Unnatural adhesions of the external labia occasionally take place, occurring in early life from the healing of excoriation and ulceration caused by neglect of cleanliness. Perhaps the closure is not to such an extent as to prevent escape of the discharges, but still it is inconvenient and requires attention. The parts must be divided in the proper direction and to the necessary extent, and, by the interposition of dressing, reclosure is prevented.

Contraction of the vagina at a distance from the orifice sometimes occurs. On one occasion I was requested by an accoucheur to examine and divide a very tight, firm stricture, scarcely admitting the finger. Labour had commenced, and the expulsion of the fœtus was prevented by the stricture; it was attributed to injury inflicted in a former delivery. By a probe-pointed bistoury, guided on the finger, it was notched pretty deeply at many points—a proceeding which I have frequently followed with advantage in simple stricture of the rectum. Everything proceeded happily.

Occasionally the contraction of the vagina is to a great extent; the uterine discharges are not permitted to escape at all, and great uneasiness is thereby occasioned. In one case, in which the canal may be said to have been wholly obliterated, from what cause or at what period it did not distinctly appear, I ascertained the position of the uterus by the finger passed into the bowel, pushed a curved trocar on to it through a considerable thickness of parts, and afterwards dilated this artificial passage by bougies gradually increased in size. The vagina was thus reëstablished, and menstruation again occurred, and without interruption. A case, in which the vagina was obliterated to the extent of from two to three inches, occurred some months ago at the North London Hospital. It took place, it appears, after an accouchement, the genital organs being raw and sore, with considerable loss of substance from phagedænic ulceration. A large tumour could be felt betwixt the hand placed on the hypogastric region and the finger in the rectum. The patient was exceedingly urgent in her entreaties to have the canal restored, and the attempt was made. The contiguous viscera being emptied, a trocar, guided by the finger in the bowel, was pushed in the course of the vagina as far as was thought safe; the canula was retained, and, some days after its withdrawal, the part was farther dilated by gentian root. It was intended to have carried the pointed instrument farther, but symptoms of peritoneal inflammation supervened about the tenth day, and in spite of active treatment proved fatal. The uterus, os uteri, and from an inch and a half to two inches of the upper part of the vagina, were enormously distended with dark, putrid, grumous, and bloody fluid, of the consistence of tar; the trocar had reached the parietes of the cavity, and, if pushed forward another line, must have entered the vagina, and allowed the fluid to escape. There was a quantity of putrid and dark-coloured serosity in the cellular tissue of the pelvis and behind the peritoneum. It is to be regretted that I did not feel warranted in the first instance in pushing the instrument forward more boldly. Had the fluid been allowed to drain off, the probability is, that the future infiltration and peritonitis would not have occurred. The intention was, being foiled in the first attempt, to dilate the canal sufficiently to admit the finger, and by the direct guidance of that to carry the perforation farther.

Violent and deep inflammation of the external parts of generation is not uncommon,—the result of bruise or wound. It is generally met with in the lower class of prostitutes. The inflammation often attacks the vagina and neighbouring parts, followed by great swelling; and, if not allayed, extensive abscess forms, with much fever and pain; pointing takes place betwixt the external and internal labia. The parts must be copiously leeched, and afterwards fomented; strict rest and antiphlogistic regimen must be observed, and when matter has formed, a free opening should be made early, to prevent deep and extensive mischief. A sinus sometimes, though rarely, results; generally the cavity fills up, and the discharge ceases in a very few days. These parts are much more vascular than the lower part of the bowel, and when in a diseased condition, are not of necessity so frequently put in action; hence extensive incision and division of the sphincter is here very seldom necessary.

Tumours of various kinds are met with about the external female organs; more rarely, internally. Encysted tumours of the labia are not uncommon, and sometimes solid swellings, varying in size and structure, grow from these parts. I had occasion to remove one of the latter description, which weighed many pounds, and had been productive of great and long inconvenience. The general rules for the extirpation of tumours apply to them. Considerable hemorrhage may be expected. The operation must be done so as to deform and impair the functions of the parts as little as possible.

New and unnatural growths, or enlargements of the natural parts, as of the prepuce, of the clitoris, or of the internal labia, sometimes occur, and may require curtailment.

The external parts of elderly females may be the seat of warty excrescences, degenerating into malignant ulcer, and demanding free removal by incision.

Tumours of a medullary nature sometimes proceed from the interior of the pelvis, and displace and interfere with the functions of the vagina, bladder, and the neighbouring parts; such cases are of course hopeless, and the treatment must be merely palliative.

Polypous tumours, of various size, structure, and consistence, sometimes grow from the cavity of the uterus, or from its orifice, or from the parietes of the vagina. They are generally attached by a narrow pedicle, except when of a truly malignant nature—occasioning discharge, mucous and vitiated, sometimes bloody, often profuse. Bearing-down pains are complained of, and the health declines in consequence of the discharge. Most of such tumours are benign, troublesome only from their bulk and situation, and from the irritation which they produce in the surrounding membrane. They very frequently have their origin in the substance of the uterus, and are extruded from it, covered by the mucous lining. Removal by ligature is generally the most advisable method of extirpation. The site and nature of the attachment are ascertained, and a strong wire of fine silver, or a piece of whipcord, is noosed round the base by the finger, and pushed down close to the origin, care being taken not to include the healthy parts beyond the growth. The ligature is tightened by passing it through a canula, or along a strong probe, with a ring at each extremity, to the lower of which it is secured. It is drawn more tightly from time to time, till the tumour drop away. A double canula, the portions of which can be separated, is often used for the purpose. By practice only can dexterity in such manipulation be acquired; the object being understood, it must be attained by perseverance.

Malignant disease of the uterus is common. Various morbid alterations are here met with; soft, or hard, or bloody masses, earthy deposits, &c. The disease generally commences in the neck, with fulness and thickening; in many females it is attributable to faulty menstruation, to leucorrhœa, or to other irritations in the neighbourhood. Ulceration sometimes occurs, not of a malignant nature, from similar causes; but in old females this is either of a bad kind from the first, or degenerates, presenting all the usual characters of malignant sore on a mucous surface. The surrounding induration is usually great, and quickly spreads to the neck and body of the organ, contaminating also the neighbouring tissues and the lymphatics.

Some bloodthirsty accoucheurs and operators have attacked the uterus unrelentingly; more than one appears to have been seized with the monomania of cutting out part or the whole of the organ. Numerous females, at a period of life when malignant diseases rarely show themselves, have been subjected to excision of the os and cervix uteri. Some forty and fifty were operated on within a very few months; in almost all of these cases the proceeding was, without a doubt, cruel, reckless, and unnecessary. Attention to the general health, with local applications, would, in all probability, have restored the parts to a healthy condition in the greater number.

