernia cerebri, published by Dr. Gurdon Buck in the fourth number of the New-York Journal of Medicine and Surgery. The paper in question is founded on an analysis of thirty-three cases, all collected, save one which occurred in his own practice, from the writings and reports of different American and European surgeons.

Of these cases only two occurred in the female. The age of the youngest was two years and a half; of the oldest, forty; seventeen were twelve years or under; nine from thirteen to twenty years; and seven, twenty-one or upwards. The seat of the wound giving rise to the disease, occupied, in fourteen cases, some part of the frontal region; in seventeen the parietal; and in two the occipital. In fourteen cases the brain was lacerated, and a portion of its substance discharged; in five it was wounded without loss; in one its surface was simply denuded; in ten there was no exposure; and in three its condition is not noticed. The dura mater was torn in twenty-one cases, and in another perforated; the cranium in all, except one, was broken into several fragments; and in twenty-four the scalp was more or less lacerated; in another it was pierced; in three there was no solution of continuity; and in five no mention is made of its condition.

The period of the appearance of the morbid growth from the occurrence of the injury varied in different individuals. In eleven cases it manifested itself prior to the sixth day; in fifteen between the seventh and twelfth; and in five between the twelfth and twenty-fifth. In one instance it did not begin until the eighth week: in another the time is not specified. The earliest period of its appearance was the third day, and that in two cases only; in more than three-fourths it commenced on or before the twelfth day. The average period was the ninth day from the accident.

In regard to the volume of the tumour, it varied from half an inch in diameter to a mass measuring six, by three and a half inches upon the surface, and two and a half in thickness. In twenty-two cases in which the dimensions are stated, the tumour in five was of the size of a hen’s egg; in eight it exceeded that magnitude; and in nine it fell short of it. The morbid growth was dissected only in eleven of the cases; in nine of these it consisted of cerebral substance, in which the cortical and medullary tissues were distinctly recognised, and in the other two it was composed of coagulated blood of a fibrous texture. In seven cases the tumour assumed a sloughing character; in five it yielded a fetid, sanious discharge; in one it bled freely on the slightest touch; in three it was enveloped by the pia mater; and in three others the surface was coated with a layer of clotted blood. In the centre of the largest tumour a cavity existed, filled with an ounce of limpid serum, and lined by a transparent, glistening membrane.

The general symptoms, indicative of disturbance of the vascular system, and of the cerebral functions, may be next considered. In twenty-three cases there was more or less excitement of the heart and arteries; in four none was apparent; and in the other six the symptoms are not stated. “In fourteen cases some one or more of the following symptoms of disturbance of the brain and nervous system were present: coma, delirium, pain in the head, general irritability, and insensibility. In six paralysis of the side of the body opposite to the injury was superadded to the preceding symptoms; and in two convulsions. Three cases were remarkable as presenting some striking exceptions to the general characteristics, and are, therefore, deserving of more particular notice; one of them, from the circumstance that there was no apparent shock to the nervous system, not even as the immediate effect of the injury, though its severity was so great that several fragments of bone and pieces of coal penetrated the brain, causing a discharge of three or four teaspoonsful of its substance. In another the patient remained in a state of complete insensibility and general paralysis for twenty-three days; the hernia appearing on the seventh day, and no inflammatory symptoms supervening. The third case exhibited a character of most frightful violence. Besides paralysis of one side, there were spasmodic actions of the muscles of the face and of all the limbs; nausea, retching, quivering of the eyelids, fixed eyeballs, strabismus, grinding of the teeth, alternate contraction and dilatation of the pupils, intolerance of light and sound, and other signs of the most alarming nervous commotion, often threatening to terminate life.”

Of the thirty-three cases in question, seventeen recovered, at a period varying from three weeks to four months; and sixteen terminated fatally, on an average, about the twenty-fourth day. More young persons recovered than old. Of the sixteen fatal cases, eleven were examined, and exhibited the following lesions: in eight the portion of the brain subjacent to the hernia was softened, pulpy, more or less disorganised, and sometimes intermixed with clots, while in the account of the other three no notice is taken of its condition. In eight other cases there were signs of acute inflammation of the arachnoïd membrane as indicated by thickening, opacity, adhesions to the dura mater, and deposits of lymph or pus. The portion of the dura mater around the opening through which the fungous mass protruded was thickened, black, and sloughy, in three of the eleven cases in question. In four the ventricles were filled with bloody serum; in one there was a large abscess in the brain full of pus, and lined with a false membrane. In one case a clot of blood was found between the dura mater and the cranium; in four the fracture extended through the base of the skull; and in one of these the edges of the osseous aperture, through which the hernia protruded, were rounded off by absorption.

In respect to the general treatment, it was uniformly antiphlogistic, consisting of the abstraction of blood by venesection and leeching, and the use of purgatives, proportioned to the urgency of the inflammatory symptoms. The local means employed were, excision of the hernial tumour, the application of the ligature, pressure, and caustics, either singly or together. In one of the cases that resulted favourably a spontaneous cure took place after copious hemorrhage from the morbid mass, excited by an accidental attack of vomiting. In another, after the ineffectual use of the nitrate of silver and other escharotics, the ligature was applied and gradually tightened from day to day; in five pressure alone was sufficient; in two the pressure was conjoined with lime-water; and in one with the nitrate of silver. In seven other favourable cases excision was resorted to, either once, or repeatedly, accompanied with pressure; in some dilute nitric acid—twenty drops to the ounce of water—lime-water, or nitrate of silver, were employed in addition. In the sixteen cases that terminated fatally the local treatment was, pressure alone in two; in five excision with pressure; in two the ligature; in one both ligature and excision; and in another escharotics. In five no mention was made of the local means.—ED.]

[27] [Dr. Maunoir, of Geneva,[28] relates a curious instance, strongly corroborative of the occasional hereditary tendency of this affection. While investigating this subject, he became acquainted with the history of a woman whose grandfather, uncle, two aunts, and two cousins, all on the paternal side, had had cataract, and who had all been operated upon. She herself, at the age of twenty, was attacked with it. Finally, out of four children which she had, one was born with cataract; and, what is remarkable, neither her father, mother, nor sisters, had ever had any affection of the kind. The same writer states that Roux once operated for this disease upon three brothers, whose father and grandfather had suffered similarly. A brother, much younger than themselves, had the affection in its incipient stage. Instances more frequently occur in which several members of a family are affected with cataract, without any traceable hereditary predisposition on the part of either parent. Professor Drake met with a case not long ago, where five out of nine children were blind from this cause; and last autumn I operated on two boys and a girl from Mississippi, who had lost their sight in a similar manner.—ED.]

[28] Essay on Cataract, translated by Dr. Bowditch, of Boston.

[29] [The two subjoined tables, the one constructed by Mons. Maunoir, and the other by Professor Fabini, demonstrate the immense influence which age exerts upon the production of cataract:—

TABLE I.

From 20 to 29 years 5 patients 30 39 3 40 49 11 50 59 25 60 69 41 70 82 27 ——— 112

TABLE II.

From 1 to 10 years 14 patients. 11 20 16 21 30 18 31 40 18 41 50 51 51 60 102 61 70 172 Above 70 109 ——— 500

It has been said that men are more liable to cataract than women; the difference, however, if any, is probably very slight. Thus, in the first table, 61 were males and 60 females; in the second, 268 were males and 232 females.—ED.]

[30] [This expression admits of some modification. In young persons with good constitutions, whose previous health has been good, and who have not been subject to ophthalmia, I should not hesitate to operate on both eyes at the same time. In six or eight cases, in which I have lately followed this practice, no unpleasant effects whatever occurred: in all the inflammation was exceedingly moderate.—ED.]

