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.