Malignant disease affecting the uterus may be removed, at an early stage, by incision, with propriety and safety, and I have done so successfully. The part is examined by means of a hollow tube of tin, polished inside, gently and cautiously introduced. A dilator as well as a speculum is required in the operative proceedings for removal of the parts; and for this purpose the instrument mentioned, when treating of vesico-vaginal fistula, is to be employed. When this has been introduced, the os uteri is laid hold of by one or more vulsella, and pulled down; the diseased portion is then removed by a blunt-pointed knife, the incisions being carried beyond the hard and altered part. There is not much loss of blood, and it is easily arrested by stuffing the vagina. Afterwards bland fluids are injected, and, after a time, those of a gently stimulating nature, to wash away the superfluous discharge, and promote healing. The state of the sore can be occasionally examined by means of the speculum, and nitrate of silver or other applications employed when necessary.

When the disease is in an advanced stage, the neck of the uterus is involved completely, and there is an uncertainty as to how far the morbid alteration extends. Only palliative treatment can be adopted,—soothing applications, and internal remedies according to the symptoms. The practice of some, however, is more bold and decisive. The uterus has been cut out by incision of the abdominal parietes. It has also been removed through the outlet of the pelvis. As was to be expected, the patients have perished from loss of blood, and the shock of such barbarous proceedings; one or two, perhaps, survived, only to die from extension of the disease to the internal parts, within a very few months. Such doings are not justifiable; and, if repeated, should be punished by the execration of all professional men of sound sense and principle.

The Common Iliac artery may require ligature, on account of extensive aneurism, involving the internal iliac, or its branches at their origin, or encroaching on the external iliac to near the bifurcation. It may also be necessary, in consequence of wound of the artery, or in cases of secondary hemorrhage from branches of either the external or the internal iliac.

An incision is made through the abdominal parietes, commenced over the passage of the cord through the transverse fascia, and extending upwards, and a little outwards, for five or six inches; its extent depending on the size of the patient, the thickness of the parts to be divided, and the consequent depth of the vessel. By this first incision, the skin and superficial fascia of the abdomen are divided, and then the muscles are penetrated, the line of the preliminary wound admitting of their being cut in the direction of the fibres. After the external oblique has been passed, the proceedings require to be conducted with great caution. The fibres are cut by the hand unsupported, and then the transverse fascia is scratched through, slightly and with great precaution, cutting upon the finger or a director introduced at the lower angle of the wound. By means of the finger, the opening is dilated, and the fascia separated from the peritoneum. This membrane and the parts within it are then, with the utmost gentleness, pushed inwards and upwards, by the hands of an assistant, so as to expose the bottom of the wound. The course of the vessel is now felt for, and by separating the edges of the wound, either by the fingers, or by broad and thin copper spatulæ, its bifurcation may be seen. About an inch or so above this point, the artery is slightly detached from its connections by the point of the knife, separating it from the vein on its posterior and inner surface, and a blunt-pointed needle, armed with a firm ligature, is pushed beneath, without force, and close to the coats of the vessel. The deligation is made firmly, and both ends of the ligature are brought out at the wound; this is then approximated by a sufficient number of stitches, and a compress and bandage applied.

This operation is not often required. I had recourse to it once in bleeding, after very high amputation of the thigh, occurring some days after the operation. The hemorrhage was effectually arrested, but the patient did not recover from the effects of the previous loss of blood, and continued to sink.

Aneurism of the branches of the internal iliac, whether spontaneous or the result of wound, is rare. When it does exist, its signs are sufficiently distinct. The old operation—opening the tumour by direct incision, and tying the vessel close to the cyst—has been performed successfully in one remarkable case on record. But this is attended with much risk, there being no means of commanding the bleeding during the incisions, nor until the ligature is placed and secured. The preferable proceeding is to tie the internal iliac near its origin, as has been put in practice successfully in a few cases. The same incisions are made as for reaching the common iliac, and then the sacro-iliac junction is felt for; with the nail of the forefinger the cellular tissue is cautiously and gently separated, and a needle and ligature placed under the vessel. In a corpulent adult, a needle, with a moveable point, may perhaps be useful, as also the copper spatulæ, to keep the parts aside; and a serrenœud may assist in the securing of the noose. It was the fashion once, and perhaps is so still, for every young and aspiring surgeon, when he was about to attempt lithotomy for the first time, to invent or alter some strange crooked tool, for smoothing, as he thought, his way into the bladder. The rage now, more especially on the other side of the Atlantic, is all for curious aneurism needles and tonsil shavers. It ought never to be forgotten, that the simplicity of any proceeding and of every machine is the measure of their perfection. I have had by me a lot of needles, all very ingenious, at the various operations for aneurism which I have had occasion to perform—many of them of the most difficult nature—and the simple needle has always been found to answer the purpose most perfectly.

Aneurism in the groin is not uncommon, and is very easily recognised. The old operation has been attempted, and unsuccessfully. Ligature has been placed on the distal side of the tumour, with no favourable result. One horrid example of the latter operation is on record, in which the femoral artery had been completely obliterated spontaneously, and nerves, vein, and portions of the muscles, were all included in ligature, by one random thrust of a large sharp needle. The external iliac is to be tied—a proceeding now regarded as one of the regular operations of surgery, and likely to insure a favourable result. It was first undertaken in a case of secondary bleeding after ligature of the femoral, and since, has often been performed for the cure of inguinal aneurism, with almost uniform success. It has also been practised successfully, on account of hemorrhage after amputation. I was under the necessity lately of putting a ligature round the external iliac, on account of profuse bleeding from an opening in the groin, made five weeks previously, to secure the common femoral, on account of hemorrhage from a stump of the thigh. This operation should have been had recourse to in the first instance, the deligation of the common femoral being an operation not likely to be followed by permanent closure of the vessel, in consequence of its shortness, and the branches given off from it both above and below. The patient ultimately recovered from these three capital operations. The incisions are made in the same direction as recommended for ligature of the common and internal iliacs, but not nearly so extensive. This is preferable to incision, either in the direction of the vessel, or of a semilunar form with one of the corners pointing upwards; the abdominal muscles are less weakened, less injury being inflicted on them, and no troublesome bloodvessels are encountered. The artery is well circumstanced for the application of ligature, affording a considerable extent without the giving off of any branches. It is easily exposed by cautious separation of the cellular tissue, and the ligature is secured either towards its middle, or at its upper part, according to the size and situation of the aneurism.

Popliteal aneurism is of more frequent occurrence than any of the preceding; and in regard to it, also, the old operation has deservedly fallen into disuse. It seems in most cases to be occasioned by partial laceration of the coats of the vessel; a sudden pain, and a feeling as of the receipt of an injury on the part, are generally felt, during some violent or unusual exertion; the pain continues, and an unwonted beating is soon perceived in the ham, along with inconsiderable swelling; the tumour with pulsation increases, and may ultimately attain a large size, causing pain, general uneasiness in the limb, and lameness, sometimes œdema. In cases of long duration, and when the patient is cachectic, the bones become diseased, absorption being caused by the pressure of the tumour, and deep extensive abscess may form in the soft parts.