[31] [In congenital cataract there can be no valid reason for postponing the removal of the opaque lens even to as late a period as that mentioned in the text. The operation is perfectly simple, unattended with risk, and may be performed within six or eight weeks after birth.—ED.]

[32] [This must, I suppose, be a typographical error. The author can certainly not mean that the instrument should be introduced at the centre of the cornea, as would inevitably happen if we were to carry out his directions. The proper point is the lower and outer part of the cornea, about a line anterior to its junction with the sclerotic coat.—ED.]

[33] See Elements of Pathological Anatomy, vol. i., p. 489, for description of this fascia.

[34] Boston Medical and Surgical Journal, Dec. 29th, 1841.

[35] [This opinion is certainly erroneous. That the obstruction occasionally exists in the situation adverted to, cannot be doubted, but that it does so constantly, or even generally, is not true. When the lining membrane of the antrum is inflamed, it does not follow that it must be so throughout its entire extent; most commonly, indeed, there is reason to believe that the morbid action is circumscribed, and hence when matter forms it may readily, in many cases, find its way into the nose. It is only where the whole of the mucous lining is involved, or that portion of it which covers the inner wall of the antrum, that the edges of the communicating aperture will be likely to be so much thickened as to produce complete obstruction. It is difficult to conceive how Mr. Liston could have committed such an error.—ED.]

[36] [These abscesses are sometimes acute, the suppuration occurring as a consequence of active inflammation. They are seated in the submucous cellular substance, and often acquire a large size; at first there is merely soreness in the throat and pain in swallowing, but when matter begins to be poured out difficulty of breathing is superadded, from the pressure which it exerts upon the epiglottis and mouth of the larynx, and if it be not speedily evacuated the patient may die from suffocation. As soon as fluctuation is recognised, or even before, if there be much swelling and difficulty of respiration, relief should be afforded by a free incision, made with a sharp-pointed bistoury with the back towards the tongue, which is to be depressed with the forefinger of the left hand.—ED.]

[37] [There is no subject of greater importance to the country practitioner than the extraction of the teeth; an operation which, from his insulated situation, he is constantly obliged to perform. Like the operation of venesection, it may be executed well or indifferently, and precisely as he does the one or the other will be the measure of his standing with his patients. The following observations in relation to this subject are condensed mainly from the excellent work of Mr. Bell, “The Anatomy, Physiology, and Diseases of the Teeth,” which should be in the hands of every physician in the country.

Mr. Bell thinks that the separation of the gum from the teeth, as a preliminary measure, is unnecessary; a view in which I must entirely disagree with him. That it materially facilitates the removal of the organ from its socket, ample experience has long since convinced me. The operation may be performed with a gum-lancet, or, what I have always preferred, a sharp penknife, which should be passed completely round the neck of the tooth, down to the alveolar margin of the jawbone. In the removal of the first teeth in children the previous separation of the gum is unnecessary.

The incisors of the upper jaw will require the use only of a small pair of straight forceps, the application of which is extremely simple. As the roots of these teeth are conical, and generally perfectly round, they will require merely a slight rotation, when they may be drawn downwards in the direction of the socket. The forceps should be placed as high on the root as the alveolar process will admit, and pressed so firmly as to prevent the blades from slipping, while at the same time care is taken not to crush the tooth.

The extraction of the lower incisors is effected in a very different manner. The roots of these teeth being very much flattened laterally, it is obvious that they cannot be dislodged upon the principle of simple rotation in the socket. When the tooth is even, or nearly so, with the others on each side of it, the best instrument will be the hawk’s-bill forceps, of very small size, and with narrow blades. The instrument being fixed as low on the neck of the tooth as possible, a gentle but firm movement is to be made forwards, so as just to separate the organ from the back part of the alveolar cavity, and then, continuously with this motion, the tooth is at once to be raised out of the socket.

The superior cuspid and bicuspid teeth may generally be removed by means of the same straight forceps as the incisors. The extraction of the former will be considerably facilitated, by giving a slight degree of rotation previous to its actual dislodgement from the socket. The bicuspids, on the contrary, having flatter sides, and less solid roots, will not allow of any degree of rotation; and must therefore be dislodged by first of all moving them a little outwards towards the cheek, so as to destroy the attachment to the inner alveolar plate, and then, by a perpendicular pull, they may be lifted directly from the socket.

The cuspids of the lower jaw are to be removed by the same means as the incisors. For the extraction of the bicuspids the key is the best instrument. The claw, placed in the usual position, should be rather small, and the fulcrum well covered with lint.

The removal of the first and second molars of the upper jaw will generally be best effected with a pair of large forceps, slightly bent at the blades. In applying this instrument to the teeth in question, the edges must be thrust as far under the border of the gum as possible, and a firm, steady hold taken of the tooth. It is then to be dislodged by first a steady, gradual bearing outwards until it is slightly moved, when, with a contrary motion into its former position, followed by a firm pull downwards, the tooth is removed with considerable facility. The corresponding teeth of the lower jaw may be extracted by the same means, or with a pair of hawk’s-bill forceps, the longer blade of which is to be placed on the inner gum. The operator standing on that side of the patient from which the organ is to be removed, and having taken a firm hold, first moves the tooth a little outwards towards himself, and then, with a steady and continuous movement, draws it almost straight from the socket; a motion which the inclination of the handle will greatly facilitate. The wisdom-teeth are best extracted with the forceps; their roots are small, and but little force is required for their removal.

When the crowns of any of the teeth are so entirely destroyed that the forceps and the key are alike insufficient to remove the roots which remain, the elevator, as it is called, will be found a very simple and efficient means to effect it. The edge of the instrument is to be inserted between the root and the alveolus, so far as to secure a sure hold, and the root is then to be lifted, as it were, from the socket, by resting the instrument upon the alveolar process, or even upon the side of a neighbouring tooth. There is not the least danger of injuring the latter if care be taken not to depend too exclusively, nor to bear with too much force upon it.—ED.]

[38] [I have been in the habit, for many years, of keeping the edges of incised wounds of the face, forehead, and eyelids, in contact with gold pins finer than the most delicate sewing-needle. They should be from an inch to an inch and a half in length, and be provided with heads of sealing-wax, by which they can be more easily carried across the skin than in any other way. From the materials of which they are composed they are entirely exempt from oxidation, which is not the case with the common needle; and I am convinced, from ample experience, that wounds thus healed are seldom attended with permanent deformity, from the formation of unsightly scars.—ED.]

[39] [In this country goitre is most common in the mountainous districts of Pennsylvania, Virginia, New-York, Connecticut, New-Hampshire, and Vermont. It is very rare in the natives of the western and southern states.—ED.]

[40] [I have in two instances succeeded completely, and in another partially, in curing goitre of long standing, by the internal and external use of iodine; and am disposed to place more reliance upon this remedy in the treatment of this affection than upon any other with which I am acquainted. To be beneficial, it should be administered in large doses, and be continued for at least three or four months. The local remedy which has best succeeded in my hands consists of equal parts of iodine and of camphorated mercurial ointment, rubbed thoroughly upon the surface of the tumour twice a day.—ED.]

[41] [To obtain a full stream of blood, the lancet should be carried obliquely upwards and outwards, by which means the fibres of the platysma-myoid will be cut across, instead of being divided vertically, and the edges of the incision will retract so as to form a much larger orifice. The pressure below the opening should not be removed until the wound has been closed, to avoid the introduction of air into the vein, an accident which may occur when this precaution is neglected.—ED.]