The superficial femoral is to be tied, and the preferable point is where it is crossed by the sartorius muscle. This is always a better practice than removal of the limb, which has not unfrequently been resorted to in cases of large aneurism; there is great risk in such a proceeding, the anastomosing vessels in the thigh are all much enlarged, profuse hemorrhage takes place during the incisions, not completely arrested by any pressure, and probably twenty arteries or more require ligature, as I have witnessed; after all, the occurrence of secondary bleeding is not unlikely. I have tied the femoral artery, with a favourable result, in some cases of very large aneurismal tumour, and in one instance after the cyst had been imprudently punctured. An incision is made from three to four inches in length, and in an oblique direction in regard to the thigh, tracing the inner border of the sartorius muscle, and so placed that its middle may correspond with that part of the artery on which the ligature is to be put. In order to insure the wound being thus situated, there is no need for measurements; these are but a clumsy substitute for anatomical knowledge. The surgeon, well acquainted with the relative situation of the parts, finds it sufficient to ascertain the exact course of the muscle by manipulation, whilst the thigh is slightly bent, and then guides his knife by the eye, unfettered with mathematical diagrams. The muscle is exposed almost by the first incision; the dissection is then continued through the cellular tissue on its inner border, until the sheath of the bloodvessels is reached, the branches of the crural nerve on the fore part being carefully placed aside uninjured; the sheath is cautiously opened immediately above where the muscle conceals it, and the artery separated from its connections to a very slight extent; the needle is then passed, and the ligature applied. The operation, when thus conducted, is exceedingly simple. But embarrassment and delay have often been experienced from following an opposite method, cutting down on the outside of the sartorius; the muscle must either be dissected from its attachments and turned over, or cut across; or the artery cannot be found, and an additional external wound is necessary.

The artery may require ligature at a higher point, either in consequence of wound, or for the cure of femoral aneurism. This disease, however, is very unfrequent. When it does exist, it is usually so situated as not to admit of the favourable application of a ligature below the origin of the profunda; and it may be considered necessary to tie the common femoral. The course of this artery being superficial, is easily ascertained; an incision of convenient extent is made in the same line, penetrating the skin and fatty matter; the cellular tissue is carefully separated, and the sheath exposed; a limited opening is made, with corresponding detachment of the vessel, and the ligature applied, close to the lower edge of the ligament of Poupart. But ligature of the external iliac is in all cases to be preferred, for the reasons already given. This has proved successful in more than one case of double aneurism, one in the groin, the other in the ham.

In ligature of the common and of the superficial femoral, the vein is in more danger than the nerve, and the utmost caution is required lest it be punctured. It has been wounded—I witnessed one instance of it; the opening was drawn together and closed by ligature, inflammation of the vein supervened and proved fatal.

When secondary bleeding occurs, on the separation of the ligature, either after this operation or after that for popliteal aneurism, compression is not to be trusted to, nor should the vessel be tied higher in the thigh. From imprudent reliance on the former method I have known patients perish. An incision must be made in the same line as the former, and a ligature placed on the vessel both above and below the bleeding point, as may be necessary.

The arteries of the leg very seldom require ligature, except for wound. In such cases, the source of the bleeding must be the guide to the incisions, and these should be placed so as to interfere with the muscles as little as possible, always in the direction of their fibres. When the bleeding point is arrived at, the vessel is exposed to a short distance, and tied above and below the wound. During the dissection, it will in most cases be necessary to arrest the bleeding by pressure in the ham, either by the fingers of an assistant, or by means of a tourniquet.

The thigh may be the seat of aneurismal varix, the result of wound, as in the following case. Fourteen years ago, a young man wounded the lower part of his thigh deeply by the accidental thrust of a narrow chisel. The puncture was in the direction of the femoral artery; violent hemorrhage was the immediate consequence, and after he had fainted the wound was stuffed and compression applied. In eight days the parts had healed, and he returned to work as usual. But about twelve months afterwards, troublesome pulsation was perceived in the part, at the same time the veins of the leg became varicose, and a succession of ulcers formed on the lower and anterior portion of the limb. The affection attracted but little of his notice till about six months since, when he observed a considerable swelling in the site of the wound, beating strongly, and the pulsations accompanied with a peculiar thrilling sound and feel—not confined to the tumour, though strongest there, but extending to the groin along the course of the femoral vein, which was evidently much dilated throughout its whole course. At present the tumour is nearly equal to the fist in size, of regular surface and globular form, pulsating very strongly, and imparting to the hand the peculiar sensation of aneurismal varix, remarkably distinct and powerful. The pulsation and thrilling are continued, in a less degree, to Poupart’s ligament, and down to the calf of the leg. On applying the ear close to the tumour, or listening through the stethoscope, the peculiar noise is not only felt, but heard of almost startling intensity—somewhat resembling the noise of complicated and powerful machinery, softened and confused by distance. By making firm pressure on the tumour, the thrill is lost, and the regular pulsation alone perceived; at the same time, the turgescence of the femoral vein disappears, and on compressing the femoral artery in the middle of the thigh, both pulsation and thrilling are arrested, and the swelling much diminished,—but only temporarily, for the collateral circulation is free and complete. He feels little pain, but exercise and exertion of every kind are seriously impeded; constant and firm pressure on the swelling, with uniform compression of the whole limb, has been employed, with the effect of relieving all the symptoms, and rendering the limb much more useful, and by its continuance it is to be hoped that the disease will at least be considerably palliated.

In the lower extremity, as in the upper, the bursæ become enlarged, in consequence either of pressure or of external injury. The affection may be acute, following a blow or squeeze, but is most frequently chronic, enlarging gradually and with little or no pain, and caused by habitual pressure on the part. From this, it will at once be understood, why the bursa over the patella should be the one most commonly affected. Its vulgar name, housemaid’s-knee, marks its cause—the avocations of such persons requiring them to rest on one or both knees, frequently, and often for a long time. It also occurs in shop-keepers, and other persons accustomed to shut drawers with their knee, or in other ways to make frequent pressure on that part,—in gardeners, and those employed in similar pursuits. In the acute swelling from injury, local depletion, fomentation, and rest are required, and these are generally sufficient to arrest the swelling, and promote its subsidence; but, in some cases, the fluid is deteriorated and the surface inflames, free incision is required, followed by poultice, and afterwards by simple dressing. In the chronic collection of clear fluid, gentle and continued stimulation of the surface, as by the gum and mercurial plaster, causes gradual decrease by absorption; the causes of the affection being at the same time studiously avoided. The tumour sometimes, as here shown, attains a large size, and from repeated inflammatory attacks becomes consolidated. The cyst is thickened, and lymph is effused into the cavity so as to convert an encysted swelling into one of solid consistence. In such cases as these, the tumour may cause such inconvenience as to make the patient desirous to have it dissected out. This is easily and safely effected; the incisions are made in the direction of the limb, and it is kept at rest in the extended portion for some time, so as to favour the healing of the wound.

Unyielding parts, habituated to pressure, defend themselves by the interposition of a moveable bag containing fluid; betwixt them and the surface the cellular tissue condenses into a cyst, its internal surface assuming a serous appearance, and secreting a fluid resembling the synovial. Such adventitious bursæ are not unfrequent on the ankles and feet, as in tailors, or others usually sitting cross-legged. They may attain a considerable size, and so produce deformity; but they should not be interfered with unless they become inconvenient, as from excited action.

When the extremity of the metatarsal bone of the great toe is large, and consequently the seat of pressure, a bursal formation is produced in the soft parts covering it; this from increase of pressure, or other irritation, may inflame—forming the painful and troublesome disease termed Bunnion. Sometimes unhealthy abscess occurs, with thickening, infiltration, and condensation of the surrounding cellular tissue; in such cases, incision and poultice are required, and occasionally it is necessary to destroy the unsound cellular tissue and the degenerated cyst by free application of the caustic potass. The cyst is thus got rid of, healthy granulation takes place, and by afterwards avoiding undue pressure upon the part, a permanent cure is obtained.

It has been elsewhere mentioned, that cartilaginous bodies sometimes form within articulating cavities, occasionally attached by a narrow and slender connection with the secreting surface, but generally loose, seldom numerous, and usually of no great size. They are most commonly met with in the knee-joint, producing inconvenience by impeding progression. Sometimes they are neither painful nor annoying, being small, and seldom becoming interposed between the articulating extremities of the bones during motion; such ought not to be interfered with. But when large, they may be so troublesome as to warrant incision and removal. The foreign body is made to project on one side, and, having been made as superficial as possible at a favourable point, is fixed by the fingers of an assistant. The integuments are then drawn to one side, and an incision made over the body, the capsule is cut to as limited an extent as possible, and removal effected by pressure—or it may be laid hold of by a hook, and extracted; if the cartilaginous substance be attached by a pedicle, this must be divided, but with great caution. The integuments are immediately allowed to resume their natural situation, and so to close the wound of the capsule by overlapping it; the skin is then accurately approximated by adhesive plasters. The limb is kept extended, and not the slightest motion of the joint permitted. The patient is confined constantly to the recumbent posture, purged, and kept on low diet; the utmost vigilance is necessary to prevent inflammation of the synovial apparatus. In some patients on whom I have performed this operation, the wound closed by the first intention, and no untoward symptom threatened, motion and the erect position being resumed in a few weeks. But in the last case which came under my care, though the extirpation was performed with the utmost care, most violent inflammation supervened; the wound opened, synovial secretion flowed out in large quantity, profuse escape of unhealthy matter followed, and exhausting discharge continued for many weeks. At one time the constitutional disturbance was so great as to endanger life; the limb was saved with difficulty, the joint anchylosed. From the result of this case, I am disposed to dissuade operative interference, unless the patient strenuously urge it, and be willing to take the responsibility for the consequences on himself.

[The most common distortion to which the human body is liable is Club-foot; an affection which has at all times attracted the notice of the profession, but which has received unusual attention within the last ten years on account of the novel operation suggested for its cure by Dr. Stromeyer of Hanover, in Europe. The lesion is, for the most part, congenital. It may, however, be developed after birth, and even at an advanced period of life, from the foot being accidentally placed in a constrained position, and so retained until the soft structures—particularly the muscles and ligaments—are moulded into a new shape, or until they become fixed in their new situation. Various mechanical causes may give rise to this malady, such as splints and bandages, by which the parts to which they are applied are injuriously compressed, or thrown out of their natural relations. Similar results are produced by convulsions, dentition, nervous irritation, contusions, sprains, fractures, partial luxations, and preternatural laxity of the ligaments. In some instances the defect is occasioned by the presence of a corn, an ulcer, or some other disease which induces the person to walk on one side of the foot, the tip, or the heel, to ward off pressure from the tender parts. A vicious habit is thus established, which, if it be kept up, as it often is, for any length of time, leads to irregular action in the muscles, and to distortion of the bones into which they are inserted.

The formation of congenital club-foot has never been satisfactorily explained. By some—as Meckel, St. Hilaire, Serres, and Breschet—it has been ascribed to an arrest of development. This theory, however, for various reasons, is untenable, and has therefore not been generally adopted by surgical men. Mons. Martin, a recent French writer, thinks it is mainly occasioned by the pressure of the parietes of the uterus on the feet of the infant during gestation, owing to a deficiency of the amniotic fluid; an opinion in which he is joined by Professor Cruveilhier. That the disease may proceed from this source in some instances maybe readily supposed, but that this is the only cause, is what few will believe. The most plausible hypothesis, in my opinion, is that of Mons. Guerin of Paris. He supposes that the primary mischief is in the nervous system, and that the spasmodic and permanent shortening of the muscles of the affected limb is altogether consecutive. He sums up the results of his numerous observations in the following propositions:—1. Congenital club-foot is the effect of a convulsive contraction of the muscles of the leg and foot. 2. In the absence of general or direct traces of the convulsive affection we may almost always discover some immediate characters which indicate the nature of the exciting cause. 3. There are three constituent elements in the retraction of the muscles of the part: namely, the immediate shortening of their substance and tendons; a certain degree of paralysis; and, lastly, a consecutive arrest in the development of their substance. 4. There are no other causes of genuine congenital club-foot than convulsive muscular retraction. The pressure of the parietes of the uterus on the fœtus appears, indeed, in some cases, to produce a deformity of the limbs and feet, similar to but not identical with club-foot. The views of Mons. Guerin are confirmed, in some degree, by the history of those cases which occur after birth; but future observation must determine whether they are correct or otherwise.

The congenital variety of this distortion often affects both feet simultaneously, though rarely to the same extent. In one hundred and sixty-seven cases reported by Dr. Detmold of New-York, the disease was double in nine-three; in forty-one it occurred in the right foot only, and in thirty-three only in the left. Of eighty cases collected from various sources by Mons. Bouvier of Paris, or observed by himself, two-fifths were double; one-third affected the left limb, and one-fourth the right. Of sixty-one cases furnished by Martin, another French writer, twenty-six were double and thirty-five simple: of the latter, eighteen were of the right and seventeen of the left foot. Mons. Helt has published the results of thirty-one cases, in nineteen of which the disease was double; in two it was more distinctly marked on one leg than on the other; and in one instance the calcaneal form of the lesion was united with the inverted. In twenty-one cases observed by Scoutetten, both feet were deformed in nine; and in the other twelve the right limb was exclusively involved seven times; the left five times.

The disease would appear to be more frequent in males than in females, though the relative proportion has not been ascertained. The following table, embracing three hundred and twenty-nine cases, will throw some light on this subject:—

There are certain facts which would seem to show that club-foot is sometimes hereditary; or, at all events, that it may occur in several members of the same family. Thus, Dr. Detmold states that he has been able to trace the hereditary predisposition to this deformity in not less than eighteen cases, and in all excepting one, to the father’s side. Whether this was a mere coincidence, or obtains generally, it is impossible to say. Mons. d’Ivernois relates an instance in which four brothers were all born with the feet twisted inwards; and another writer, Mons. Helt, speaks of a family, which consisted of six children, all of whom were afflicted with congenital club-foot. In the latter case the disease was probably hereditary, as one of the parents was labouring under the same infirmity. It should be observed, however, that club-footed parents do not always produce club-footed children.