[42] [I am induced to subjoin the following example of axillary aneurism for which the subclavian artery was tied, in the belief that, from the unique manner of its termination, it will be interesting and instructive to the reader. The particulars of it, together with an analysis of twenty-six other cases reported by different surgeons, will be found in the Western Journal of Medicine and Surgery for June, 1841.

Daniel Monday, a married negro, thirty-six years of age, of a stout muscular frame, and a brickmaker by occupation, consulted me, in February, 1841, for a circumscribed, pulsating tumour, produced by the recoil of the butt-end of a yager, and situated beneath the right pectoral muscle, extending from the clavicle down towards the cartilage of the fourth rib. It was of an irregular, conical shape, and about the volume of a large fist, measuring fully four inches at its base in one direction, by three and a half in the other. In its feel it was tense, as well as inelastic; the blood rushed into it with a whizzing noise, and the pulsation was so distinct that it could be seen at the distance of some feet from the patient. The clavicle was thrown above its natural level; the whole limb, from the top of the shoulder to the ends of the fingers, was benumbed, painful, and almost deprived of power; the pectoral muscle was much stretched; and the patient constantly inclined his head towards the affected side, keeping the elbow nearly at a right angle, and supporting it carefully with the opposite hand, to prevent tension of the tumour. The swelling of the limb, however, was slight; the temperature was also good, and the pulse at the wrist was nearly as distinct as in the natural state. For the last four weeks the pain was almost incessant; it was particularly severe at the chest and shoulder, and had become so agonizing of late as to deprive him of sleep, and even prevent him from lying down. The appetite was also much impaired, and the countenance expressive of the deepest distress. The tumour had grown with great rapidity during the last two months; and, as there was danger of its bursting, an operation was at once decided upon.

The patient was placed upon a narrow table of moderate height, the head and chest being elevated with pillows, and the face turned slightly towards the opposite side, while an assistant pulled at the wrist, to depress the affected shoulder. The integuments over the clavicle being stretched upon the chest, I made my first incision along the centre of that bone, beginning near the sternal origin of the mastoid muscle, and passing out towards the acromion process of the scapula for about three inches and a half; thus dividing at one stroke the skin, cellular substance, and fibres of the platysma-hyoid. The parts being allowed to retract, left the lower margin of the cut parallel, and on a level with the superior border of the clavicle. A second incision, about two inches in length, was carried along the posterior edge of the sterno-mastoid muscle, at a right angle with the preceding. The triangular flap thus formed was then dissected up and held away, care being taken not to interfere with the external jugular vein, or any of the smaller arteries of the neck. Having advanced thus far, the cervical aponeurosis was detached from the clavicle by cautious strokes of the handle of the scalpel, which laid bare the brachial plexus of nerves and the omo-hyoid muscle. At this stage of the operation a small vein, a branch of the subclavian, was divided, and, although it bled very little, it was immediately secured by a temporary ligature. Taking the omo-hyoid for my guide, I divided the loose cellular substance in the triangular space bounded above by the muscle just mentioned, by the clavicle below, and by the anterior scaleni muscle internally, and thus approached the artery as it passed over the first rib. The vessel here lay at some distance from the inferior branch of the brachial plexus of nerves, rather deeply behind the collar-bone; and with a common aneurism needle, armed with a double ligature of saddler’s silk, no difficulty was experienced in securing it, the instrument being carried from before backwards and from below upwards. The ligature was then drawn very firmly with the fingers, and tied with a double knot within a few lines of the anterior scaleni muscle: as soon as this was accomplished, all pulsation in the sac, as well as at the wrist, ceased. One end of the ligature being cut off, the other was left protruding at the inner angle of the wound, the edges of which were closed by three sutures and adhesive strips. Not half an ounce of blood was lost during the operation, which lasted twenty minutes.

The patient being put to bed, the limb was laid in an easy position, and wrapped in cotton wadding. In less than an hour the temperature, which had been considerably depressed, was thoroughly restored; the pain and numbness had greatly abated; and the poor fellow expressed himself more comfortable than he had been for a month. In less than twenty hours the tumour was quite solid; the ligature came away on the morning of the thirteenth day; and the patient was in all respects convalescent, the swelling having diminished fully one-half in size. No untoward symptoms of any kind occurred until the morning of the twenty-seventh day, when the patient was suddenly seized with intense pain in the right side of the chest, attended with short, hurried, and laborious respiration, quick and tense pulse, great anxiety of countenance, prostration of the vital powers, and entire subsidence of the aneurismal tumour. Being absent from town, he was kindly visited by my friends, Dr. T. L. Caldwell and Dr. S. B. Richardson, until he expired, early on the thirty-first day after the operation.

The body, carefully examined after death, was somewhat emaciated; the wound had completely cicatrised, and the pectoral muscles were a good deal wasted, though in other respects unchanged. The subclavian artery terminated abruptly at the outer margin of the scaleni muscle, where the ligature had been applied, its calibre being closed by a mass of solid fibrin, about one-third of an inch in length, which adhered firmly to the lining membrane, and thus presented an effectual barrier to the passage of the blood. Between this and the thyroid axis the vessel was occupied by a dark coagulum, which, as it was loose, was probably formed only a short time before death. Beyond the seat of the ligature the artery had a rough, ragged appearance, and was sufficiently pervious to admit of the ready passage of a small probe into the aneurismal sac. Superiorly the tumour was overlapped by the brachial plexus, while in front, at its lower part, was the subclavian vein, which, besides being thrown out of its natural course, was considerably diminished in size. No pus was anywhere perceptible, the structures involved in the operation being consolidated by plastic lymph. The aneurismal tumour, placed immediately below the clavicle, was of a conical form, and about the volume of a moderate-sized orange, being two inches and a quarter in diameter at its base. Its walls varied in thickness at different points, from half a line to the eighth of an inch; and its interior communicated, by means of an oval aperture, one inch and three-quarters in length by an inch and a half in width, with the pleuritic cavity: it was situated between the first and second ribs, nearly equi-distant between the sternum and the spine, and was the result obviously of ulcerative absorption induced by the pressure of the tumour. Both ribs were denuded of their periosteum immediately around the opening, and the serous membrane had a shreddy, ragged aspect. The aneurismal sac contained a few reddish clots arranged in a laminated manner, and closely adherent to its inner surface, especially at the part corresponding with the apex of the tumour.

The right thoracic cavity contained nearly three quarts of bloody-looking serum, intermixed with flakes of lymph and laminated clots; the latter of which were of a reddish-brown colour, and had evidently escaped from the aneurismal sac. The pleura exhibited signs of extensive inflammation; and the right lung was greatly reduced in volume, from the compression of the effused fluid. The left lung was considerably engorged, and at one or two points almost hepatized. The heart and pericardium were sound, as were also the abdominal viscera, and the larger arterial trunks.

From the description of this operation in the text, it will be seen that Mr. Liston recommends two incisions, as performed in the above case. Were I to be again called upon to tie the subclavian artery above the clavicle, I should certainly omit the vertical incision, from a conviction that it is altogether unnecessary: it does not expedite the operation, nor does it facilitate the application of the ligature.—ED.]

[43] [I had occasion last winter to tie the humeral artery, for a wound inflicted upon it in bleeding at the bend of the arm, in a youth eighteen years of age, from one of the border counties of this state. The accident had occurred about six weeks previously with a thumb-lancet. It was soon followed by great swelling and discoloration of the limb, which gradually extended downwards nearly to the middle of the forearm and upwards as far as the axilla. The pain was excessive, the appetite much impaired, the sleep constantly interrupted, and the countenance blanched and expressive of great suffering. About the fourth week a large opening formed at the seat of the original orifice, from which upwards of a quart of thick grumous blood was discharged. He was brought to town on the 27th of December, and placed under the care of my friend, Dr. Drane. At this time his health was frightfully deranged; his strength was much exhausted; he had not slept for several nights; and the whole limb, benumbed and excessively painful, was swollen from the wrist to the shoulder. The parts pitted under pressure, two small foul-looking ulcers existed at the bend of the arm, the skin was discoloured, and fluctuation could be distinctly felt all the way up from below the elbow to the insertion of the deltoid muscle.