Club-foot may be conveniently divided into four varieties—the inverted, everted, phalangeal, and calcaneal—which differ from each other not only in regard to the character of the distortion and the accompanying phenomena, but likewise in relation to the frequency of their occurrence and the nature of their proximate causes. The most common form by far is the inverted, usually denominated varus, in which the patient walks upon the outer ankle, the great toe being directed inwards and upwards. The muscles of the calf and the adductors of the foot are contracted, and hence there is not only elevation of the heel, but a peculiar inward twist of the foot, analogous to supination of the hand. This alteration occasions the most serious impediment to progression, and when it reaches its highest point imparts a most disagreeable aspect to the affected limb. In the higher grades of the disorder, the sole of the foot is literally scooped out, as it were, as well as deeply furrowed; the instep, on the contrary, is unusually convex and prominent; the small toes generally present in a vertical position, while the big one, separated from the rest, looks upwards and inwards; the outer margin of the foot, which, in conjunction with the corresponding malleolus, chiefly sustains the weight of the body, is almost semicircular in its shape, rough, and callous; and the tendo-Achillis, forced obliquely towards the inner side of the leg, forms a tense, rigid chord beneath the skin.

Sometimes both feet are affected with varus, so that their points form an acute angle with the leg; or approach so nearly as to touch, or even overlap one another. In the majority of cases the thigh and leg retain their natural conformation, being merely somewhat atrophied; occasionally, however, one or both knees project slightly inwards or outwards, owing to the contraction of the hamstring muscles.

The second variety of this deformity, anciently called valgus, may be regarded as the opposite of varus, the patient treading on the internal margin of the foot, while the external is entirely removed from the ground. The sole is directed outwards and slightly backwards, the toes are more or less elevated, and the outer ankle is in a state of semiflexion. The heel is drawn upwards and somewhat outwards, the internal malleolus is uncommonly prominent, the instep is flatter than natural, and the muscles of the calf, together with the adductors of the foot, are permanently contracted. When the disease has attained its highest point, the patient has an unsteady, vacillating gait, from the difficulty which he experiences in preserving his centre of gravity. Valgus is comparatively rare; and, like the first variety of the distortion, it may affect one or both limbs. It is seldom a congenital affection, but is almost always produced by some local injury—as a sprain or blow.

The phalangeal club-foot—the pes equinus of the older writers—is caused by a shortening of the gastrocnemial and soleal muscles, aided, in some cases, by the flexors of the toes. In this species of the deformity the individual walks upon the ball of the foot, the toes, or upon the metatarso-phalangeal articulations, without the heel or any other part of the sole touching the ground. The distance at which the heel is raised varies in different cases, from six lines to four or five inches, according to the extent of the contraction upon which the distortion depends. Considerable diversity is observed in regard to the manner in which the person treads on the ground; most commonly the ball of the little toe bears the brunt of the pressure, but in some instances the weight is thrown upon the great toe, or it is diffused over the whole of the fore part of the plantar surface. In the worst gradations, the heel is so much elevated that the foot forms nearly a straight line with the leg, the toes are much deformed, the instep is unnaturally convex, the plantar aponeurosis is greatly contracted, and the skin above the heel is thrown into dense wrinkles.

In the fourth variety—the calcaneal, recently described by Mons. Scoutetten—the limb rests upon the heel, the toes being drawn upwards, towards the anterior surface of the leg, with which they sometimes form an acute angle. The immediate cause of the deformity seems to be a contraction of the anterior tibial muscle and of the extensor of the great toe, assisted occasionally by that of the common extensor of the foot. The tendons of these muscles form an evident protuberance under the skin, where they present the appearance of tense, rigid chords, which powerfully resist the extension of the limb. The inner margin of the foot, as seen in the cut, is sensibly elevated above the outer, and there is always considerable atrophy of the leg. The distortion, which is almost always congenital, is exceedingly rare. Occasionally the foot inclines slightly outwards, owing to the inordinate contraction of the common extensor muscle.

The changes which the bones, ligaments, and muscles undergo, vary, not only in the different species of club-foot, but in the different stages of the same case. The greatest alteration appears to exist on the part of the tarsal bones, which, although they are rarely completely dislocated, are generally somewhat separated from each other, twisted round their axis, variously distorted, atrophied, or marked by irregular spicula or exostoses. The calcaneum, cuboid, scaphoid, and astragalus, always suffer more than the other bones; which, however, as well as those of the metatarsus and of the toes, usually participate, more or less, in the deformity. The ligaments, in recent cases of club-foot, do not present any material changes, but in those of long standing, or in the higher grades of the affection, they are invariably stretched in the direction of extension, and relaxed in that of flexion. In some instances the original structures are partially replaced by bands of new formation, of a dense fibrous character—the volume and resistance of which vary according to the duration of the disease and the pressure of the parts which they serve to connect together. The muscles also are not much altered in the first instance, except that they deviate from their natural direction, and that, like the ligaments, they are elongated on the one hand and shortened on the other. In ancient cases the whole limb is always considerably wasted, and many of the muscles are remarkably thin and pale, or even transformed into soft, fatty bundles. The cellular substance is condensed and diminished in quantity; the adeps is absorbed; and even the vessels and nerves supplying the affected part are apparently reduced in volume. The skin of the foot, which receives the principal brunt of the pressure in standing and walking, is generally very much thickened and indurated, and large synovial bursæ are often formed beneath it, which are apt to inflame, and thus add to the suffering of the patient. Such is an outline of the more important changes experienced by the different textures in cases of club-foot: to enter more minutely into the subject would be foreign to the design of this article, the object of which is merely to present a general idea of the nature, causes, and treatment of this singular distortion.

The treatment of this affection should be delayed as little as possible. The sooner, indeed, it is attended to, the more probable will be the chances of effectually removing it. This is equally true, both of the congenital and of the accidental form of the disease. The bones in early life and in recent malformations are much more easily restored to their normal position than in youth and manhood, or in cases of long standing; and the muscles also regain much sooner, as well as more completely, their original power. In the worst grades of the disease it is often exceedingly difficult, if the treatment be delayed until after the age of puberty, to accomplish a cure without great carving of the tendons, and the constant employment for months of various kinds of apparatus.

It is still a disputed point, whether, in the treatment of this affection, particularly in infants and young subjects, it is necessary, or even justifiable, to divide, as a preliminary step, the tendons of the muscles which are instrumental in keeping up the distortion. Without endeavouring to settle this question, for which the time has not perhaps yet arrived, I must express my conviction that the present rage for tenotomy is calculated to do a vast deal of harm, not only in individual cases, many of which do not require it, but, what is worse and more deeply to be lamented, in bringing discredit upon an operation, which, if judiciously performed, cannot fail to be of the greatest benefit. In most of the cases occurring in children under two or three years of age, division of the tendons is altogether unnecessary; indeed, one of our most distinguished orthopedic surgeons, Dr. Chase of Philadelphia, seems to trust almost entirely to the employment of apparatus, and to resort to tenotomy only in the worst grades of the disease. Whether this practice will ultimately be adopted by the profession generally, or the division of the tendons be restricted to particular cases, it would be premature to predict; but my opinion is, that much more cutting is now done than is necessary, or than would be done if the treatment of the disease were better understood than it appears to be.