With the assistance of Dr. Drane, an incision, five inches in length, was made over the course of the humeral artery; and after much difficulty, owing to the confused state of the parts, a ligature was placed above and below the orifice, which was found to be at least six lines long! All the grumous blood, amounting to nearly a quart, was squeezed out, when the edges of the wound were brought together with adhesive strips and a roller extending from the wrist upwards. Very little sloughing took place; and, notwithstanding the exhausted condition of the patient at the time of the operation, he made a very speedy recovery.—ED.]

[44] [Encysted tumours of the breast containing milk are sometimes met with. They are commonly produced by closure of one or more lactiferous ducts, either from the effusion of lymph, or some other accidental formation, or from external pressure. The swelling, which generally arises during the early months of lactation, may be globular, ovoidal, or pyriform, and rarely exceeds the size of an orange. It is almost always attended with a peculiar sense of distention, and distinctly fluctuates under the finger. On cutting into it the contents are found to be of a whitish colour, and of the consistence of milk, cream, or whey; the quantity ranging from a few drachms to several ounces.

A most singular and instructive case of this disease is reported by my distinguished friend, Professor Parker, in the New-York Medical Gazette, for January, 1842. The woman, who was thirty years of age, was the mother of five children, the youngest nine months old, and had always enjoyed good health. The swelling occupied the right breast, and was first noticed about three months after her confinement: it was free from pain, and without tenderness on pressure. The skin was a little more vascular than in the sound state, the veins were enlarged, and there was evident fluctuation. The child had nursed from both breasts. With a trocar, not less than three quarts of milk were drawn off at one operation! Professor Parker requested the woman to wean her child, and to return to his clinique in a week. At the expiration of this period the fluid had reaccumulated to the amount of three pints. In a fortnight thereafter it was evacuated a third time, but in what quantity is not stated. Since then, as the professor has recently informed me, he has not heard from his patient; and it is, therefore, uncertain how much, if any, she has been benefited by the operations in the way of a permanent cure.

Small swellings of this kind rarely require any treatment beyond the application of some stimulating embrocation, to promote the absorption of the effused fluid. When the accumulation, however, is very large, as in the case above mentioned, it will be necessary not only to evacuate the milk, but to obliterate, if possible, the sac. This may be done, I conceive, either by stimulating injections, such, for example, as are used for the radical cure of hydrocele, by the introduction of the seton, or by laying open the tumour, and wearing a tent. In the former case, which, on the whole, I should prefer, assistance might be derived from methodical compression. Diminishing the quantity of milk by weaning the child would be an important preliminary step.—ED.]

[45] [In a case of artificial anus which came under the notice of the late Dr. Physick, in 1808, relief was afforded by the following procedure. A crooked needle, armed with a ligature, was passed from one portion of the intestine to the other through the contiguous sides, about one inch within their orifices. The ends of the ligature were then tied with moderate firmness at the external aperture, where they were left protruding. In this situation it gradually made its way through the parts which it embraced by ulcerative action, at the same time that it produced strong adhesion between the two folds of the bowel. After several weeks had elapsed, Dr. Physick divided with a bistoury all the parts which now remained included within the noose of the ligature, thus establishing a direct communication between the upper and lower extremities of the gut.

Dr. Lotz, of Pennsylvania, succeeded a few years ago in curing a case of a similar kind, by means of an instrument which possesses some advantages over that of Dupuytren, and an account of which is published in the eighteenth volume of the American Journal of the Medical Sciences. It is composed of two blades, each six inches long, which are worked by two screws, and which terminate in front in two fenestrated branches, twelve lines in length by three in width. One blade being inserted into each extremity of the gut, they are carefully adjusted by tightening the screws, and are thus made to compress the intervening membranes. The pressure may be increased or diminished at pleasure. In the case treated by Dr. Lotz, the portion of the bowel corresponding with the fenestræ was excised with a gum-lancet on the fourth day from the application of the instrument, and in this manner a direct passage was created between the two ends of the tube.—ED.]

[46] [When the wounded bowel protrudes, the aperture, unless it be very small, should be closed either with the continued or the interrupted suture, and then returned within the abdomen. This procedure is far preferable to the mechanical contrivances recommended by Reybart, Denans, and other surgeons; or even to the more ingenious but almost impracticable method of stitching the intestine, proposed by Mons. Lembert of Paris. From some experiments, upwards of forty in number, which I performed upon dogs last summer with a view of more fully elucidating the subject under consideration, I am led to infer that it does not matter what kind of suture be employed, provided we use the precaution of closing the opening so completely as to prevent the escape of fecal substance. This is undoubtedly the grand principle which should regulate the conduct of the surgeon in the treatment of injuries of this nature. Let him guard against fecal effusion, and the patient will be comparatively safe, or free from the danger of peritoneal inflammation. To attain this object the continued, or glover’s suture as it is termed, is unquestionably preferable to any other, especially when made, as I would suggest it should be, with a small sewing-needle, armed with fine silk, and passed between the muscular and mucous coats, or, what is the same thing, through the substance of the cellulo-fibrous lamella. After the suture has been applied, the protruded part of the mucous lining, if there be any, should be pared off with a sharp knife, to facilitate the process of reparation, the surface of the bowel should be cleansed with tepid water, and the whole carefully returned into the abdomen. If the interrupted suture be used, the intervals between each two respective threads must not exceed two lines, or the sixth of an inch, otherwise there will be danger of fecal extravasation, and the ends, instead of being brought out at the external aperture, should be cut off close to the knots. The reason why I prefer the continued suture, made in the manner above mentioned, is simply because we can thereby more effectually close the wound, at the same time that the parts are placed in the best possible condition for speedy reunion, from the want of protrusion of the lining membrane, and consequently the more perfect contact of the serous surfaces.

The ligatures which are employed in sewing up a wounded intestine are detached at a period varying from ten days to three or four weeks, according to the nature of the suture. When the extremities are cut off close to the knots, they invariably fall into the cavity of the bowel, and are finally discharged along with the feces; if, on the other hand, they are brought out at the external opening, they pass off in that direction instead of the one just mentioned.

When the opening in the gut is small, not exceeding three or four lines in extent, the margins may sometimes be advantageously encircled with a ligature, with the ends cut off close to the peritoneal surface. Sir Astley Cooper tied up an aperture in this manner in the human subject, in a case of strangulated hernia, and the patient recovered without a bad symptom. Professor Gibson, of the University of Pennsylvania, states that he has performed a similar operation with similar results. My experiments on dogs convince me that the plan is a good one. The ligature should be drawn pretty firmly, to prevent it from slipping, and the ends must be cut off close to the knot. It generally makes its way into the bowel in from eight to ten days.