Different kinds of apparatus are in vogue for the cure of this deformity, and it is therefore impossible to determine which is the best, or which should be employed to the exclusion of the others. Every practitioner seems to have his own notions on the subject, and to adopt such measures as whim, fancy, or caprice may dictate. Whatever apparatus be resorted to, the great caution to be observed, on the part of the surgeon, is, that the extension be made in a slow and gradual manner, that the skin be protected from friction and uneven pressure, and that the dressings be steadily retained during the night, as well as during the day, until several weeks after all deformity has disappeared. The object of these directions is self-evident, and too important to be neglected in our curative procedures. The time required for restoring the limb to its normal position must necessarily vary in different cases, and depend upon so many circumstances as to render it impossible to lay down any specific rule. From six weeks to four months, however, may be considered as a fair average, though occasionally a much longer period will elapse. The division of the tendons of the contracted muscles generally expedites the cure by several weeks.

In the operation for dividing the tendo-Achillis the patient may either lie on his abdomen or sit on a chair, and the heel is to be drawn downwards by an assistant with the left hand, the right being placed upon the plantar surface of the toes. The necessary tension being thus given to the part that is to be cut, the surgeon passes a narrow, straight, sharp-pointed bistoury through the skin, from one to two inches above the internal malleolus, flatwise between the tendon and the deep-seated structures. The knife is then pushed on until it reaches the opposite side of the tendon, when its edge is brought in contact with the anterior surface of the chord, which is now completely divided by steady pressure upon the handle of the instrument. The separation of the parts is indicated by an audible snap, and by the immediate cessation of the tense resistance of the tendo-Achillis. Scarcely a drop of blood is lost during the operation, which is almost unattended with pain, and is accomplished in a few seconds. A strip of adhesive plaster is applied over the little puncture, which generally heals by union by the first intention; and the limb, laid in an easy position, should be supported by a paste-board splint and a common roller. The apparatus for keeping up permanent extension may be advantageously employed in three or four days after the operation.

The interval between the divided extremities of the tendon is filled up with coagulating lymph, which is often poured out in considerable quantities. As in other situations, it becomes gradually organised, and is finally converted into a firm, dense substance, not unlike the original structure.

The tendon of the posterior tibial muscle may be cut most advantageously about two inches above and behind the internal malleolus. The operation is conducted upon the same principles as in the preceeding case, and the only particular caution to be observed is to avoid the posterior tibial artery and nerve, which might be endangered by carrying the knife too deeply. The most favourable situation for dividing the anterior tibial muscle, is where it passes over the ankle-joint: the long flexor of the great toe may be cut in the sole of the foot, where, when it interferes with the rectification of the limb, it forms a tense, prominent chord.—ED.]

The phalanges of the toes in general resemble those of the fingers in their diseased actions. Exostosis of the extremity of the distal phalanx, however, has no analogy in the upper extremity; it is by no means an uncommon affection, and usually occurs in the great toe. The growth is generally globular and rough in its extremity, narrow at its origin, attached on the dorsal aspect, projecting obliquely upwards, and always of similar structure with the phalanx. Sometimes they are met with of a size nearly equal to that of the bone from which they spring, but the majority are considerably smaller. The only one I have met with springing from a small toe is here sketched. At first the patient complains merely of pain in the part while walking; soon the pain increases so as to impede progression very seriously; then the nail is found to be raised at its margin, and to cover a hard, unyielding, and tender swelling. The elevation of the nail increases, and the tumour becomes more apparent, covered by hardened cuticle, causing great uneasiness, and almost entirely preventing walking exercise.

It has been recommended to expose the tumour by incision, and remove it at its origin. This affords temporary relief, but the disease is generally in no long time reproduced, and the incision must either be repeated, or the phalanx amputated. The preferable practice, according to my experience, is to remove the phalanx at once. It is less tedious and painful than the incision, produces very little, if any, impediment to progression, and of course is quite effectual in eradicating this most annoying though apparently simple disease.

Of Fractures.—Deformity, shortening, loss of power, unnatural motion on extending and moving the part, pain, and grating, mark solution of continuity in bone, or fracture. Swelling, with spasmodic of these symptoms may be wanting; there is little deformity, and no shortening, when one of two or more action of the muscles, soon takes place. One or several parallel bones is fractured. In fracture of the extremities, extrication of air into the cellular tissue, about the ends of the bone, is not unfrequent, though difficult to account for—giving rise to crepitation, superficial, and quite a distinct sensation from that imparted by the broken bone.

Bones become brittle as age increases, and fragility is also induced by certain disordered and debilitated states of the constitution. In some patients, the bones give way on very slight force being applied, after what may have been supposed a rheumatic attack; the thigh is broken by turning in bed, or by walking from the bed to a chair. In one instance, I had put up a fracture of the thigh with a long splint, and in three weeks afterwards the humerus was broken over the end of the splint during an attempt by the patient at change of posture. In many such cases union either does not take place, or is very imperfect.

In children, the bones frequently contain little earthy matter, bend easily, and often break partially on the convexity of the curve. Even at the age of twelve or thirteen, bending of the bones from injury sometimes occur to a great extent, as of the forearm from a fall on the palm of the hand; in adjusting the parts, a slight crackling is heard when they are brought nearly straight. Complete solution of continuity, though more rare, is occasionally met with in very young subjects.

Fractures are generally the result of great force applied directly to the shaft of a bone, or to its extremity; but they are also not unfrequently caused by twisting of the limb whilst the muscles are in a powerful action. Bones are broken transversely; but more frequently there is a degree of obliquity in the fracture, and the fragments are generally detached. A bone may be split longitudinally, as from a musket-ball striking its shaft in the centre; and fissures often extend from a cross break to a considerable extent, sometimes into joints.

Swelling is often rapid, from extravasation of blood; at other times it is slow, and of a serous character. At first it is soft and yielding, but after a time painful inflammatory tumescence supervenes, the violence and extent of which will depend on the severity of the injury, and very much also on the treatment to which the parts are subjected. If the bones be put as nearly as possible into their original position, and retained so, judiciously—the limb being laid in a comfortable and unconstrained posture, and the bandages, splints, &c., properly adapted—little or no pain or inflammatory swelling will occur; no more action ensues than is required for reparation of the injury. If, on the contrary, the bones are allowed to remain unreduced—perhaps after being well handled—their broken ends, laying among the soft parts, are pulled out by violent spasms, lacerations of the muscles and vessels is increased, effusion, swelling, and violent inflammatory action occur, the pain becomes excruciating, fever and delirium follow; there is an imminent risk of gangrene, and extensive suppuration among the muscles is almost inevitable. If the patient recover, the union is bad, and the limb deformed.

A fracture is said to be simple, where there is no wound of the superimposed integuments. The external parts may be bruised, or the deep structure much injured, with laceration of the vessels and rapid and great swelling; or there may be little or no injury of the soft parts. Great danger may exist without division of the integuments; these, yielding under the force, may remain entire, whilst by great and direct violence the bone is comminuted, the muscles broken up, and the vessels and nerves torn,—the limb is infiltrated with blood, and must become gangrenous as soon as reaction takes place. But usually these untoward circumstances do not exist in simple fractures, the soft parts being but slightly injured.