When the bowel is completely severed, or mortified in its entire calibre, the edges, after being properly prepared, should be brought in contact, and retained by the continued or the interrupted suture. Cases of this kind, although apparently desperate, are not always of so hopeless a character as might at first sight be supposed. This is shown, not only by experiments on the inferior animals, but by what occurs in the human subject, in sphacelated hernia, and in intussusception. In the former, the greater part, or even the whole, of the circumference of the tube may be destroyed, and yet the patient ultimately recover, with perhaps the temporary inconvenience merely of an artificial anus; and in the latter, large pieces are not unfrequently detached without any serious suffering, save what is experienced during the antecedent and concomitant inflammation. In my morbid collection is a preparation of this kind, evidently a portion of the colon, nearly a foot long, which was discharged by a child six years old, who, notwithstanding, made a speedy and perfect recovery. Thirty-five cases of a similar character, collected from the writings of different pathologists, have been reported by Dr. Thompson of Europe.[47] In a dog, from which I removed two inches and a half of the ileum, and treated the edges of the wound with six interrupted sutures, complete recovery took place, unattended with a single bad symptom. The threads were introduced at equal distances from each other, with a small sewing-needle, and the ends cut off close to the knots. Four months after the operation, being in good health, and the outer wound entirely healed, he was killed. Externally the bowel was perfectly smooth and natural, as if no injury had ever been inflicted upon it: the mucous membrane was of the same appearance as elsewhere, with the exception of a small depression corresponding with the edges of the wound.—ED.]

[47] See the Editor’s Elements of Path. Anatomy, vol. ii., p. 260.

[48] [From my own observations and dissections I have long been convinced that there are two distinct and well marked varieties of hemorrhoidal tumours; one of which essentially consists in an enlargement of the capillary vessels of the mucous and submucous cellular tissue, the other in the formation of a small sac filled with fluid, coagulated, or organised blood. The latter, situated at the verge of the anus, or immediately within it, are composed partly of skin, partly of mucous membrane; they vary in size, from a pea to that of a small marble, are of a red florid complexion, hard and tender to the touch, and exquisitely painful when inflamed. The blood which they contain is at first fluid, but soon coagulates, and ultimately, if allowed to remain, becomes organised. Hence, in cases of long standing, the tumour is generally of a hard, gristly consistence, pale, and free from pain, producing no other than mechanical inconvenience.

In the other variety, the tumour is situated within the bowel, from six lines to two inches above the external orifice. Consisting, as was before intimated, in a varicose condition of the capillary vessels, especially the venous: it is soft and compressible, of a deep purple colour, extremely liable to bleed, and of various sizes, from a small bean to that of an almond or upwards. It rarely occurs as an isolated swelling, but in groups or clusters, as many as six or eight being sometimes situated upon a surface not more than an inch and a half or two inches in diameter.—ED.]

[49] [Until recently it was the opinion of surgeons, almost universally, that the fistula opened into the bowel at the distance of from two to three inches from the anal outlet; an error which often led to severe and hazardous operations, by which the unfortunate patient was sometimes rendered miserable for life. Mons. Ribes of Paris, who was the first to investigate the subject in a careful and extended manner, ascertained that the internal orifice is generally situated immediately above the place where the lining membrane of the rectum unites with the skin, sometimes a little higher, but never more than five or six lines. In eighty subjects affected with this malady it did not exceed this elevation, and in a considerable number it was not higher than a third or fourth of an inch. In my own operations and dissections I have rarely found the internal aperture more than a line or two above the internal sphincter muscle. The observations of the late Professor Bushe, of New-York, tend to a similar conclusion.—ED.]

[50] [This is undoubtedly the treatment which should always be adopted in the sacculated variety of the disease, as it is not only free from danger, but affords the most speedy and effectual relief. If the blood, upon the presence of which the irritation and swelling mainly depend, be allowed to remain, it finally becomes organised, and so incorporated with the walls of the tumour that it is impossible to dispose of it in any other way than by excising the whole excrescence.—ED.]

[51] [My own experience does certainly not accord, in this instance, with that of the distinguished author. I can recall to mind at least six or eight cases, several of them in delicate females in dilapidated health, in none of which I used less than two ligatures, and in some as many as three or four, without any serious consequences whatever. When the tumours are numerous, it can never be necessary to tie more than three or four at a time, since the inflammation thus induced generally extends to those around and effects their obliteration. It is always preferable, indeed, to repeat the operation, than to run the risk of producing too much irritation.—ED.]

[52] [Much may be accomplished in chronic cases by means of astringent injections, of which the best perhaps is a solution of alum in a decoction of oak-bark, in the proportion of two drachms of the one to a pint of the other. From two to three ounces of this should be thrown up the rectum twice a day; the bowels being at the same time kept in a soluble state by gentle laxatives, and the patient compelled to void his feces in the standing posture. In cases of an inveterate kind, in which the ordinary remedies prove unavailing, the operation of Dupuytren, which consists in cutting away some of the radiating folds of the skin around the anus, generally affords prompt and effectual relief. When the protruded part is large, it may be necessary to excise from four to six of these folds, and to prolong the incisions into the rectum as far as the junction of the skin with the mucous membrane. The object of this operation is to produce a diminution of the orifice of the anus, which it does by the cicatrization and contraction of the little wounds made in the operation.—ED.]

[53] Bushe on the Rectum, p. 220.

[54] [When the pain is considerable the camphorated liniment with morphia, laudanum, or belladonna, will be of great service. It should be rubbed upon the scrotum every four or five hours, avoiding of course injury to the inflamed testicle and epididymis. When the acute symptoms of the disease have subsided, under the treatment recommended in the text, the most efficacious practice is compression of the enlarged organ, by strapping it with the gum and mercurial plaster. Dr. Fricke of Hamburg pursues this plan in the very commencement of the inflammation, however severe, with the effect often of curing his patients in a few days. The plaster should be cut into narrow strips, not more than half an inch in width, and be applied in a circular manner round the testicle, which is to be previously drawn to the bottom of the scrotum. The first piece is to be placed round the insertion of the cord, just above the epididymis, and after the whole organ has been thus enveloped, another series of strips is to be applied from below upwards, to confine the first, and more completely equalise the pressure. Great care is to be taken not to pucker the skin, which should be previously divested of hair. “If the pressure of the plaster occasions pain or irritation, the strips are to be removed till the inflammation and sensibility are diminished. In many instances the patient experiences almost immediate relief from the application.” This remedy, which has been recently claimed by a European writer as new, appears to have been employed, with marked success, in the Pennsylvania Hospital, in the early part of the present century.—ED.]

[55] The principal objection to this method is, that it is not always successful, and that it requires, in some cases, to be repeated again and again before a sufficient amount of adhesive action is induced to obliterate the vaginal sac. Moreover, by carelessness on the part of the surgeon, the canula may slip out of the vaginal sac, and so allow the fluid to pass into the cellular substance of the scrotum, where, if it be not speedily evacuated by free incisions, it is sure to occasion gangrene. But this is not all. The operation, even when well performed, is sometimes followed by violent inflammation and suppuration; in one instance, indeed, I knew it to be productive of tetanus. The patient, a stout, robust mechanic, about twenty-six years of age, whom I saw twice in consultation, was doing apparently well during the first eight days after the operation; when, owing to exposure to cold, the symptoms of the disease in question manifested themselves, and in less than twenty-four hours the man expired. Upon examination after death, the vaginal tunic was found to be considerably thickened, and its cavity to contain several ounces of sero-sanguinolent fluid, intermixed with a small quantity of unhealthy-looking pus. No adhesions had taken place between the opposite sides of the sac. A case of a similar kind is alluded to by Sir George Ballinggall, in his “Outlines of Military Surgery.”

The operation by injection has, I know, many advocates, both in this country and in Europe; and, when well executed, is generally unattended with risk, if not always successful. The fact, however, that it may be followed by serious mischief, with occasional loss of life, should be sufficient to deter the practitioner from resorting to it, more especially when we reflect that we are in possession of another remedy, not only entirely devoid of danger, but always, so far as my observation extends, most effective. This remedy is the seton, which I have been in the habit of employing, in repeated instances, for some years past, and from which I have never experienced any other than the most happy results. The operation is perfectly simple, the amount of inflammation produced by the presence of the foreign body may be easily regulated, and there is no danger of sloughing of the scrotum, much less of the development of tetanus, or other mischief.

In performing the operation, a large round trocar is introduced at the usual place, and after the fluid has been thoroughly evacuated, the instrument is again conveyed along the canula to the upper and fore part of the scrotum, for the purpose of effecting a counter-opening, which should be from an inch and a half to two inches from the first. The trocar is now withdrawn, when an eyed-probe, armed with a skein of silk or piece of tape, is passed along the tube, upon removing which the operation is completed. The seton need seldom be retained longer than four or five days; during which period, as well as for some time subsequently, the recumbent posture should be enjoined, along with suspension of the scrotum, and the usual antiphlogistic means. When the inflammation, tenderness, and swelling have considerably abated, the reduction of the tumour may be promoted by the daily inunction of equal parts of iodine and camphorated mercurial ointment.—ED.

[56] In upwards of one hundred cases examined by Mons. Breschet of Paris, only one occurred on the right side. With this result, the experience of nearly every practitioner must coincide. Cirsocele may take place at any period of life, in the young as well as in the old; but it is most common, by far, within the first ten years after puberty, or during the period of the greatest excitement of the genital system. In twenty-seven cases observed by Mons. Landouzy, in which this subject was particularly noticed, seven occurred between the ages of nine and fifteen; seventeen between fifteen and twenty-five; three between twenty-five and thirty-five.

Cirsocele appears to be occasionally hereditary. Professor Blandin of Paris, in an able article on this disease, in the “Dict. de Medicine et Chirurgie Pratiques,” refers to three brothers with whom he was personally acquainted, who were all exempted from military duty on account of the existence of this malady: the father was similarly affected. An analogous case is mentioned in an inaugural dissertation published a few years ago at Paris.

The causes of cirsocele are, venereal excesses, masturbation, protracted exercise on foot or horseback, contusions of the scrotum, inflammation of the testicle, and mechanical obstacles to the return of the blood to the spermatic veins, whether produced by the presence of a tumour, fatty accumulations of the omentum or mesentery, or the wearing of tight and ill-constructed trusses. Of these the first two are probably the most frequent and influential. Indeed, I am persuaded, from considerable experience, that this is the case. How these causes act in developing this affection admits of ready explanation. Their tendency is not only to determine an abundant afflux of blood to, and consequent congestion in, the genital organs, but to produce more or less fatigue in the muscles of those parts, especially in the cremaster and dartos, together with a loss of nervous innervation, which diminish their power and contractile energy. The testicle being thus insufficiently sustained sinks down, by its own weight, into the scrotum, which, with the spermatic vessels, is thereby kept in a state of constant relaxation. Heat acts in a similar manner, and produces similar results. Hence cirsocele is more frequent in hot than in temperate climates, and worse in summer than in winter.—ED.

[57] [Although the symptoms of this affection are usually well marked, yet it is sometimes liable to be confounded with other lesions. The malady for which it is most apt to be mistaken is inguinal hernia, especially that variety of it in which the omentum is concerned. The best way in such cases is to place the patient on his back, and hold up the scrotum until the vessels are entirely emptied of their contents; the finger is then applied against the external ring and the patient requested to rise, when, if the disease be cirsocele, the spermatic veins will immediately refill, while, if it be hernia, the bowel will be unable to descend.

The progress of this disease is usually tardy, years elapsing before it causes much suffering or inconvenience. In some instances, however, it increases with great rapidity, and gives rise to severe local disorder, with more or less constitutional derangement. One of the most serious and unpleasant effects of this disease is atrophy of the testicle and epididymis, produced by the pressure of the enlarged veins; it may exist in various degrees, from the slightest softness and diminution of volume to almost entire wasting of the organ, and occasionally, though rarely, affects both sides simultaneously. A gloomy and melancholy state of mind, sometimes bordering upon alienation, frequently attends this condition of the testicle.—ED.]

[58] [The least objectionable operation, in my opinion, is that of tying the affected veins, after having carefully separated them from the spermatic artery, vas deferens, and nerves of the testicle. The vessels may be ligatured at one or more points, according to the extent of the enlargement; and, by carefully excluding the structures just mentioned, there will be no danger of cutting off the nervous and vascular supply, as must necessarily happen, in some degree, in the proceeding recommended by Mr. Liston, and which must therefore lead to further wasting of the testicle; a circumstance which should be most sedulously avoided. The external incision need not exceed an inch and a half in length.

I am induced to subjoin the following account of a novel but harsh operation for the cure of cirsocele, lately devised by Mons. Breschet of Paris, not from any belief or hope that it will be generally adopted, but because it has made some noise in the surgical world. It is founded upon the anatomical arrangement of the part, or the facility with which the varicose vessels can be isolated from the spermatic artery and vas deferens, and afterwards compressed so as to obliterate their calibre. This is effected by means of a forceps with flattened plates, which are worked by a screw. The pressure is applied in a gradual manner, but with sufficient force to destroy the vitality of the scrotum and of the affected vessels. The instrument is usually removed in from six to eight days, during which the patient is left on his back, cold lotions are applied to the scrotum, and the case treated on general principles. When the sloughs are detached, the edges of the sore are approximated by adhesive strips, and the person is permitted to walk about. In this way Mons. Breschet is said to have operated successfully in more than a hundred cases; the average period required for a complete cure being twenty-three days. I have never performed this operation, the severity of which is such as to induce the belief that very few persons in this republican country would submit to it. An American surgeon, Dr. F. Hamilton, of New-York, has recently recommended castration for the relief of this affection, and has published several cases in which he performed the operation in illustration of its efficacy. This is certainly a radical mode of doing business, but in my opinion a very objectionable one.—ED.]

[59] [Of 5376 calculous cases mentioned by Civiale,[60] 2416 were children, 2167 adults, and 793 old persons. Of these 1946 occurred before the age of ten, 943 from ten to twenty, 460 from twenty to thirty, 330 from thirty to forty, 391 from forty to fifty, 513 from fifty to sixty, 577 from sixty to seventy, 199 from seventy to eighty, and 17 after eighty.

Children are more subject to this affection in certain districts than in others; and the same is true in regard to adults. The greater proportion of calculous cases in Wirtemberg, in the mountains of Switzerland, the Neapolitan States, and some of the provinces of England, occur in young persons, from causes which have not hitherto been explained. In the United States a larger number of children are afflicted with this disorder in Kentucky, Tennessee, and Alabama, than perhaps in any other sections. In very warm or cold latitudes, on the contrary, adults, and, above all, old people appear to be most liable to it.

Whether this affection is actually hereditary or not is not yet fully decided. Facts certainly warrant the inference that it is. Thus, Civiale relates the case of a man on whom he practised lithotrity, whose mother had had the stone, and one of whose children died of it. He also performed the operation on two brothers, whose grandfather and two uncles had laboured under the disorder. Prout speaks of a family of which the grandfather and father were affected with uric acid calculi, and who had a son, aged thirteen years, that was very much predisposed to the same disease.—ED.]

[60] Treatise on Calculous Affections: MS. translation by Dr. Colescott.

[61] [In comminuted fractures of the lower jaw, it sometimes happens, in spite of our best-directed efforts, that the ends of the fragments cannot be maintained in contact. Under these circumstances it may become necessary to tie the pieces together by means of a gold or silver wire, or to make the patient wear a thin metallic plate, adapted to the shape of the jaw, and interposed between the cheeks and dental arches; to the latter of which it should be immoveably fixed.—ED.]