Fracture is compound when the integuments are divided by the external force, so as to expose the broken bone. But the wound may not penetrate to the bone; and then the accident is termed fracture with wound, not compound fracture. The soft parts are often divided by the sharp end of the bone; this is frequently the case in oblique fracture, occasioned by a fall from a height, the lower fractured extremity being pushed forcibly upwards. The muscles are usually much injured. The wound is either large or small, lacerated or clean.

Fracture, simple or compound, is comminuted when the bone is divided at the broken point into fragments, either small and loose, or large and adherent to the covering of the bone and other soft parts.

Fracture may be complicated with wound or displacement of a neighbouring joint, and with laceration of large bloodvessels and nerves.

Union of divided bones, as of soft parts, is preceded by incited circulation in the part, and effusion of organisable matter. The extent of action is regulated by that of the injury, whether inflicted by accident or by operation. If the soft parts have not been much bruised, if the bone and its covering are merely separated and slightly displaced, and then speedily put in contact, the incited action and the effusion are limited to the divided parts. There is no irregularity afterwards at the point of fracture, the new matter that is not required being absorbed soon after deposition; the bone is smooth and even as before. The deposit of new matter under the periosteum and into the medullary canal is here well exhibited. By this means only is the bone kept together for a very considerable period; afterwards the broken ends are united, and the temporary callus absorbed. If, on the contrary, there is much displacement, and if that is not entirely removed, intense action ensues both in the soft and hard parts, there is great effusion of new matter, or callus, soft and yielding at first, but gradually becoming hard and dense—bony particles being deposited from the vessels ramifying in the extremities, or in the attached fragments, of the old bone. When detached portions of callus are found lying in the soft parts, a piece of old bone which retained its vitality has generally formed the matrix of the deposit. When the ends of bones have been badly placed, and meet each other at an angle or curve, occasionally osseous deposit seems to form in the concavity. This increases in size, unites with the portions of the shaft, and forms a sort of bridge uniting them. This by M. Gulliver has been termed accidental callus.

In badly reduced fracture the swelling is great and hard. The callus is exuberant, much being required for the union of the fractured ends that overlap, and are perhaps far from being in contact; the vascular action and accompanying effusion are great, according to the necessity for them. The bone at the united part is enlarged to perhaps double its original thickness, or even to a greater size. After some time, the ends of the old bone, and part of the new deposit, are rounded off by absorption of the protuberances, and the part becomes more shapely. The canal of the bone and the cancellated texture is again restored. The accompanying sketch of a section of the humerus shows a double fracture. The superior one near the neck, where there is still some thickening, had been well adapted, and the canal is quite perfect. In the other and more recent there is considerable overlapping. The portion of outer osseous shell projecting into the medullary canal would in the end have been removed by the absorbents, and the deformity much diminished.

When the ends of the bone are not well placed, or when they are moved occasionally whilst the uniting medium is still soft, there is danger of a false joint being formed—the callus either giving way, or being all along imperfect, and the extremities at the soft part becoming smooth and moveable on each other; or incited action may run high and terminate in suppuration, with death or ulceration of portions of the bone.

Fragments are sometimes entirely detached at the time of the accident, and perish at once; or are so slightly connected with the shaft that they lose their vitality on the first accession of inflammation, become surrounded by purulent matter, part from their slight attachments, and come towards the surface. Or the shaft itself may be so bruised by the violence of the injury as to be incapable of resisting incited action, though slight. By malpractice, such untoward consequences as the preceding, and many others beside, are frequently induced.

The uniting medium of separated bones remains soft for some time, as was already observed; and often, whether from the state of the constitution, or the circumstances connected with the fracture, the parts remain long moveable. Pregnancy is said to prevent union; but I have often seen fractures in pregnant women unite as speedily and firmly as if the patients had been in that state, and otherwise in robust health; profuse uterine or vaginal discharges, or determination to particular parts or organs, will certainly retard union.

In ordinary cases, the limb, if not lying altogether straight, can be moulded into a proper form after the lapse of eight or ten days from the time of injury, without the patient suffering any great degree of pain, without the process of union being at all interrupted, or the cure protracted; even at the late period of five or six weeks, badly united fractures may sometimes be much improved by gradual pressure and change of position. A gentleman fell from his horse, and sustained simple fracture of both bones of the leg, near the middle. It had been laid and retained on its side. I saw him exactly six weeks after the injury; the leg was much curved forwards, and the foot turned outwards. The limb was placed on the heel, and a long splint, with a foot-piece, applied on the outside; by attention to its position, and by gradually tightening of the bandages, it soon became quite handsome. Care should be taken not to allow the patient to rest too soon on the fractured limb; for though quite straight, symmetrical, and of the proper length, when the retentive apparatus is discontinued, it may become short and deformed in a few days from even slight weight being put upon it.

The period at which firm union takes place varies; the process is more rapid in young people than in those advanced in life, and will depend more on the extent of the injury, and its vicinity to the centre of the circulation than on the size of the broken bone. The requisite length of confinement is regulated by these circumstances, and by the use to which the part is to be afterwards put; the lower limbs require longer time for consolidation than the upper.

In the treatment of fracture, as in solution of continuity in the soft parts, great advantage is gained by placing the disjoined parts as nearly in their original position as possible, retaining them so, and allowing of no motion. These indications ought to be accomplished very soon after the accident; many evils are thus prevented—the further laceration of the soft parts, the inflammatory effusion into all the tissues, and the consequent startings and spasms of the muscles. This cannot be too much insisted on. There is much folly and absurdity in allowing a broken limb to lie unrestrained—leaving the ends of the bones displaced, the one riding over the other—whilst attempts are being made to keep down the inflammation, by applying leeches, cold lotions, or large poultices—all perfectly ineffectual so long as the palpable cause of incited action remains unheeded. The circumstances which kindle and keep up inflammation should always be understood; they are easily discovered in fracture, and when understood should never be lost sight of. If the parts be replaced there will seldom be inflammation; if they remain displaced, the inflammation is so great that it is impossible to subdue it by any means short of removal of the cause. There is also an impossibility,—not to mention the patient’s sufferings,—of reducing bones to a good position some weeks after the accident. Such practice has been extensively followed and recommended by some, even modern writers; they set about reducing a fracture at a period after the accident, at which, by proper treatment, union would have been completed, or at least far advanced. The confinement and suffering of the patient are increased threefold, and after all the cure is bad, and there is a risk of false joint.

In all fractures, whether simple or compound, comminuted or complicated, if an attempt is to be made to save the limb, let reduction be immediate; coaptation and retention of the separated parts cannot be made too soon. A neglected case may be met with, in which the intensity of inflammatory action in all the tissues may forbid immediate interference. But even though inflammatory action has taken place to some extent, there are no surer means of arresting it than removal of its cause—the irregular ends of the bones being taken away from among the soft parts—provided it can be done without violence or increase of tension. Reduction is facilitated by proper position of the limb, by relaxation of certain sets of muscles. Extension and counter-extension are made, and but very little force is required; the surgeon extends the limb with one hand, and resists with the other; when the system is excited, and the muscles act spasmodically, an assistant may be required to steady the limb, and to resist the extending power which the surgeon employs. Then the position of the limb and of the patient, when long confinement is required, must be considered, and rendered as easy as possible, though at the same time secure. The apparatus for retaining the bones in the right position must be varied according to circumstances.

In compound fractures, when the wound is so small and clean that adhesion readily takes place, the cure is as rapid as in the simplest form of accident; but when the soft parts are much lacerated, the breach in them must be repaired by granulation; there will be profuse discharge from the wound, with risk of deep suppuration, and union of the bone will be slow. To accomplish reduction, long and sharp pieces of bone may require to be removed by means either of the saw or of the forceps, or else the wound must be dilated; both proceedings may be necessary in some cases. Detached portions of bone, and foreign bodies, if any, must be taken away; and the edge of the wound may be approximated when a reasonable chance of adhesion exists. The limb must then be properly placed and secured. Inflammatory action, should it threaten, must be kept down, but bleeding and purging are to be employed with caution. The action and its consequences are moderated by one or two depletions, but these must not be had recourse to without due consideration of circumstances; strength is required to effect the action necessary for union, and to withstand the subsequent suppurations, though these may be prevented or at least moderated by timely depletion. Abscesses are to be opened early, the parts are fomented, and then perhaps poulticed. The limb must all along be kept in a correct position, dead portions of bone must be removed when detached, and the strength supported by generous diet and wine. Opiates are of great use in alleviating the pains and twitchings in the limb. Poulticing is to be continued only for a short time; in many cases it may be altogether superseded by fomentations; and the latter should be used only when abscess is threatened, or when the patient is much pained at one or more parts of the limb. Support and gentle pressure are indispensable soon after evacuation of the matter, when no fresh collection is threatened.

The injury is often so great as at once to demand removal of the limb. There is no alternative, when, from laceration of the soft parts, superficial, deep, or both—comminution of the bone to a great extent—rupture of large vessels—and opening of joints—either gangrene or an overpowering suppuration are rendered not only probable but almost certain. The period at which the operation is to be undertaken requires judicious selection. Some patients are not affected constitutionally even by great and violent injury, such as dreadful laceration of the limbs; whilst others, even after slight wounds, are seized with delirium, tremors, vomiting, lowness of spirits, depressed circulation, paleness of the surface, and appear on the eve either of rapid sinking or of immediate dissolution. In the first class of patients immediate amputation may be had recourse to with safety and advantage. In the second, the patient must be reassured, and stimulated both by external and internal means; in short, reaction must be brought about, and then let the surgeon operate. If he amputate before this, his patient will most probably die on the table, or very soon after his removal from it; reaction will never take place, and sinking of the vital powers be accelerated by the ill judged interference. A greater or less time is required for the occurrence of reaction in different individuals; the usual period is from two to six hours. Commencement of it is a sufficient warrant for operation; the surgeon must not delay till inflammatory fever has been lighted up, for then he will interfere with great disadvantage. He must then subdue the inordinate action as much as possible, and wait for the suppurative stage. When the patient has become hectic from profuse and long continued discharge, when, perhaps, no union has taken place—then also the limb must be removed. In civil practice, patients as often recover from secondary as from primary amputation. But according to the experience of military surgeons, the result is otherwise—many recover after primary and few after secondary; much may depend on the accommodation of the patient afterwards. A great deal must necessarily be left to the judgment, discretion, and conscientiousness of the surgeon.

Fractures of the cranium were treated of as connected with disturbance of the important organ which it protects.

The bones of the face are occasionally broken and displaced. The frontal sinus is sometimes opened by fracture of the external plate. No small degree of force is required to effect this injury:—I recollect an instance of it, with opening into the sinus, occasioned by an attempt at suicide; the man had struck his forehead violently with a large stone, wishing to knock his head to pieces. The integuments are generally divided, and, during expiration, blood, sometimes frothy, is poured out through the opening. When there is no wound of the integument, emphysema of the forehead and eyebrows has resulted from disruption of the bones that compose this cavity, or others connected with the nostrils.

The ossa nasi are fractured and displaced by direct violence. They may be broken and comminuted without much displacement, or separated from their connections and depressed without much fracture. Even slight cases are generally attended with laceration of the Schneiderian membrane, and with profuse hemorrhage from the nostrils. The soft parts over the bones are thin and tense, and consequently in many cases divided. Great swelling is apt to ensue, at first either bloody or œdematous. Inflammatory swelling to a great extent, both externally and internally, is to be dreaded and guarded against. Abscess of the Schneiderian membrane, frequently of the septum narium, occurs from slight injuries, if neglected; and, if not actively and properly treated, may terminate in loss of substance and consequent deformity of the features.

The existence of fracture of the ossa nasi is very readily ascertained; the part is distorted, being either uniformly depressed, or hollow at some points, and abruptly prominent and sharp at others. With the view of remedying deformity produced by displacement, and preventing the bad consequences already spoken of, the bones must be restored to their original position. They are to be raised by means of a strong probe or director, covered with lint, and introduced high into the cavity. Whilst, by means of this instrument, pressure outwards is made, the fingers of the surgeon are applied externally, so as to mould the organ into a proper shape. Unless force be again applied to the part, there is no risk of subsequent displacement; no apparatus is required to preserve the bones in situ.

In compound fracture the detached spiculæ are to be picked out, and the wound cleansed of blood and extraneous bodies; its edges are to be brought neatly together, and retained by one or more stitches, with slips of unirritating plaster. Inflammatory symptoms are to be warded off and combated by purgatives, antimonials, local abstraction of blood, and fomentations. Formation of matter in the nasal cavity is to be prevented, by scarification of the swollen membrane that fills the nostrils and precludes the passage of air; and if matter has been allowed to collect, it must be early discharged.

Opening into the frontal sinus, whether the result of accident or of exfoliation, may sometimes be closed by paring the edges of the integuments and bringing them together, or by covering the deficiency with a flap borrowed from a neighbouring part. Such measures should not be resorted to, in the case of opening from accident, till after all inordinate action has subsided, otherwise adhesion will fail.

Cases of fracture of the superior maxilla, os malæ, and zygoma, have been met with. Great displacement cannot occur, nor is any peculiarity of treatment required. If the fracture is compound, loose portions of bone may require removal.

The inferior maxilla is exposed to violence, but from its construction and consistence is capable of resisting a great degree of force. It may be broken at various points; the usual site of fracture is where the canine or the first small molar tooth is implanted; but it not unfrequently gives way at the symphysis, or near the angle. The alveolar processes are often detached, with loosening of one or more teeth. The fracture is frequently compound; being produced by a direct blow, as the kick of a horse. The bone sometimes breaks at a part not struck, as at the symphysis from a blow near the angle. The accident is easily recognised; in fact, the patient, if sensible, has himself discovered fracture before he applies for assistance. There is distortion of the part, and the broken extremities, when moved, are felt grating on each other; there is discharge of blood, perhaps of teeth, from the mouth; and in compound fracture the ends of the bone are visible. At the symphysis the parts are not much displaced; they are more so when the fracture is in the site of the first molar. In the latter situation it is occasionally difficult to replace the bone, and retain it in its proper position.