[62] [The bones, owing to falls, blows, or other external violence, are occasionally bent, with or without partial fracture. Within the last few years a considerable number of cases of this accident have been reported by American and European practitioners. The first regular account of it was published in 1810, by Professor Jurine of Geneva; and in 1821 a very able article on the subject appeared in the American Medical Recorder, from the pen of that distinguished surgeon, Dr. John Rhea Barton, of Philadelphia.

Simple bending is most common in the radius and ulna, though it is by no means confined to them. For obvious reasons it happens only in children, before the completion of the ossific process, or in whom there still exists a predominance of animal matter. In older persons the bones more readily break than bend. The diagnostic signs of the accident are, pain and deformity at the seat of the injury, loss of power in the limb, want of displacement of fragments, and absence of crepitation. The deformity consists in an unnatural curvature, which can be made to disappear under pressure and extension, but recurs, to a certain extent, when the limb is liberated. When attended with partial fracture, the symptoms are the same, excepting that, instead of a curvature, there is angular deformity opposite the seat of the accident. When the injury occurs in the forearm, and only one bone is implicated, extension generally produces no change in the appearance of the limb. The treatment, in both cases, is to be conducted upon the same principles as that of fractures. The attempts to remove the curvature by extension should neither be too violent nor long continued, otherwise they must prove injurious. Mr. Mantel of England, distinguished alike as an able surgeon and an accomplished geologist, thinks that the application of leeches and the usual antiphlogistic means should alone be trusted to when there is much pain and swelling, alleging that the action of the muscles will ultimately restore the limb to its natural form.—ED.]

[63] [A comparison of the results of the different kinds of treatment of disunited fracture, furnished by Dr. Norris of Philadelphia, in an able and elaborate article in the American Journal of the Medical Sciences, for January, 1842, leaves no doubt as to their relative value. Of forty-six cases in which the seton was employed, thirty-six were cured, three partially relieved, five not benefited, and two died. In twenty-one the seton was introduced with, and in twenty-four without, previous incision: of the former seventeen were cured, two improved, one failed, and one died; of the latter eighteen were cured, one was benefited, five failed, and one died. In reference to the seat of the fracture, the cases stand as follows:—

13 for the femur, of which 9 were cured. 10 ” leg, ” 10 ” 16 ” humerus, ” 10 ” 6 ” forearm, ” 6 ” 1 ” jaw, ” 1 ”

The average period of the existence of the fracture in the above cases was nearly twelve months and a half, the longest ten years, the shortest six weeks. The mean period of the retention of the seton was seven weeks and three days. In one instance—that of a fractured humerus—it was left in thirteen months, notwithstanding which it finally failed. The average time required for the cure was nearly three months, the longest eight months, the shortest three weeks. Arterial hemorrhage occurred in two of the cases; in ten, severe fever, erysipelas, or profuse suppuration.

Of thirty-eight cases in which resection was performed, twenty-four were cured, one improved, seven failed, and six died. The seat of the injury was as follows:—

12 were in the femur, of which 7 were cured. 6 ” leg, ” 5 ” 12 ” humerus, ” 6 ” 7 ” forearm, ” 5 ” and 1 improved. 1 ” jaw, ” 1 ”

The longest period of the existence of the fracture in these cases was five years, the shortest ten weeks, the average thirteen months and nineteen days. The average time required for effecting a cure was four months, the shortest one month, the longest thirteen months. In seventeen of the cases other methods of treatment had been ineffectually tried: in six the resection was followed by erysipelas, in one by phlegmasia dolens, and in two by profuse suppuration and abscesses.

Of thirty-six cases healed by pressure and rest, twenty-nine were cured, one improved, and six failed. The seat of fracture was:—

In 13 cases in the femur, of which 9 were cured. ” 7 ” leg, ” 7 ” ” 12 ” humerus, ” 9 ” ” 4 ” forearm, ” 4 ”

The average duration of the fracture in the above cases was five months and twelve days, the longest twenty-two months, the shortest four weeks. The mean period required for a cure was nine weeks, the longest nine months, the shortest eighteen days. In one of the cases the treatment was productive of excoriations, in three of severe pain and inflammation.

Cauterization of the ends of the fragments, after free exposure of them by the knife, was successfully employed in six cases; in two others it completely failed. The article most frequently used was the caustic potash. Frictions succeeded in eleven cases.

From a careful analysis of all the circumstances connected with the preceding cases, one hundred and thirty-nine in number, and of which the above is an abstract, Dr. Norris has deduced the following conclusions:—1. That non-union after fracture is most common in the thigh and arm. 2. That the mortality after operations for its cure follows the same laws as after amputations and other great operations on the extremities, the danger being in proportion to the size of the limb and the proximity of the injury to the trunk. 3. That failures after operations are more frequent in the humerus than in other bones, and in middle-aged and elderly persons than in young ones. 4. That the seton, variously modified, is safer, speedier, and more successful than resection or caustic. 5. That incising the soft parts previously to introducing the seton augments the danger, but renders the cure more certain and expeditious. 6. That allowing the seton to remain in for a long time exposes to accidents, and does not facilitate the cure. 7. That the seton is least successful in the femur and humerus.—ED.]

INDEX.

Abdomen, affections of, 412 injuries, 438, 440

Abscess, 31 lumbar, 441

Adhesion, 25

Albugo, 264

Amaurosis, 275

Amputation, 612 arm, 624 fingers, 619 foot, 628 forearm, 622 hip-joint, 631 leg, 628 shoulder-joint, 625 thigh, 630

Anchylosis, 73

Aneurism, 118, 121 by anastomosis, 127 popliteal, 125, 541 axillary, 389 osseous, 158

Aneurismal varix, thigh, 542

Anthrax, 63

Antrum maxillare, inflammation of, 317

Anus, pruritus, 460 artificial, 434

Arterial system, diseases, 116, 121

Articular cartilages, atrophy and hypertrophy, 75

Artificial anus, 433, 434

Artificial pupil, 287

Ascites, 435

Axillary aneurism, 389

Bladder, inflammation of, 469 irritable, 470

Blennorrhœa, 247

Bone, diseases, 94 fractures, 552

Brasdor’s operation, 126

Bronchocele, 377

Bruise, 610

Bubo, 197

Bubonocele, 416

Bunnion, 544

Burns, 211

Bursæ, diseases of, 80 inflammation of, 543

Calculus, in the female, 530 salivary, 336 vesicæ, 508

Carbuncle, 63

Carcinomatous tumours, 142

Caries, 96

Castration, 507

Cataract, 277, 279, 280

Chancre, 201

Chemosis, 259

Chest affections, see Thorax.

Chimney-sweeper’s Cancer, 495

Choroiditis, 274

Cirsocele, 417

Club-foot, 545

Compression, 226

Concretions, salivary ducts, 336

Concussion, 218

Congestion, 23

Corectomia, 287

Corneitis, 261

Corodialysia, 288

Corotomia, 287

Coxalgia, 81

Croup, 354

Cynanche trachealis, 354

Deafness, 375

Delitescence, 26

Dislocations, 588 ankle, 606 carpus, 599 clavicle, 592 elbow-joint, 596 fingers, 599 hip-joint, 600 congenital luxation, 604 lower jaw, 591 patella, 605 radius, 597 shoulder-joint, 592 tarsus, 606 wrist-joint, 598

Distortion of the feet, 545 varus, 547 valgus, 548 pes equinus, 548 calcaneal, 549

Ear, diseases of, 373 foreign bodies in, 375

Ear, polypus, 375

Eburnation, 75, 113

Ectropion, 254

Eczema rubrum, 211

Emprosthotonos, 183

Empyema, 410

Encanthis, 252

Encysted tumours, 151, 336, 406 of eyelids, 253 of the breast, 406

Enterocele, 415

Entero-epiplocele, 415

Entropion, 255

Epiphora, 247

Epiplocele, 415

Epispadias, 495

Erethismus, 211

Erysipelas, common, 55 hospital, 57 phlegmonous, 56

Erythema, 55

Excision, diseased bone, 632 of joints, 634

Exomphalos, 415

Exophthalmia, 266

Exostosis, 153 of distal phalanx, 551

Eye, diseases, 245

Fever, hectic, 42 inflammatory, 19 irritative, 43

Fistula lachrymalis, 248 in ano, 449, 450 in perineo, 472

Fractures, 552 clavicle, 564 cranium, 227, 558 compound, 553, 556 disunited, 586 face, 558 femur, 575 humerus, 569 metacarpal bones, 574 olecranon, 571 patella, 581 pelvis, 574 phalanges, 574 radius, 572 ribs, 566 scapula, 565 shoulder, 567 simple, 553 spinal column, 560 sternum, 567 tarsus, 584

Fractures of the tibia and fibula, 583 ulna, 710

Frænum linguæ, division of, 334

Fragilitas ossium, 110

Fungus hæmatodes, 147

Furunculus, 62

Ganglia, 401

Gangrene, 43

Genital organs, affections of, 461

Glaucoma, 277

Gonorrhœa, common, 462 in females, 531 præputialis vel spuria, 490

Gonorrhœal lichen, 532

Gums, inflammation, 337 tumours, 337

Gunshot wounds, 180

Hare-lip, 323

Hæmatocele, 503

Hemorrhage, 129, 166

Hemorrhoids, 445 distinct varieties, 445

Hectic fever, 42

Hernia, 412 of the iris, 264 cerebri, 233 congenital exomphalos, 415 scrotal, 413 crural, or femoral, 416 infantilis, 414 inguinal, direct, 415 oblique, 416 scrotal, 416 umbilical, 430 humoralis, 467

Hospital gangrene, 191

Humeral artery, 394

Hydatic tumours, 161

Hydrocele, 417 of the neck, 381

Hydrops articuli, 68

Hydrophthalmia, 266

Hydrothorax, 410

Hypopium, 273

Hypospadias, 495

Incontinence of urine, in females, 489

Inflammation, 13

Injuries of the head, 215

Iritis, 272

Irritation, 20

Irritative fever, 43

Joints, diseases of, 67 growths from synovial membranes, 79 hip-joint disease, 81, 91 loose cartilages, 80 neuralgic affections, 78 scrofulous disease, 77

Keratonyxis, 284

Larynx, foreign bodies in, 363 ulceration, 361

Laryngitis, 354

Leucoma, 264

Leucorrhœa, 531

Ligature of arteries, 123 axillary, 392

Ligature, brachial, 392 carotid, 385 femoral, 159, 541 humeral, 394 iliac, 539

Ligature of innominata, 387 subclavian, 387, 389

Lips, congenital deficiencies, 322 ulcers, 319

Lithotomy, 519

Lithotrity, 517

Lower jaw, osteosarcoma, 343 spina ventosa, 341

Lumbar abscess, 441

Lupus, 310

Luxations, see Dislocations.

Malignant pustule, 193 polypi, 303

Mamma, diseases, 405 encysted tumours, 406

Melanosis, 142

Metastasis, 26

Mollities ossium, 110

Morbus coxarius, 81

Mortification, 43

Mucous membranes, inflammation, 65

Myocephalon, 264

Nasal polypi, 310 nævi, 128, 130

Nebula, 264

Necrosis, 103

Neuralgia of the rectum, 460

Neck, hydrocele, 381 distortion, 382

Noli me tangere, 310

Nose, diseases, 308

Œdema glottidis, 358

Œsophagus, foreign bodies, 371 stricture, 369

Œsophagotomy, 372

Onychia, 399

Opisthotonos, 183

Ophthalmia, 257 neonatorum, 261 purulent, 260 tarsi, 265

Osseous aneurism, 156

Osteosarcoma, 154

Otitis, 373

Ovarian dropsy, 436

Ozœna, 310

Palate, congenital deficiencies, 332 ulcers, 329

Paracentesis abdominis, 435

Paraphymosis, 491

Paronychia, 396

Periostitis, 94

Pes equinus, 548

Phagædena, sloughing, 191

Pharyngitis, 368

Phlebitis, 130

Phlegmonous erysipelas, 56

Phthisis laryngea, 360

Phymosis, 491

Piles, 445

Polypus, 150 nasal, 301 ear, 375

Prolapsus ani, 453

Pruritus of the anus, 460

Pterygium, 256

Puncture of the bladder, 488

Pus, 29

Pustule, malignant, 193

Rachitis, 110, 112

Ranula, 335

Rectum, affections, 445 inflammation, 447 schirro-contracted, 452 neuralgia, 460

Resolution, 25

Retention of urine, 478 in females, 533

Rhinoplastic operations, 312

Rickets, 110

Sarcocele, 505

Scalds, 211

Scrofula, 34

Serous membranes, inflammation, 66

Sinus, 40

Sphacelus, 44

Spina bifida, 444

Spina ventosa, 157

Sprain, 607

Strabismus, 292

Staphyloma, 261

Stillicidium lachrymarum, 247

Stricture of the œsophagus, 369 rectum, 450 urethra, 470

Struma, 34

Subclavian artery, 387, 389

Suppuration, 29

Sympathies, 19

Syphilis, 195 tertiary, 203, 209

Teeth, caries, 338 extraction, 340

Testis, inflammation of, 467

Tetanus, 183

Tertiary syphilis, 203, 209

Thecæ, collections of fluid in, 401

Thorax, affections of, 409

Thrombus, 405

Tongue, inflammation of, 332 ulcers, 331

Tonsils, abscess of, 327 enlargement, 328

Tonsils, inflammation of, 326

Trachea, foreign bodies in, 363 stricture, 369

Tracheotomy, 364

Trichiasis, 255

Trismus, 183

Tubercle, painful, 149

Tumours, 134 adipose, 137 of the antrum, 304 of bones, 153 carcinomatous, 142 encephaloid, 142 encysted, 151, 336, 406 fibrous, 138 melanoid, 142 aneurismal, 158 osseous, 158 hydatic, 161 in the neck, 379 in the orbit, 290 painful tubercle, 149 of the scalp, 243

Tympanum, puncture of, 377

Ulcers, 186 of the genital organs, 195

Ulcers, indolent, 188 irritable, 189 of lips, 319

Urethra, stricture of, 470

Urinary organs, affections of, 461

Urinary calculi, 508

Uterus, affections of, 537

Uvula, elongation of, 328

Vagina, affections of, 534

Valgus, 548

Varicose aneurism, 393 veins, 132

Varix, aneurismal, 393 of thigh, 542

Varus, 547

Vein, external jugular of, 384

Veins, inflammation of, 130

Venesection, bend of the arm, 403 jugular vein, 384

Vertebral column, diseases of, 442

Vesico-vaginal fistula, 534

Whitlow, 396

Wounds, 164 by stings of insects, 177, 178 of the brain, 232 bruised and lacerated, 175 of the face and neck, 347 gunshot, 180 of the palmar arches, 395 poisoned, 176 punctured, 176 of the scalp, 215 of the temporal artery, 216 of the intestine, 440

Wry-neck, 382

THE END.

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